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Arthrography Spring 2009 Draft.

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Presentation on theme: "Arthrography Spring 2009 Draft."— Presentation transcript:

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 SYNOVIAL MEMBRANE: Inner surface of the JT capsule Is connective tissue Covers all structures within the JT except hyaline cartilage Produces synovial fluid HYALINE ARTICULAR CARTILAGE Is located on the bearing surfaces of the bones composing the JT Does not contain nerve endings or blood vessels INTRA-ARTICULAR JT STRUCTURES Aid in providing efficient lubrication of the articular surfaces LIGAMENTS Can be in the JT space as well as in the JT capsule Limits motion in undesirable directions and functions as sense organs of motion and position.

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
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 Patient PREP Get thorough pt history PT comfort
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

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 Needles Connector tube Sterile towels
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 Additional Equipment & Supplies
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)

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) This widening or spreading of the joint space of the intrastructural spaces permits better spread of the contrast around the meniscus.

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 Side effects can be:
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 MRI Knee Arthrography

37 Shoulder Arthrogram Indications: Single or double contrast can be used
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 ml Double 3-4 positive contrast and 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: Normal AP, with contrast media surrounding the biceps tendon sleeve and lying in the intertubercular (bicipital) groove (arrows). The axillary recess is filled has a normal medial filling defect (arrowheads) created by the glenoid labrum. DOUBLE CONTRAST: Normal AP double contrast shoulder arthrogram. Single Contrast Double Contrast

40 Shoulder Single and Double contrast
Normal axillary double contrast shoulder with PT in supine position. (O) opaque medium (A) air created density SINGLE CONTRAST Normal axillary single contrast shoulder arthrogram. 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 CT shoulder arthrogram. The radiographic arthro in this patient was normal However, the CT shoulder arthro shows a small chip fx (arrow) on the ant surface of glenoid cavity. Head of humerus (H), air surrounding biceps tendon(arrowheads), air contrast medium (A), opaque contrast medium (O), and glenoid portion of scapula(G) are evident. 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
Digital subtraction of the same image as the left image. Contrast medium (black) shows better demonstration of the JT. Contrast around the prosthesis in the proximal and lateral femoral shaft (arrows) indicates a loose prosthesis. Lindes of the medial and lateral aspect of the femur (arrowheads) are subtraction registration artifact caused by slight PT movement during the injection of contrast medium.

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


49 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

50 Wrist Arthrogram

51 Wrist Arthrogram Rheumatoid Arthritis

52 TMJ Arthrogram CT and MRI have largely replaced TMJ arthrography because they are noninvasive Useful in diagnosing Abnormalities of the articular disk Indications: pain, clicking sound, lock jaw when chewing sticky candy Starburst Taffy Useful in diagnosing abnormalities of the articular disk, the small oval, fibrocarilaginous or fibrous tissue plate located between the condyle of the mandible and mandibular fossa. Disk damage can be a result of trauma or a stretched or loose posterior ligament that allows the disk to be anteriorly displaced causing pain.

53 TMJ Arthrograms Tomography MRI
Often tomo and standard x-rays are taken as scouts. Then under fluoro the contrast media is injected and spot images are taken to evaluate mandibular motion. Both open and closed mouth radiographs, tomo and fluoro spots are indicated. Tomography MRI

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