Shoulder Arthrogram

Scout anteroposterior (AP) radiographs of the patient's shoulder are done in internal and external rotation with 10° to 15° caudal angulation. The injection is performed with the patient lying supine on the fluoroscopic radiographic table, with the arm minimally abducted and the thumb

FIGURE 1 Anteroposterior view of shoulder shows early contrast filling within the joint capsule following proper needle placement in the glenohumeral joint.

in the up or 12 o'clock position. There is no need to oblique the patient to view the joint in tangent because this will only cause the fibrocartilaginous labrum of the glenoid to be positioned over the joint space, causing difficult needle placement. Under fluoroscopic guidance, a lead marker or BB is centered on the midpoint of the glenohumeral joint, and this point is then marked on the skin for the site of injection. Following marker placement, sterile preparation of the shoulder and administration of a local anesthestic, a 20- or 21-gauge 3.5 in. spinal needle is directed straight down into the center of the glenohumeral joint. With proper placement, a test injection will result in contrast flowing away from the tip of the needle and covering the humeral neck, humeral head, and subcoracoid (subscapular) recess (Fig. 1). Following successful needle placement, 4 to 5 cc of iodinated or noniodinated contrast is followed by an injection of 10 cc of room air. The needle is removed, and supine radiographs identical to the scout internal and external views are obtained (Fig. 2). Additional radiographs obtained include erect films with the arm

FIGURE 2 Anteroposterior view of shoulder shows contrast-filled joint following needle removal.

FIGURE 3 Erect anteroposterior of shoulder view shows double-contrast effect within joint capsule.

holding a 5 to 10 lb. weight or sandbag; these are done again with caudal angulation, internal and external rotation, and pre- and postexercise (Fig. 3). Exercise involves the patient rotating the shoulder for several minutes. If necessary, fluoroscopic spot radiographs are obtained to visualize a particular area such as suspected undersurface partial rotator cuff tears. There is no need to obtain additional views like axillary, bicipital groove, or Grashey projections.

Indications for shoulder arthrography include detection of partial or complete rotator cuff tears, adhesive capsulitis, loose bodies, bicipital tendon rupture, and steroid therapeutic injections. For evaluation of prosthetic loosening, 5 to 10 cc of contrast media is instilled at the level of the metallic neck (Fig. 4) (2,3).

Subacromial bursography is rarely performed, except for steroid therapy of symptomatic bursitis.

ELBOW ARTHROGRAPHY

Scout radiographs are obtained in the flexed lateral and straight AP projections. While the patient can sit next to the X-ray table, it is preferable to lie prone on the table with the elbow

FIGURE 5 Needle placement at level of radiocapitel-lar articulation.

flexed in front of the head. With the elbow flexed 90°, a marker is positioned over the radio-capitellar joint space. This point is marked over the skin as a site of injection. Following sterile preparation and administration of local anesthetic, a 21- or 22-gauge 1.5 in. needle is directed down into the radiocapitellar joint (Fig. 5). A test injection is performed with a small amount of contrast or air. Successful needle-tip placement occurs when the contrast or air extends anteriorly to the humeral shaft, elevating the anterior fat pad or seen running in the joint space between the radius and capitellum. Once needle position is confirmed, single or double-contrast injection can be performed. With single contrast, the elbow joint holds approximately 8 to 10 cc of contrast (Figs. 6 and 7). With double contrast, 1 to 2 cc of contrast can be injected with 7 to 8 cc of room air.

FIGURE 6 Lateral elbow view shows contrast-filled joint space.

FIGURE 7 Anteroposterior elbow view shows contrast-filled joint space including periradial recess {arrow).

Limited elbow flexion and extension suffices, whereas postinjection exercise is not advisable as it may rupture the joint capsule. Postinjection radiographs include a lateral view of the humerus with 90° of flexion, a lateral view in full extension, an AP view, and both oblique views. Computed tomography arthrography may be utilized with double-contrast technique for evaluation of loose bodies, if it is desirable to locate all loose bodies, determine their size and position, as well as to evaluate cartilage thickness and degree of degenerative joint disease (4).

Indications for elbow arthrography include detection of loose bodies, osteochondritis dissecans, ligament and capsule tears, and steroid therapeutic injections (5,6).

WRIST ARTHROGRAPHY

Scout radiographs include AP and lateral views of the wrist. The patient is placed supine on the X-ray table, with the hand placed palm down at the side and the wrist flexed over a small triangular rubber pad or pillow; this position widens the radiocarpal joint, making easier needle placement. Fluoroscopic observation of carpal motion may be useful with a history of a "clicking" disorder (7).

Under fluoroscopic guidance, a lead marker is placed over the radiocarpal joint at the level of the mid-scaphoid, and this point is marked on the skin at the site of injection (Fig. 8). It is important not to place the needle too close to the scapholunate articulation as this may result in erroneous injection into the mid-carpal row. Following administration of local anesthetic and under sterile technique, a 21-gauge 1.5 in. needle is passed directly down into the radioscaph-oid joint. A test injection will result in contrast flowing away from the needle outlining the radiocarpal joint. Three cubic centimeters of contrast will successfully fill the radiocarpal joint at which point the needle is removed (Fig. 9). Following injection, AP and lateral views of the wrist are obtained followed by postexercise radiographs in the AP projection supplemented by adduction and abduction AP views. The carpal deviation views help evaluate the spaces between the scapholunate, lunate, and triquetrum for tears of the corresponding ligaments. It is preferable to fluoroscopically monitor the initial injection as this is the best way to visualize and identify intercarpal ligament tears as contrast flows into the mid-carpal row or into the distal radioulnar joint through a tear of the triangular fibrocartilage.

The so-called "triple joint" injection requires initially the radiocarpal injection and films, followed, four hours later, by injecting 1 cc of contrast into the distal radioulnar joint (25-gauge needle) and then immediately followed by a 3 cc midcarpal contrast injection (21- or 22-gauge needle) (Figs. 10 and 11) (8).

FIGURE 8 Posteroanterior wrist view shows site (O) of contrast injection between the scaphoid and radius.

FIGURE 9 Posteroanterior wrist view shows proper needle location and contrast filling the radiocarpal articulation.
FIGURE 11 Posteroanterior wrist view shows selective mid-carpal joint contrast injection, with opacification of scapholunate and triquetrolunate articulations down to site of normal ligament attachments (arrows).

Indications for wrist arthrography include detection of intercarpal ligament tears, triangular fibrocartilage tears, adhesive capsulitis, and communicating ganglia (9).

HIP ARTHROGRAPHY

Scout radiographs are obtained in the AP and lateral projections. The patient is placed supine on the X-ray table, with the hip held in neutral or internal rotation position for optimal visualization of the femoral neck. The femoral artery is palpated and avoided during injection. Under fluoroscopic guidance, a lead or BB is placed over the center or lateral margin of the mid-femoral neck, and this point is marked on the skin to indicate the site of injection (Fig. 12). Under sterile technique and following the administration of local anesthetic, a 20-gauge 3.5 in. spinal needle (5.5 in. spinal needle for obese patients) is directed downward until it touches the femoral neck preferably at the level of the mid-neck or lateral edge. When the tip of the needle touches the bone, it is slightly withdrawn and aspiration of synovial fluid is attempted. If an aspiration study and no fluid is obtained, 10 mL of sterile saline (nonbacteriostatic) may be

FIGURE 12 Anteroposterior view shows possible injection sites (O) for hip arthrography.

FIGURE 13 Anteroposterior hip view shows contrast-filled joint space.

injected and reaspirated. If the needle is intra-articular, the contrast will flow freely away from the tip of the femoral neck filling the joint capsule (Fig. 13). Six to ten cubic centimeters of contrast medium can be injected and the needle removed. Routine postinjection radiographs include AP and lateral views. Postexercise films are not usually necessary.

For prosthetic replacements, the needle should be directed onto the metal neck and a small amount of contrast injected after aspiration. A pseudocapsule will fill if the needle is placed correctly. Up to 10-15 cc of contrast may be injected when evaluating for prosthetic loosening.

Indications for hip arthrograms include joint aspiration for septic-joint diagnosis, steroid therapy, and detecting arthroplasty complications (Fig. 14) (10-13).

FIGURE 14 Anteroposterior view shows total hip prosthesis with proper needle (arrow) placement onto the metallic neck.

KNEE ARTHROGRAPHY

Scout radiographs of the knee are taken in the AP and lateral view with slight flexion. The patient is placed supine on the fluoroscopic radiographic table, with the leg in extension. Following sterile preparation of the knee, local anesthesia may be administered although I personally find it unnecessary. A 20-gauge 1.5 in. needle is directed between the undersurface of the patella and the top of the femoral condyle (Fig. 15). This space can be enlarged by grabbing the patella and pulling it toward oneself. With placement of the needle and following aspiration of all possible joint fluid, a small amount of test-contrast dose should be evaluated for intra-articular location. With intra-articular location, the contrast moves away from the needle tip and runs into the lateral recesses of the suprapatellar pouch and into the tibiofemo-ral joint (Figs. 16 and 17). If the needle is extra-articular, contrast will pool around the needle

FIGURE 15 Lateral view of knee shows site (O) of proper needle placement.

FIGURE 17 Lateral space knee view shows double-contrast-filled joint with filling of suprapatellar bursa (arrow).

tip and not flow off to the sides of the smooth-walled suprapatellar bursa. With intra-articular location of the needle, there should be no resistance felt during the injection of either contrast or air.

For double-contrast examination of the knee, 5 cc of contrast is injected followed by an injection of 30 cc of room air. Following removal of the needle, the patient is placed in the prone position, the knee flexed several times, and then a stress device applied to the knee in such a way as to allow the arthrographer to stress the medial and lateral joint sides. With adequate stress, there is proper distraction and visualization of each meniscus. A series of radiographs of each meniscus is done as the patient is rotated under stress from the posterior horn to the anterior horn (14). The subsequent radiographs include a minimum of 12 images per meniscus. Following meniscal examination, a lateral flexed view of the knee is performed with anterior stress (drawer test) on the tibia to visualize the anterior cruciate ligament, which is then spot radiographed. Subsequent AP and lateral extension films of the knee are obtained for evaluation of joint anatomy and possible communicating popliteal cyst.

Indications for knee arthrography include detection of meniscal tears, osteochondritis dissecans, chondromalacia, communicating popliteal cysts, and anterior cruciate tears (15,16).

ANKLE ARTHROGRAPHY

Scout radiographs of the ankle are obtained in AP and lateral projections. Before performing an injection, the dorsalis pedis artery is palpated to avoid its injection. The patient is placed on the side and the ankle is placed in lateral position on the fluoroscopic radiographic table, with the foot held in plantar flexion to open the anterior aspect of the tibiotalar joint. Under fluoroscopic guidance, a lead marker is moved either up or down so it is at the same level as the anterior tibiotalar joint. This point is marked on the skin as the site of injection. Following sterile preparation and administration of a small amount of local anesthetic, a 22-gauge 1.5 in. needle is advanced into the anterior ankle joint capsule. Following needle placement, a test injection of contrast is performed. If the tip of the needle is intra-articular, the contrast will flow into the anterior joint capsule and enter the joint at the level of the talar dome (Figs. 18 and 19). Injection of 6 to 10 cc of contrast media will result in full distention of the joint capsule. Plantar and dorsiflexion will disperse the contrast evenly. Postinjection radiographs include AP view, lateral view, and both oblique views.

Indications for ankle arthrography include detection of medial and lateral collateral ligament tears, loose bodies, osteochondritis dissecans, syndesmosis rupture, and adhesive capsulitis (17,18).

FIGURE 18 Lateral ankle view shows contrast-filled joint space. Proper needle placement requires entry into the anterior joint capsule (arrow).

POSTINJECTION COMPLICATIONS

Complications following arthrography are few in number (19,20). The patient may experience pain at the injection site, which may be related to the number of needle passes necessary to obtain intra-articular location. Patients may develop syncopal reaction or vasovagal reactions during the examination, which require standard medical treatment. With the use of nonionic contrast, there has been a decrease in the incidence of synovitis of the involved joint, which may begin two to four hours after the study and last for up to 12-24 hours. The incidence of nerve blocks and intraosseous injections are very rare, utilizing the techniques described above. Very rarely, lidocaine skin reactions may occur.

Bursography and other joint injections occasionally are performed for therapeutic steroid treatment. Bursas that can be injected include subacromial subdeltoid, iliopsoas, and trochanteric bursae (Fig. 20). Joints that can be injected include temporomandibular, acromioclavicular, proximal tibiofibular, sacroiliac, symphysis pubis, subtalar, and facet joints (Figs. 21-24) (2,21).

FIGURE 19 Anteroposterior internal oblique view of ankle shows contrast outlining joint margins, including the syndesmotic recess (arrow).

FIGURE 20 Contrast-filled iliopsoas bursa visualized from lesser trochanter cephalad.

FIGURE 21 Proper needle placement and contrast injection within the acromioclavicular joint.

FIGURE 22 Proper needle placement and contrast injection within the proximal tibiofibular joint.

FIGURE 23 Proper needle placement and contrast injection within the inferior aspect of the sacroiliac joint.

FIGURE 24 Proper needle placement and contrast injection in the symphysis pubis.

FIGURE 24 Proper needle placement and contrast injection in the symphysis pubis.

REFERENCES

1. Pasternak S, Resnick D, Niwayama G, Danzig L, Haghighi P. The effects of watersoluble contrast media on the synovial membrane. Radiology 1982; 143:331-334.

2. Resnick D. Arthrography, Tenography and Bursography. Philadelphia: W.B. Saunders, 1996:113-135.

3. Goldman A. Shoulder Arthrography. In: Technique, Diagnosis and Clinical Correlation. Boston: Little Brown, 1982:164-167.

4. Pavlov H, Ghelman B, Warren R. Double contrast arthrography of the elbow. Radiology 1979; 130:87-91.

5. Goldman A. Procedures in Skeletal Radiology. Orlando: Grune and Stratton, 1984:295-338.

6. Steinbach L, Schwartz M. Elbow arthrography. Radiol Clin N Am 1998; 36:635-649.

7. Protas J, Jackson W. Evaluating carpal instabilities with fluoroscopy. Am J Radiol 1980; 135:137-140.

8. Levinsohn M, Rosen I, Palmer A. Wrist arthrography: value of the three-compartment injection method. Radiology 1991; 179:213-219.

9. Linkous M, Gilula L. Wrist arthrography today. Radiol Clin N Am 1998; 36:651-672.

10. Tehranzadeh J, Schneider R, Freiberger R. Radiologic evaluation of painful total hip replacement. Radiology 1981; 141:355-362.

11. Berquist T, Bender C, Maus T, Ward E, Rand J. Pseudobursae: a useful finding in patients with painful hip arthroplasty. Am J Radiol 1987; 148:103-106.

12. Aliabadi P, Baker N, Jaramillo D. Hip arthrography, aspiration, block and bursography. Radiology Clin N Am 1998; 36:673-690.

13. Weissman B. Imaging of the total hip replacement. Radiology 1997; 202:611-623.

14. Freiberger R, Pavlov H. Knee arthrography. Radiology 1988; 166:489-492.

15. Tegtmeyere C, McCue F, Higgins S, Ball D. Arthrography of the knee: a comparative study of the accuracy of single and double contrast techniques. Radiology 1979; 132:37-41.

16. Coumas J, Palmaer W. Knee arthrography: evaluation and current status. Radiol Clin N Am 1998; 36:703-728.

17. Olson R. Ankle arthrography. Radiol Clin N Am 1981; 19:255-268.

18. Dory M. Arthrography of the ankle in chronic instability. Skeletal Radiol 1986; 15: 291-294.

19. Hall F. Morbidity from shoulder arthrography: etiology, incidence and prevention. Am J Radiol 1981; 136:59-62.

20. Hugo P, Newberg A, Newman J, Wetzner S. Complications of arthrography. Semin Musculoskel Radiol 1998; 2:345-348.

21. Baker K, Gilula L. The current role of tenography and bursography. Am J Radiol 1990; 154:129-133.

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