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Arthrography

Arthrography. Spring 2009 Draft. Arthrography. Used to obtain diagnostic information regarding the: Joint space Surrounding soft tissue Cartilage Lesions of the menisci Delineates the joint space and its surrounding structures Largely replaced by MRI. Joint Overview.

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Arthrography

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  1. Arthrography Spring 2009 Draft

  2. Arthrography • Used to obtain diagnostic information regarding the: • Joint space • Surrounding soft tissue • Cartilage • Lesions of the menisci • Delineates the joint space and its surrounding structures • Largely replaced by MRI

  3. Joint Overview • Broken down into 3 classifications • Fibrous (slightly movable or immovable) • Cartilaginous (slightly movable or immovable) • Synovial (freely movable) • For arthrography we are mainly interested in synovial joints

  4. Synovial Joint • Get their name from synovial fluid within joint space • It is enclosed in a fibrous layer called the joint capsule • These fibers are arranged irregularly • Connects articulating bones just beyond joint space uniting the bones of the joint • Further contains synovial membrane, hyaline cartilage, intra-articular joint structures and ligaments

  5. Synovial Fluid • Synovial fluid is clear viscous fluid that serves as a lubricant • Fluid works with structures such as menisci, disks and fat pads to reduce friction • Resembles the white of an egg in consistency • Nourishes hyaline cartilage (lines articular surfaces) • Is produced in the synovial membrane

  6. Anatomy of a Synovial Joint • Synovial membrane • Hyaline articular cartilage • Intra-articular JT structures • Menisci, fat pads, and intra-articular disks • Ligaments

  7. Most Common Areas of Examination • Arthrography can be done on any encapsuled JT • Knee is most common type of arthrogram performed • Other joint spaces include: • Wrist • Shoulder • TMJ • Hip

  8. Pneumoathrograms • Air or gaseous medium is used • 100-150 ml • Produces painful distention of joint • Possible air embolism • Accuracy is considerably less than that when 2 contrast methods are used

  9. Positive or Opaque Arthrography • Water soluble iodinated contrast • Ionic or non-ionic • 30-100ml can be used • Contrast is readily absorbed, tolerated and excreted • Produces greater diagnostic accuracy • Concentration should be no more than 30%

  10. Double contrast Arthrography • Both gaseous and water soluble contrast employed • By using both contrasts less of each can be used. • Reducing patient discomfort • Decreasing chance of air embolism • Highly accurate diagnostic study

  11. Contrast Precautions • Verify it is the correct contrast • Ionic or Non-ionic iodinated contrast • Omnipaque or Isovue (non-ionic) • Correct concentration • Check expiration date • Keep contrast vial in room until procedure is complete

  12. Indications and Contraindications for Arthrography • Indications: • Suspected injury of meniscus (tears) • Suspected capsular damage • Rupture of articular ligaments • Cartilaginous defects • Arthritic deformities (specifically TMJ) • Congenital luxation ( dislocation) of hip • Extent of damage from trauma • Contraindications: • Hypersensitivity to iodine

  13. Clinical Symptoms • Pain • Swelling • Limited range of motion • Recurrent instability (such as ankle)

  14. Risks • It is an invasive procedure therefore there are certain risks to the patient • Reaction to contrast media • Vasovagal reaction • Nausea, perspiration and pallor • Allergy to anesthetic agent • Inflammatory synovitis

  15. Get thorough pt history Reason for exam Allergies Ease patients anxieties Answer questions Explain procedure PT comfort Allow them to use restroom Get pt into gown Blankets Obtain informed consent Sometimes hospitals require doctor to do this Patient PREP

  16. Procedural PREP • Obtain Arthrogram tray • Additional supplies needed • Skin PREP • Shave area if needed • Betadine to clean area of interest in circular motion from inside to outside (often times DR prefers to do this)

  17. Arthrogram Tray • Syringes • 5cc, 20 cc and 30cc luer lock • Needles • 25g, 20g, 18g • Connector tube • Sterile towels • Sterile drape • Gauze pads (4x4) • Prep sponges • Adhesive tape • Anesthetic • Sometimes DR draws this up and some do not have this on tray

  18. Aseptic Technique • Do not contaminate arthrogram tray • Tray is sterile • Do not contaminate area of interest after scrubbed

  19. Shields Towels and blankets Contrast Sterile gloves Antiseptic solution Gauze Ace bandages (if needed) Fluoroscopy & radiographic capabilities Gown Extra syringes and needles Bandaids Forceps (if part of protocol) Gloves Specimen tubes (if needed) Additional Equipment & Supplies

  20. Needles • Smaller gauge has a larger number • Larger gauge has a smaller number • Length and gauge of needle is usually part of protocol • DR’s preference • Part being examined

  21. Radiation Safety • Have shields for PT’s, DR and yourself • Question LMP and the possibility of being pregnant • Use cardinal rules • Time • Distance • Shielding • ALARA • Use pulse if possible • Save the last image on screen when possible

  22. General Guidelines • Also refer to DEPT protocol • Many hospitals have different protocols for different DR’s • Make sure you have everything ready • This makes the procedure go smoothly

  23. Aspiration • Dr’s may aspirate fluids before injecting contrast media • If there is a joint effusion especially • Fluid is sent to lab in specimen vials

  24. Clinical Indications for Knee Arthrograms • Pain, swelling and limited ROM • Trauma or athletic injuries • Suspected damage to menisci and capsule • Rupture of articular ligaments • Cartilaginous defects • Arthritis

  25. Knee Arthrogram: Vertical method • Apply all principles from slides 15-21 • Scout films: often AP, Lateral and oblique • Check with DEPT protocol • Anesthetic injected • Contrast is injected (single contrast study)

  26. Knee Arthrogram: Vertical Method • Place PT prone • Place PT in frame or stress device to open JT space • Sometimes support is placed under distal femur and small sandbag on ankle to widen JT space • Part is manipulated to disperse contrast and often multiple spot films are taken under fluoroscopy

  27. Knee Arthrogram: Vertical Method • Overheads are done • AP, lateral, 20 degree right and left oblique • Sometimes Interconyloid fossa projections are required • Single contrast study for a torn meniscus may fail to demonstrate the tear • Usually single contrast studies are used to demonstrate loose particles of the JT • Post procedure • PT may feel tightness • This should go away in 1-2 days • Can be treated with analgesics

  28. Vertical Knee Radiographs Medial Meniscus Tear

  29. Meniscus Tears • Symptoms may include: • "Popping" sound at the time of the injury • Pain • Tightness • Swelling within the knee, often called "water on the knee" • Locking up, catching, or giving way of the knee • Tenderness in the joint

  30. Knee Arthrogram: Horizontal Method • Usually a double contrast study • With this type smaller amounts of contrast can be used • Decreases discomfort to PT • Provides are more accurate study • Demonstrates menisci the best • Positive contrast coats menisci • Air rises

  31. Knee Arthrogram: Horizontal Method • Apply all principles from slides 15-21 • Scout films: often AP, Lateral and oblique • Check with DEPT protocol • Anesthetic injected • Contrast is injected (double contrast study) • PT placed semiprone

  32. Knee Arthrogram: Horizontal Method • Knee is manually stressed while spot films are taken (medial & lateral meniscus) • Draw a line on medial or lateral side of knee and then direct CR to the meniscus • Rotate knee toward the supine position • Turn 30 degrees for each of the projections

  33. Horizontal Knee Radiographs Spot Films Medial Meniscus AP LAT

  34. For Cruciate Ligaments • Double Contrast study • PT’ s sits with knee flexed 90 degrees over the side of the table • Firm pillow placed under knee so that forward pressure can be applied • PT holds IR with grid • Closely collimate • Tightly overexposed lateral projection is made

  35. CT Knee Arthrography • PT gets a regular arthrogram in radiology • Then is taken to CT for imaging • Can be single or double contrast (water soluble iodine) • Usually double

  36. MRI Knee Arthrography • Gadolinium contrast is used • It is a clear substance that when injected into a vein accumulates in abnormal tissue • Side effects can be: • Mild headache, nausea, local pain, low blood pressure, allergic reaction, urticaria and SOB. • Contraindications include metal in body, claustrophobia, & PT size

  37. Shoulder Arthrogram • Indications: • Partial or complete tears of rotator cuff • Tears of glenoid labrum • Persistent pain or weakness • Frozen shoulder • Single or double contrast can be used • Single 10-12 ml • Double 3-4 positive contrast and 10-12 of air

  38. Shoulder Arthrogram • The usual objection site is approx ½ inch inferior & lateral to the coracoid process • Usually spinal needle is used because the joint capsule is usually deep • Scout films: AP (internal & external), 30 degree oblique, axillary, tangential • See Chapter 5 for PT and part positioning AP scout

  39. Normal Shoulder Arthrograms Single Contrast Double Contrast

  40. Shoulder Single and Double contrast Single contrast Double contrast

  41. Rotator Cuff Tear

  42. Shoulder Arthrogram • After double contrast shoulder arthrogram CT may be used in some patients • In 5mm intervals through shoulder joint • CT scans have shown to be more sensitive and reliable in diagnosis Small chip on anterior surface on glenoid cavity

  43. MRI Arthrogram of Shoulder

  44. Hip Arthrogram • Performed most often on children for congenital dislocation pre and post treatment • Performed on adults to detect loose prosthetics or confirm presence of an infection • Cement & barium are added to hold prostheses and to be able to check it radiographically • BA and cement have approx same Z# making evaluation of JT by arthrography • Digital subtraction is used to overcome this problem

  45. Hip Arthrogram & Digital Subtraction

  46. Hip Arthrogram • Common puncture site • ¾ “ distal to the inguinal crease • ¾” lateral to the palpated femoral pulse • Spinal needle is used due to how deep the hip joint is into the body.

  47. Children Hip Arthrography

  48. Wrist Arthrogram • Indications: trauma, persistent pain, limited ROM. • Contrast is injected through the dorsal wrist at the articulation of the radius, scaphoid and lunate • 1.5-4ml water soluble iodinated contrast • After injection the wrist is carefully moved to spread contrast • Under fluoro or tape recording the wrist is rotated for exact area of leakage • AP, LAT and both obliques often taken (check DEPT protocols

  49. Wrist Arthrogram

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