Arthrography

Arthrography

 The indications contraindications and complications of arthrography describe pertinent Anatomy imaged on an arthrogram discuss pre-procedure preparation and assessment of a patient undergoing arthrography identify radiation protection and technical factors used during arthrography identify contrast agents used and their indications for an arthrogram described the patient positioning and procedural steps of an arthrogram of the hip and shoulder discuss post-procedure care and instructions for patients following an arthrogram procedure the patients.

 The performance of the procedure a focused physical examination of the patient's affected joint may be performed labs are usually not needed on patients who are not on anticoagulant therapy for patients on warfarin therapy pro Stompin time or PT partial thromboplastin time or PTT INR and platelet count can be ordered, patients in anticoagulant therapy do not need to stop their medications prior to the procedure informed consent by the patient or surrogate must be obtained

The fluoroscopy and last image hold or it may be employed to decrease patient dose reducing post fluoroscopy to 7.5 pulses per second and reducing the filming frame rate to one exposure per second greatly reduces radiation exposure to patients and others in the room allow the user to save the image on the monitor without exposing the patient at a higher exposure dose to take a spot image images and fluoroscopic field of view or for should be manually collimated as much as possible to limit radiation exposure to the patient the detectors should be placed as close to the patient as safely possible to reduce magnification and patient dose automatic dose rate controls and automatic brightness controls which automatically adjust the killer voltage pink or kvp and milliamperage or ma should be used as part of as low as reasonably achievable  the patient size will ensure the appropriate kVp and ma will be appropriate for the procedure being performed the use of magnification increases spatial resolution but also increases the radiation dose to the patient and should be used sparingly during the procedure the total theme on time should be reduced as much as possible by using intermittent fluoroscopy lih and post fluoroscopy digital subtraction imaging maybe used to evaluate for ligamentous tears or for loosening of arthroplasty.

Wear radiation safety equipment including but not limited to lead aprons thyroid shields etc if the fluoroscope being used as a lead protective curtain it should be removed so it will not interfere with the integrity of the sterile field the Bucky slot cover should be engaged to reduce exposure to staff and others the hands of the operator should be kept out of the fluoroscopic for asthma as possible or LED gloves should be used to reduce the dose a preliminary or scout image of the joint should be evaluated.

The technologist may be directed to provide additional radiographic overhead images of the joint the kV P for digital images should be in the appropriate range for the anatomy being examined the equipment required for this procedure includes an arthrogram tray the tray should include an 18 gauge one and a half inch or 3.8 1 centimeter needle to draw up the contrast and a 25 gauge one and a half-inch needle to Iniesta size the skin the tray should also include an extension set an antiseptic solution such as povidone-iodine or Korra hexagon solution it should also include a preservative-free 1% solution of lidocaine some 4x4 gauze a fenestrated sterile drape adhesive bandages an assorted 1-milliliter gadolinium contrast and a normal saline solution for joint injections a 22 gauge 3 and 1/2 inch spinal needle or a 20 gauge needle can be used for large joint arthrocentesis laboratory tubes for culture 

The patient supine on the fluoroscopy table with the shoulder to be examined the whole cyst to the examiner expose the shoulder for the procedure tape may be used to secure the patient's gown to their skin to prevent possible contamination of the sterile area if the patient moves during the procedure externally rotate the patient's hand with the palm up a weight or sandbag may be placed in the patient's palm to help hold the position.

Don sterile gloves and prep the patient's skin in this sterile fashion with antiseptic solution allow the solution to dry and apply the sterile fenestrated drape to localize the entry site with the metallic hemostat the rotator interval can be found at the level of the coracoid process over the upper medial quadrant of the humeral head close to the articular joint line the anterior approach or Snider technique will use an entry site at the junction of the middle and inferior thirds of the anterior aspect of the glenohumeral joint pollinate the area to reduce radiation exposure mark the area with an indelible marker and anesthetize the entry site an anticipated needle tract with 1% lidocaine now with the stylet fully inserted in the needle pierces the skin at the entry site the needle should be superimposed upon itself in the horizontal and vertical axes.

 Arthrography the joint is maximally distended with iodine aidid contrast until resistance is met or the patient experiences discomfort related to the fullness of the joint this requires approximately 15 milliliters when performing the hip arthrogram injection the first step is to perform a timeout procedure as per hospital protocol next medical personnel should wash their hands and place the patient supine on the fluoroscopy table with the hip to be examined closest to the examiner expose the hip for the procedure tape may be used to secure the patient's gown to their skin to prevent possible contamination of the sterile area if the patient moves during the procedure internally rotate the patient's foot approximately 10 degrees to 15 degrees a sandbag may be placed next to the patient's lateral malleolus to help hold the position healthy and mark the femoral artery with an indelible marker dawn sterile gloves and prepped the patient's skin in a sterile fashion with antiseptic solution allows the solution.

Injection of contrast is performed to ensure appropriate needle placement if resistance is met upon the injection withdraw the needle slightly and continue the injection if the contrast collects at the needle tip the needle is extra-articular and must be repositioned contrast should flow away from the needle tip to indicate intra-articular placement injection of contrast is performed under continuous fluoroscopic monitoring for medication injections once the intra-articular needle placement is confirmed disconnect the extension tubing from the contrast syringe and connected to the syringe containing the prescribed medications inject the medications.

In conventional arthrography, the joint is maximally distended with iodine aidid contrast until resistance is met or the patient experiences discomfort related to the fullness of the joint this requires approximately 15 milliliters to replace the stylet fully and remove the needle clean the antiseptic solution from the skin and place a sterile dressing at the entry site obtain spot images of the hip in internal and external rotation images with the lake in abduction.

On the fluoroscopic table with the affected arm closest to the examiner the affected arm is extended above the head with the elbow bent at a 90-degree angle with the thumb up an alternate position would have the patient sitting in a chair next to the fluoroscopic table the arm to be examined is placed on the fluoroscopic table with the elbow  bent at a 90-degree angle and the thumb up a 25 gauge one and a half-inch needle is placed in the cavity between the proximal radial head and capitulum for wrist joint Arthur grams and injections the patient is placed thrown on the fluoroscopic table with the affected wrist closest to the examiner the affected arm is extended above the patient's head with the palm down a rolled-up towel or triangular sponge is placed under the wrist to allow for passive flexion of the wrist ulnar deviation may be used to open the radiocarpal joint space an alternate position is with the patient sitting in a chair next to the fluoroscopic table the affected wrist is placed on the fluoroscopic table with the palm down and the elbow flexed a rolled-up towel or triangular sponge is placed under the wrist to allow for passive flexion of the wrist single double or triple compartments may be injected with a 25gauge one and a half inch needle use a new sterile needle for each compartment injected a radial carpal joint.

Fluoroscopic table with the effective mean closest to the examiner a rolled-up towel or triangular sponge may be placed under the affected knee to place the joint in mild flexion a medial patellofemoral a lateral patella-femoral or an anterior approach can be used a 22-gauge three and a half-inch spinal needle is advanced until it reaches the periosteum of the bone for a medial injection the space between the articular surface of the patella and the opposing femoral condyle is palpated the target site is beneath the upper or middle third of the patella and the medial femoral condyle for a lateral injection the space between the articular surface of the patella and the opposing femoral condyle is top dated the target site is beneath the upper or middle third of the patella and the lateral femoral condyle for an anterior injection the anterior aspect of the medial femoral condyle just beneath the patella and medial to the patellar tendon is palpated the needle is advanced with slight cephalad angulation for an ankle joint arthrogram and injection the patient is placed supine on the fluoroscopy table with the affected ankle toward the examiner the the foot is plantarflexed.