ArthrographyArthrography

Spring 2013Spring 2013

ArthrographyArthrography

Used to obtain diagnostic information regarding Used to obtain diagnostic information regarding the:the: Joint spaceJoint space Surrounding soft tissueSurrounding soft tissue CartilageCartilage Lesions of the menisciLesions of the menisci

Delineates the joint space and its surrounding Delineates the joint space and its surrounding structuresstructures

Largely replaced by MRILargely replaced by MRI

Joint OverviewJoint Overview

Broken down into 3 classificationsBroken down into 3 classifications Fibrous (slightly movable or immovable)Fibrous (slightly movable or immovable) Cartilaginous (slightly movable or immovable)Cartilaginous (slightly movable or immovable) Synovial (freely movable)Synovial (freely movable)

For arthrography we are mainly interested For arthrography we are mainly interested in in synovial synovial jointsjoints

Synovial JointSynovial JointGet their name from synovial Get their name from synovial fluid within joint spacefluid within joint space

It is enclosed in a fibrous layer It is enclosed in a fibrous layer called the joint capsulecalled the joint capsule

These fibers are arranged These fibers are arranged irregularlyirregularly

Connects articulating bones Connects articulating bones just beyond joint space uniting just beyond joint space uniting the bones of the jointthe bones of the joint

Further contains synovial Further contains synovial membrane, hyaline cartilage, membrane, hyaline cartilage, intra-articular joint structures intra-articular joint structures and ligamentsand ligaments

Synovial FluidSynovial Fluid Synovial fluid Synovial fluid is clear viscous is clear viscous fluid that serves as a lubricantfluid that serves as a lubricant

Fluid works with structures Fluid works with structures such as such as menisci, disks and fat menisci, disks and fat padspads to reduce friction to reduce friction

Resembles the Resembles the white of an egg white of an egg in consistencyin consistency

Nourishes hyaline cartilage Nourishes hyaline cartilage (lines articular surfaces)(lines articular surfaces)

Is produced in the Is produced in the synovial synovial membranemembrane

Anatomy of a Synovial JointAnatomy of a Synovial Joint

Synovial membraneSynovial membrane

Hyaline articular cartilageHyaline articular cartilage

Intra-articular JT Intra-articular JT structuresstructures

Menisci, fat pads, and Menisci, fat pads, and intra-articular disksintra-articular disks

LigamentsLigaments

Most Common Areas of Most Common Areas of ExaminationExamination

Arthrography can be done on any Arthrography can be done on any encapsuled JTencapsuled JT

KneeKnee is most common type of arthrogram is most common type of arthrogram performedperformed

Other joint spaces include:Other joint spaces include:WristWristShoulderShoulderTMJTMJHipHip

PneumoathrogramsPneumoathrograms

Air or gaseous medium is usedAir or gaseous medium is used

100-150100-150 ml ml

Produces Produces painful painful distention of jointdistention of joint

Possible Possible air embolismair embolism

Accuracy is considerably less than that when 2 Accuracy is considerably less than that when 2 contrast methods are usedcontrast methods are used

Positive or Opaque ArthrographyPositive or Opaque Arthrography

Water soluble iodinated Water soluble iodinated contrastcontrast

Ionic or non-ionicIonic or non-ionic30-100ml can be used30-100ml can be used

Contrast is readily Contrast is readily absorbed, tolerated and absorbed, tolerated and excretedexcreted

Produces greater Produces greater diagnostic accuracydiagnostic accuracy

Concentration should be Concentration should be no more than 30%no more than 30%

Double contrast ArthrographyDouble contrast Arthrography

Both Both gaseous and water soluble contrast gaseous and water soluble contrast employedemployed

By using both contrasts less of each can be By using both contrasts less of each can be used.used.

Reducing patient discomfortReducing patient discomfort

Decreasing chance of air embolismDecreasing chance of air embolism

Highly accurate diagnostic studyHighly accurate diagnostic study

Contrast PrecautionsContrast Precautions

Verify it is the correct contrastVerify it is the correct contrast Ionic or Non-ionic iodinated contrastIonic or Non-ionic iodinated contrast

Omnipaque or Isovue (non-ionic)Omnipaque or Isovue (non-ionic) Correct concentrationCorrect concentration

Check expiration dateCheck expiration date

Keep contrast vial in room until procedure is Keep contrast vial in room until procedure is completecomplete

Indications and Contraindications Indications and Contraindications for Arthrographyfor Arthrography

Indications:Indications: Suspected injury of meniscus (tears)Suspected injury of meniscus (tears) Suspected capsular damageSuspected capsular damage Rupture of articular ligamentsRupture of articular ligaments Cartilaginous defectsCartilaginous defects Arthritic deformities (specifically TMJ)Arthritic deformities (specifically TMJ) Congenital luxation ( dislocation) of hipCongenital luxation ( dislocation) of hip Extent of damage from traumaExtent of damage from trauma

Contraindications:Contraindications: Hypersensitivity to iodineHypersensitivity to iodine

Clinical SymptomsClinical Symptoms

Pain Pain

SwellingSwelling

Limited range of motionLimited range of motion

Recurrent instability (such as ankle)Recurrent instability (such as ankle)

RisksRisks

It is an invasive procedure therefore there It is an invasive procedure therefore there are certain risks to the patientare certain risks to the patient

Reaction to contrast mediaReaction to contrast media Vasovagal reactionVasovagal reaction

Nausea, perspiration and pallorNausea, perspiration and pallor Allergy to anesthetic agentAllergy to anesthetic agent Inflammatory synovitisInflammatory synovitis

Patient PREPPatient PREP

Get thorough pt Get thorough pt historyhistory Reason for examReason for exam AllergiesAllergies

Ease patients Ease patients anxietiesanxieties Answer questionsAnswer questions Explain procedureExplain procedure

PT comfortPT comfort Allow them to use Allow them to use

restroomrestroom Get pt into gownGet pt into gown Blankets Blankets

Obtain informed Obtain informed consentconsent Sometimes hospitals Sometimes hospitals

require doctor to do require doctor to do thisthis

Procedural PREPProcedural PREP

Obtain Arthrogram trayObtain Arthrogram tray

Additional supplies Additional supplies neededneeded

Skin PREPSkin PREP Shave area if neededShave area if needed Betadine to clean area of Betadine to clean area of

interest in circular motion interest in circular motion from inside to outside from inside to outside (often times DR prefers to (often times DR prefers to do this)do this)

Arthrogram TrayArthrogram TraySyringesSyringes 5cc, 20 cc and 30cc luer 5cc, 20 cc and 30cc luer

locklock

NeedlesNeedles 25g, 20g, 18g25g, 20g, 18g

Connector tubeConnector tubeSterile towelsSterile towelsSterile drapeSterile drapeGauze pads (4x4)Gauze pads (4x4)Prep spongesPrep spongesAdhesive tapeAdhesive tapeAnestheticAnesthetic

Sometimes DR draws this Sometimes DR draws this up and some do not have up and some do not have this on traythis on tray

Aseptic TechniqueAseptic Technique

Do not contaminate Do not contaminate arthrogram trayarthrogram tray Tray is sterileTray is sterile

Do not contaminate Do not contaminate area of interest after area of interest after scrubbedscrubbed

Additional Equipment & SuppliesAdditional Equipment & Supplies

ShieldsShieldsTowels and blanketsTowels and blanketsContrastContrastSterile glovesSterile glovesAntiseptic solutionAntiseptic solutionGauzeGauzeAce bandages (if Ace bandages (if needed)needed)Fluoroscopy & Fluoroscopy & radiographic radiographic capabilities capabilities

GownGownExtra syringes and Extra syringes and needlesneedlesBandaidsBandaidsForceps (if part of Forceps (if part of protocol)protocol)GlovesGlovesSpecimen tubes (if Specimen tubes (if needed)needed)

NeedlesNeedlesSmaller gauge has a larger numberSmaller gauge has a larger numberLarger gauge has a smaller numberLarger gauge has a smaller numberLength and gauge of needle is usually part of protocolLength and gauge of needle is usually part of protocol

DR’s preferenceDR’s preference Part being examinedPart being examined

Radiation SafetyRadiation Safety

Have shields for PT’s, DR and yourselfHave shields for PT’s, DR and yourself

Question LMP and the possibility of being Question LMP and the possibility of being pregnantpregnant

Use cardinal rulesUse cardinal rules TimeTime DistanceDistance ShieldingShielding

ALARAALARA Use pulse if possibleUse pulse if possible Save the last image on screen when possibleSave the last image on screen when possible

General GuidelinesGeneral Guidelines

Also refer to DEPT protocolAlso refer to DEPT protocol

Many hospitals have different protocols for Many hospitals have different protocols for different DR’sdifferent DR’s

Make sure you have everything readyMake sure you have everything ready This makes the procedure go smoothlyThis makes the procedure go smoothly

AspirationAspiration

Dr’s may aspirate Dr’s may aspirate fluids before injecting fluids before injecting contrast mediacontrast media If there is a joint If there is a joint

effusion especiallyeffusion especially

Fluid is sent to lab in Fluid is sent to lab in specimen vialsspecimen vials

Clinical Indications for Knee Clinical Indications for Knee ArthrogramsArthrograms

Pain, swelling and limited ROMPain, swelling and limited ROM

Trauma or athletic injuriesTrauma or athletic injuries

Suspected damage to menisci and Suspected damage to menisci and capsulecapsule

Rupture of articular ligamentsRupture of articular ligaments

Cartilaginous defectsCartilaginous defects

ArthritisArthritis

Knee Arthrogram: Vertical methodKnee Arthrogram: Vertical method

Apply all principles from Apply all principles from slides 15-21slides 15-21

Scout films: often AP, Scout films: often AP, Lateral and obliqueLateral and oblique

Check with DEPT protocolCheck with DEPT protocol

Anesthetic injectedAnesthetic injected

Contrast is injected Contrast is injected (single contrast study)(single contrast study)

Knee Arthrogram: Vertical MethodKnee Arthrogram: Vertical Method

Place PT prone Place PT prone Place PT in frame or stress Place PT in frame or stress

device to open JT spacedevice to open JT space Sometimes support is Sometimes support is

placed under distal femur placed under distal femur and small sandbag on and small sandbag on ankle to widen JT spaceankle to widen JT space

Part is Part is manipulatedmanipulated to to disperse contrast disperse contrast Multiple Multiple spot films spot films are are taken under fluoroscopy taken under fluoroscopy

Knee Arthrogram: Vertical MethodKnee Arthrogram: Vertical Method

Overheads are doneOverheads are done AP, lateral, 20 degree right and left obliqueAP, lateral, 20 degree right and left oblique Sometimes Interconyloid fossa projections are requiredSometimes Interconyloid fossa projections are required

Single contrast study for Single contrast study for a torn meniscus a torn meniscus may fail to may fail to demonstrate the teardemonstrate the tear

Usually single contrast studies are used to demonstrate Usually single contrast studies are used to demonstrate loose particles of the JTloose particles of the JT

Post procedurePost procedure PT may feel tightness PT may feel tightness This should go away in 1-2 daysThis should go away in 1-2 days Can be treated with analgesicsCan be treated with analgesics

Vertical Knee RadiographsVertical Knee Radiographs

Medial Meniscus Tear

Meniscus TearsMeniscus Tears

Symptoms may include: Symptoms may include:

"Popping" sound "Popping" sound at the at the time of the injury time of the injury

Pain Pain

Tightness Tightness

Swelling within the knee, Swelling within the knee, often called "water on the often called "water on the knee" knee"

Locking up, catching, or Locking up, catching, or giving way of the knee giving way of the knee

Tenderness in the jointTenderness in the joint

Knee Arthrogram: Horizontal MethodKnee Arthrogram: Horizontal Method

Usually a double contrast studyUsually a double contrast study With this type smaller amounts of contrast can With this type smaller amounts of contrast can

be usedbe used Decreases discomfort to PTDecreases discomfort to PT Provides are more accurate studyProvides are more accurate study Demonstrates menisci the bestDemonstrates menisci the best Positive contrast coats menisciPositive contrast coats menisci Air rises Air rises

Knee Arthrogram: Horizontal Knee Arthrogram: Horizontal MethodMethod

Apply all principles from Apply all principles from slides 15-21slides 15-21

Scout films: often AP, Scout films: often AP, Lateral and obliqueLateral and oblique

Check with DEPT protocolCheck with DEPT protocol

Anesthetic injectedAnesthetic injected

Contrast is injected Contrast is injected (double contrast study)(double contrast study)

PT placed semipronePT placed semiprone

Knee Arthrogram: Horizontal MethodKnee Arthrogram: Horizontal Method

Knee is manually stressed while spot films Knee is manually stressed while spot films are taken (medial & lateral meniscus)are taken (medial & lateral meniscus)

Draw a line on medial or lateral side of Draw a line on medial or lateral side of knee and then direct CR to the meniscusknee and then direct CR to the meniscus

Rotate knee toward the supine positionRotate knee toward the supine position Turn 30 degrees for each of the projectionsTurn 30 degrees for each of the projections

Horizontal Knee RadiographsHorizontal Knee RadiographsSpot Films Medial Meniscus

AP

LAT

For Cruciate LigamentsFor Cruciate Ligaments

Double Contrast studyDouble Contrast studyPT’ s sits with knee flexed 90 degrees PT’ s sits with knee flexed 90 degrees over the side of the tableover the side of the tableFirm pillow placed under knee so that Firm pillow placed under knee so that forward pressure can be appliedforward pressure can be appliedPT holds IR with gridPT holds IR with gridClosely collimate Closely collimate Tightly overexposed lateral projection is Tightly overexposed lateral projection is mademade

CT Knee CT Knee ArthrographyArthrography

PT gets a regular PT gets a regular arthrogram in radiology arthrogram in radiology

Then is taken to CT for Then is taken to CT for imagingimaging

Can be single or double Can be single or double contrast (water soluble contrast (water soluble iodine)iodine)

Usually doubleUsually double

MRI KneeMRI Knee Arthrography Arthrography

Gadolinium contrast is Gadolinium contrast is usedused

It is a clear substance that It is a clear substance that when injected into a vein when injected into a vein accumulates in abnormal accumulates in abnormal tissuetissue

Side effects can be:Side effects can be: Mild headache, nausea, Mild headache, nausea,

local pain, low blood local pain, low blood pressure, allergic reaction, pressure, allergic reaction, urticaria and SOB.urticaria and SOB.

Contraindications include Contraindications include metal in body, metal in body, claustrophobia, & PT sizeclaustrophobia, & PT size

Shoulder ArthrogramShoulder Arthrogram

Indications:Indications: Partial or complete tears of rotator cuffPartial or complete tears of rotator cuff Tears of glenoid labrumTears of glenoid labrum Persistent pain or weaknessPersistent pain or weakness Frozen shoulderFrozen shoulder

Single or double contrast can be usedSingle or double contrast can be used Single 10-12 mlSingle 10-12 ml Double 3-4 positive contrast and 10-12 of airDouble 3-4 positive contrast and 10-12 of air

Shoulder Shoulder ArthrogramArthrogram

The usual objection site is The usual objection site is approx ½ inch inferior & lateral approx ½ inch inferior & lateral to the coracoid processto the coracoid process

Usually spinal needle is used Usually spinal needle is used because the joint capsule is because the joint capsule is usually deepusually deep

Scout films: AP (internal & Scout films: AP (internal & external), 30 degree oblique, external), 30 degree oblique, axillary, tangentialaxillary, tangential

See Chapter 5 for PT and part See Chapter 5 for PT and part positioningpositioning

AP scout

Normal Shoulder ArthrogramsNormal Shoulder Arthrograms

Single Contrast Double Contrast

Shoulder Single and Double Shoulder Single and Double contrastcontrast

Single contrastDouble contrast

Rotator Cuff TearRotator Cuff Tear

Shoulder ArthrogramShoulder Arthrogram

After double contrast After double contrast shoulder arthrogram shoulder arthrogram CT may be used in CT may be used in some patientssome patients In 5mm intervals In 5mm intervals

through shoulder jointthrough shoulder joint

CT scans have shown CT scans have shown to be more sensitive to be more sensitive and reliable in and reliable in diagnosisdiagnosis

Small chip on anterior surfaceon glenoid cavity

MRI Arthrogram of ShoulderMRI Arthrogram of Shoulder

Hip ArthrogramHip Arthrogram

Performed most often on children for congenital Performed most often on children for congenital dislocation pre and post treatmentdislocation pre and post treatment

Performed on adults to detect loose prosthetics Performed on adults to detect loose prosthetics or confirm presence of an infectionor confirm presence of an infection Cement & barium are added to hold prostheses and Cement & barium are added to hold prostheses and

to be able to check it radiographicallyto be able to check it radiographically BA and cement have approx same Z# making BA and cement have approx same Z# making

evaluation of JT by arthrographyevaluation of JT by arthrography Digital subtraction is used to overcome this problemDigital subtraction is used to overcome this problem

Hip Arthrogram & Hip Arthrogram & Digital SubtractionDigital Subtraction

Hip ArthrogramHip Arthrogram

Common puncture siteCommon puncture site ¾ “ distal to the inguinal crease¾ “ distal to the inguinal crease ¾” lateral to the palpated femoral pulse¾” lateral to the palpated femoral pulse

Spinal needle is used due to how deep the Spinal needle is used due to how deep the hip joint is into the body.hip joint is into the body.

Children Hip ArthrographyChildren Hip Arthrography

Wrist ArthrogramWrist ArthrogramIndications: trauma, persistent pain, limited ROM.Indications: trauma, persistent pain, limited ROM.

Contrast is injected through the dorsal wrist at the Contrast is injected through the dorsal wrist at the articulation of the radius, scaphoid and lunatearticulation of the radius, scaphoid and lunate

1.5-4ml water soluble iodinated contrast1.5-4ml water soluble iodinated contrast

After injection the wrist is carefully moved to spread After injection the wrist is carefully moved to spread contrastcontrast

Under fluoro or tape recording the wrist is rotated for Under fluoro or tape recording the wrist is rotated for exact area of leakageexact area of leakage

AP, LAT and both obliques often taken (check DEPT AP, LAT and both obliques often taken (check DEPT protocolsprotocols

Wrist ArthrogramWrist Arthrogram

Wrist ArthrogramWrist Arthrogram

Rheumatoid Arthritis

TMJ ArthrogramTMJ Arthrogram

CT and MRI have largely replaced TMJ CT and MRI have largely replaced TMJ arthrography because they are noninvasivearthrography because they are noninvasive

Useful in diagnosingUseful in diagnosing Abnormalities of the articular diskAbnormalities of the articular disk

Indications: pain, clicking sound, lock jaw when Indications: pain, clicking sound, lock jaw when chewing sticky candychewing sticky candy StarburstStarburst TaffyTaffy

TMJ ArthrogramsTMJ Arthrograms

MRI

Tomography