ARTHROGRAMS RT 255 2010 NOTES
Radiography of a joint space or it’s surrounding structures with injection of contrast media
–Injected into JOINT SPACES
“DOUBLE CONTRAST”
–IODINE
(positive contrast)
•WATER soluble
–(Ionic or Non-Ionic)
–AIR (negaitve contrast)
Arthrography is concerned with synovial joints
MOSTLY REPLACED BY MRI – non invasive, good detail of soft tissue structures
CONTRAINDICATIONS TO MRI:
•
CLAUSTROPHOBIC
•
COST / INSURANCE
REIMBURSEMENT
•
PT SIZE
• Foreign Body (metal)
Anatomy of a Synovial Joint
•Synovial membrane
–Menisci, fat pads, and intra-articular disks
•Ligaments
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 kneeshoulder, hip, wrist, TMJ
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
Clinical Symptoms
•Pain
•Swelling
•Limited range of motion
•Recurrent instability (such as ankle)
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
Contrast Media
keep bottle in room until end of studyhave several syringes available
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
Sterile Procedure
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
Aseptic Technique
ARTHROGRAM TRAY
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
Needles
Aspiration
•Dr’s may aspirate fluids before injecting contrast
media
–If there is a joint effusion especially
•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
•Fluid is sent to lab in specimen vials
Fluid from aspiration-Sent to lab
KNEE ARTHOGRAM
Most common problem :
•Pain and Swelling,
–Limited ROM (range of motion)
•athletic injuries
RADIOGRAPHY
SCOUT FILMS
AP
(CHECK WITH Radiologist)
•Knee support to stress knee
•Contrast Injected – then part is stressed or moved
to work contrast into joint spaces –
LATERAL
Other
CONTRAST INJECTION
KNEE ARTHROGRAM
(MOST COMMON)
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
For Cruciate ligaments
patient may sit on end of table
with knee flexed 90 degrees –
8 on 1 spot filming
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
Knee stressed to see medial and lateral meniscus
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
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
Knee Arthrogram
double contrast study - smaller amounts of contrast can be used
–Decreases discomfort to PT
–Positive contrast coats menisci
–Provides are more accurate study
–Air rises
–Demonstrates menisci the best
Knee Arthrogram:
•Apply same principles Scout films: often AP,
Lateral and oblique
–Check with DEPT protocol
•Anesthetic injected
•Contrast is injected (double contrast study)
Horizontal Knee RadiographsFor 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
•PT placed semiprone
•Knee is manually stressed while spot films are
taken (medial & lateral meniscus)
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
MRI Knee
Arthrography
•Gadolinium contrast is used
•Contraindications include metal in body, claustrophobia, & PT size
Ace Bandages
Wrap joint after contrast injection
MEDIAL MENISCUS
MRI
BAKERS CYST
a collection of synovial fluid which has escaped from the knee joint or a bursa formed a new synovial-lined
sac in the popliteal space
seen in degenerative or other joint diseases
HIP ARTHROGRAM
•Children - to check for congenital hip dislocation – before and after treatment
•Adults – to check position of hip prosthesis - subtraction gives better images
•Note: cement in the joint and contrast have the same density – see pg 567 Merrill’s
C-ARM FOR NEEDLE LOC
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.
Children Hip Arthrography DEVELOPMENTAL DISPLASIA OF THE HIP
Hip Arthrogram & Digital Subtraction
SHOULDER ARTHROGRAM
•Done for evaluation of partial or complete tears
of the ROTATOR CUFF
•Persistent Pain, Weakness and “Frozen
Shoulder”
•May do single or double contrast - 10-12 ml of
contrast
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
SCOUT FILMS
•AP –
–INTERNAL & EXTERNAL ROTATION
• GRASHEY (OBL FOR FOSSA)
Shoulder Arthrogram
•Indications:
–Partial or complete tears of rotator cuff
–Tears of glenoid labrum
•AXILLARY (THUMB UP) FOR GROOVE
•TRANSTHORACIC or Y -VIEW
–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
Normal Shoulder Arthrograms
Shoulder Single and Double contrast
Rotator Cuff Tear
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
Single-contrast arthrogram showing rotator cuff tear (arrow).
MRI Arthrogram of Shoulder
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 protocol
WRIST ARTHROGRAM
Trauma, persistent pain, limited rom
•Wrist gently manipulated after contrast media injection
•1.5 – 4 ml of contrast injected
OTHER JOINT SPACES
ANKLE
TMJ (USUALLY DONE IN CT)