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1. RADIOGRAPHIC
PROCEDURE:ARTHROGRAPHY

2. INTRODUCTION
• Arthrography is a medical imaging procedure which is
performed to demonstrate and assess the joint and
associated soft tissue structures for pathologic processes.
• These structures are visualized through the introduction of a
contrast agent into the joint capsule.
• Joints studied include the hip, knee, ankle, shoulder, elbow,
wrist, and temporomandibular joints (TMJs)

3. STRUCTURES OF MAJOR
INTEREST
Shoulder
The joint capsule, rotator cuff, long
tendon of the bicep muscle and
articular cartilage

4. Ankle
The joint capsule; menisci; and
collateral cruciate, and other
minor ligaments of the ankle.

5. Wrist
The joint capsule; menisci,
scapholunate ligament,
lunotriquetral ligament, and
the triangular fibrocartilage
complex, additional intrinsic
and extrinsic ligaments.

6. Pathologies
• The Primary indications for an arthrography procedure are
trauma, persistent pain, and limitation of motion resulting
from any of the following conditions

7. PATIENT PREPARATION
• Explain the procedure to the patient thoroughly before the
examination to preclude patient anxiety.
• Advise the patient of any possible complications involved
with doing the procedure.
• Patient must provide information on allergies, medication
and possible pregnancy prior to the procedure.
• Patient must sign an informed consent form before the
procedure is done.

8. IMAGING EQUIPMENT
Conventionally, image acquisition is obtained using fluoroscopy.
However, CT and MRI have largely replaced this. However,
fluoroscopic imaging may be used in conjunction with these
imaging modalities.
The contrast media is injected under fluoroscopic guidance and
the joint is manipulated with spot films being taken to ensure the
area of interest is demonstrated by the contrast media.
After the joint has been adequately evaluated under fluoroscopy,
the patient is transferred to CT or MRI for further imaging.
The exact protocol and procedure for CT or MRI arthrography
depends on the area of interest being examined and the protocol
of the facility or physician.

9. CONTRAST MEDIA
Radiolucent (negative) agent; and
radiopaque (positive) iodinated,water-
soluble agent (omnipaque 300) is used
for CT and fluoroscopic arthrography.
Gadolinium is used for MR arthrography.
Contrast media may be introduced to
the body indirectly, where it is injected
into the bloodstream and eventually
absorbed into the joint, or directly,
where it is injected into the joint space.

10. Needle Placement & Injection Process
• Shoulder
• The patient is in the supine position with the shoulder slightly
externally rotated. Skin entry site is at the junction of the middle
and inferior thirds of the humeral head medial aspect, 2mm
inside the cortex.
• After the area is anesthetized, fluoroscopy is used to guide the
needle into the joint space with a spinal needle.
• A small amount of contrast media is injected to determine
whether the bursa has been penetrated. When the contrast
media has been fully instilled, imaging begins.

12. Needle Placement & Injection Process
• Ankle
• The patient is in the AP position with the ankle rotated 90°
laterally.
• Skin entry site is medial to the anterior tibial or medial to the
extensor hallucis longus tendon. The dorsalis pedis artery should
be avoided, and its path should be marked on the skin.
• After the area is anesthetized, under fluoroscopy the needle is
placed slightly cranial beneath the anterior lip of the tibia, and is
advanced until its tip is between the tibia and the talus.

13. Ankle
• Before the joint injection of iodinated contrast media,
aspiration is performed to confirm correct position and to
avoid dilution of the contrast media. The contrast solution is
used to distend the joint capsule and observe the contrast
agent distribution within the articular space.

14. WRIST
• The patient is in the prone position with the wrist pronated.
• Wrist arthrography can be performed using: a single-
compartment (radiocarpal), double-compartment (radiocarpal
and midcarpal or radiocarpal and distal radioulnar), or triple-
compartment (midcarpal, radiocarpal, and distal radioulnar joint
(DRUJ) injection technique.
• The joint is then manipulated under fluoroscopy to spread the
contrast media and demonstrate the exact area of leakage.

15. Wrist- Injection Site

16. Wrist Midcarpal Joint Injection
• The needle's target for the
midcarpal compartment is the
scaphocapitate and
triquetrohamate spaces. A 25-
gauge needle is usually placed at
the triquetrolunohamate space
from a dorsal approach, and the
injection is carried on until the
contrast medium flows in the
capitolunate joint compartment.

18. Distal Radioulnar Joint (DRUJ) Injection
• The needle is directed near the radial border of ulnar
head. When the needle reaches the ulnar head, it is
inserted deeper into the center of the joint space.
• Triple-compartment arthrography is performed first
with a midcarpal joint injection of 3 to 4 mL of contrast
medium. If a communication between midcarpal and
radiocarpal is present, an additional 3 to 4 mL is
injected, and if a communication with the DRUJ occurs,
supplementary 1 to 2 mL is added for a total of 7 to 9
mL.
• If no communication is present, the radiocarpal and
DRUJ are sequentially injected with 3 to 4 mL and 1 to
2 mL of contrast medium, respectively.

19. POSITIONING & IMAGING SEQUENCE
Shoulder
• Imaging can be done with the patient upright or supine.
In fluoroscopy the projections often used are: AP (internal &
external rotation); glenoid fossa, transaxillary,
intertubercular (bicipital) groove.
• Scout images are performed and then repeated after the
contrast agent has been injected. If the radiographs appear
normal, the patient is directed to exercise the shoulder, and
the radiographs are repeated.
• This is followed up with CT or MRI imaging.

21. Positioning & Imaging Sequence
Ankle
• Imaging is done with the patient supine.
In Fluoroscopy the projections used are: AP, lateral, internal
and external oblique views
• If the capsule is intact passive and exercises are performed
while imaging.
• This is followed by imaging with either CT or MRI.

23. Wrist
• In fluoroscopy the projections used at typically the PA, as
well as PA with ulnar and radial deviation, lateral and both
obliques. Digital Subtraction techniques are also available
with some systems to improve visualization of the joint
spaces.

25. AFTER CARE
• Rest the joint that was injected for at least 12 hours after the
procedure.
• Ice packs or over the counter pain relief medication is
recommended to decrease pain and swelling.
• Symptoms of pain, red skin or fever 3 or more days following
the procedure should be reported to your physician.

26. RISKS ASSOCIATED WITH THE PROCEDURE
Any procedure where the skin is penetrated carries a risk of infection. The
chance of infection requiring antibiotic treatment is significantly low
There is the possibility of injuring a vessel or a nerve adjacent to the joint.
Injury to these structures, however, is minimal particularly when the
procedure is performed under imaging guidance.
Patients who have known allergies to iodine may have an adverse reaction
to the contrast material. Because the contrast material is put in a joint
and not a vein, allergic reactions are very rare, although in some cases,
mild nausea to severe cardiovascular complications may result.
There is always a slight chance of cancer from excessive exposure to
radiation. However, the benefit of an accurate diagnosis far outweighs
the risk.

27. REFERENCES
• Bontrager, K., & Lampignano, J. (2014). Special Radiographic
Procedures. In Workbook for Textbook of radiographic positioning and
related anatomy, (8th ed., pp. 715-719). St. Louis, Mo.: Elsevier Mosby.
• Dalinka, M. (2011). Arthrography. S.l.: Springer.
• Direct Arthrography. (2015, June 10). Retrieved November 9, 2015, from
http://www.radiologyinfo.org/en/info.cfm?pg=arthrog
• Masala, S., Fiori, R., Bartolucci, D., Mammucari, M., Angelopoulos, G.,
Massari, F., & Simonetti, G. (2010). Diagnostic and Therapeutic Joint
Injections. Semin Intervent Radiol Seminars in Interventional Radiology,
27(2), 160-171. doi:10.1055/s-0030-1253514