ARTHROGRAMS RT 255

1. ARTHROGRAMSRT 255 Radiography of a joint space or it’s surrounding structures with injection of contrast media

2. ARTHROGRAMS • Injected into JOINT SPACES “DOUBLE CONTRAST” • IODINE (positive contrast) • WATER soluble • (Ionic or Non-Ionic) • AIR (negaitve contrast)

3. Arthrography is concerned with synovial joints MOSTLY REPLACED BY MRI – non invasive, good detail of soft tissue structures CONTRAINDICATIONS TO MRI: • CLAUSTROPHOBIC • PT SIZE • Foreign Body (metal) • COST / INSURANCE REIMBURSEMENT

4. Anatomy of a Synovial Joint • Synovial membrane • Menisci, fat pads, and intra-articular disks • Ligaments

5. INDICATIONS FOR EXAM • This procedure is used to obtain diagnostic information regarding the joints and surrounding soft tissues or cartilage. • ligament, meniscus (cartilage), bursa Usually done for the knee • shoulder, hip, wrist, TMJ

6. 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

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

8. Contrast media • Contrast INJECTED into joint space – capsular space – bursa (30 – 100 ml may be needed) • CONTRAST – water based only – iodinated (ionic or nonionic) • Negative , positive or both (Double Contrast) • Negative – room air, CO2 • Possible hazard of air is an air embolism • Water-soluble contrast agents – easily absorbed

9. Contrast Mediakeep bottle in room until end of studyhave several syringes available

10. PROCEDURE – PREP • Patient Prep – (none prior to exam) • Pt comfort (gown, empty bladder) • get history • check allergies • SKIN PREP – may need to shave area of injection • betadine scrub – circular motions

11. Sterile Procedure GLOVES GOWN (?)

12. Sterile tray “arthrogram tray” Aseptic technique for skin cleansing • (betadine – check for allergy) • Local anesthetic • (usually on tray, put may have to draw up – sterile procedure) • do not contaminate tray

13. Aseptic Technique betadine scrub

15. ARTHROGRAM TRAY

16. ARTHROGRAM TRAY

17. SUPPLIES Needles used – • length and gauge depends on part being examined • DR may aspirate joint prior to injection of contrast media • (have large syringes available) • Sterile gauze, towels, ace bandages

18. 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

20. Supplies Needed

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

28. Fluid from aspiration-Sent to lab

29. KNEE ARTHOGRAM Most common problem : • Pain and Swelling, • Limited ROM (range of motion) • athletic injuries • Knee support to stress knee • Contrast Injected – then part is stressed or moved to work contrast into joint spaces –

31. RADIOGRAPHY • SCOUT FILMS • AP • LATERAL • Other • (CHECK WITH Radiologist)

32. CONTRAST INJECTION

34. KNEE ARTHROGRAM(MOST COMMON) Air and contrast material injected into the joint reveal the outlines of the joint space including the supra patellar pouch

35. FILMING - KNEE Filming done under fluoroscopy (Knee spot films may be done 9 on 1) Knee stressed to see medial and lateral meniscus • DOUBLE CONTRAST KNEE – FILMS TAKEN WITH HORIZONTAL BEAM = • contrast moves down – air moves up – shows good delineation of tissues

36. For Cruciate ligamentspatient may sit on end of table with knee flexed 90 degrees – • Then a cross table lateral taken

38. 8 on 1 spot filming

39. Knee Arthrogram • 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

40. Knee stressed to see medial and lateral meniscus

41. Knee Arthrogram • 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

42. 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

43. Knee Arthrogramdouble contrast study • 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

44. Knee Arthrogram: • Apply same principles Scout films: often AP, Lateral and oblique • Check with DEPT protocol • Anesthetic injected • Contrast is injected (double contrast study) • PT placed semiprone • Knee is manually stressed while spot films are taken (medial & lateral meniscus)

45. Horizontal Knee Radiographs Spot Films Medial Meniscus AP LAT

46. 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

47. 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

48. MRI Knee Arthrography • Gadolinium contrast is used • Contraindications include metal in body, claustrophobia, & PT size

49. Ace Bandages Wrap joint after contrast injection

50. MEDIAL MENISCUS