Transcript Arthrography – Joint Injection

Basic Joint Injection
“How to do it”
Steven R. Urbanski, M.D.
Jefferson Radiology
Hartford, Connecticut
Notice:
• THESE INSTRUCTIONS ARE JUST ONE APPROACH
OTHER METHODS WILL WORK JUST AS WELL
• USE THE PHOTOS TO ASSIST IN POSITIONING
AND TO DETERMINE IF YOU’RE IN THE CAPSULE
(Most photos are taken from conventional arthrograms which
are generally performed with a greater volume of contrast.
For pre-MRI injection you will only be injecting a small
amount of iodinated contrast to validate that your needle
tip is within the joint or joint capsule).
Summary
Shoulder
Elbow
-supine;
neutral or externally rotate shoulder (sandbag)
-22g spinal needle
-10-15cc contrast (10cc is fine)
-Landmark: inferomedial aspect humeral head
-prone; elbow over head flexed 90°
-25g butterfly if available
-5-10cc contrast (5cc is fine)
-Landmark: radial-capitellum joint
Hip
Wrist
-supine; pad behind knee; foot up (sandbag)
-22g spinal needle
-10-15cc contrast (10cc is fine)
-mark femoral pulse; rotate C-arm away if necessary
-Landmark: proximal-mid femoral neck, lateral to artery
Knee
-supine; pad behind knee
-any routine short needle (20g, 21g, 22g, 23g)
-10-20cc contrast (10cc is fine)
-Landmark: at lateral patello-femoral joint (by feel)
-dealer’s choice; supine, prone, sitting (least favoredas patient may become vasovagal)
-wrist should be flexed over a soft pad (see photo)
-25g butterfly if available
-several cc contrast (watch on fluoro-don’t overfill)
-Landmark: Radiocarpal compartment at mid navicular
Ankle
-First mark dorsalis pedis pulse
-Turn decubitus; side of interest side down
-25g butterfly if available
-5-10cc contrast (5cc is fine)
-Landmark: AP needle at tibio-talar joint while watching
fluoro from a lateral view
Basic Procedure: all joints
1. PROPERLY POSITION THE PATIENT to optimize needle placement
2. Use Kelly clamp/sharpie to mark your site
3. Local anesthesia (carbonated lido: 10% sodium bicarbonate)
4. Insert needle, intermittently check with fluoro
5. Validate needle position with small amount iodinated contrast
(I use connecting tube…except in the knee; butterfly for wrist and elbow)
6. Inject Dilute Gad (see next slide…. Use 0.5%)
7. Have patient exercise joint prior to imaging to distribute gad
What about Gad?
I prefer to first inject a small amount
of full strength iodinated contrast into
joint capsule prior to giving the dilute
gad to validate my needle placement.
Use photos in this presentation to
see what the joint capsules look like.
Mixing a “pinch” of Gad
(DDM recommends 0.5% solution)
Will need a TUBERCULIN Syringe to measure the “pinch”
If you have a 10cc NS bottle, then inject 0.05cc Gd into saline
If you have a 30cc NS bottle, then inject 0.15cc Gd into saline
Shake bottle to mix, draw into syringe
THE SHOULDER
Shoulder: Patient Positioning
NO GOOD !!!!
↓↓
Internal Rotation
Do NOT position with shoulder internally rotated
Shoulder: Patient Positioning
↓
YES!! ↓
Neutral – External Rotation
YES, POSITION WITH ARM IN NEUTRAL or EXTERNAL ROTATION
SANDBAG HELPS TO KEEP ARM IN POSITION WHILE YOU WORK.
Shoulder: Mark site
Mark site overlying lower inner aspect of
Humeral head (stay below the “equator”)
NEEDLE: 22 g Spinal Needle (protects cartilage/will bend)
INJECT: 10cc is fine for MRI
EXAMPLE
Case:
• Contrast should flow away from the needle
• Often fills below coracoid process before filling the axillary recess
• Only inject small amount of contrast to see if “in”; then Gd
Shoulder: normal capsule
Axillary Recess
Subscapular recess
Biceps Tendon
(usually stops at neck)
Another
Example:
Diagnostic Arthrography: EXERCISE Joint!!
Exercise (passive or active)
distributes the contrast
Post exercise Rotator Cuff Tear
easily seen.
Another example:
Needle no higher than this
“stay below the equator”
POST Exercise
Bursal injection!!
Inadvertent injection of Subscapularis Bursa
Usually from needle not in deep enough (“go to bone”)
Contrast is in bursa (not around humeral head cartilage)
Subscp burse may communicate with subacromial bursa
Shoulder: “the final product”
THE HIP
HIP: Patient Positioning
Relaxed Leg Position (use cushion behind the knee)
Foot straight up (internal rotation; sandbag helps to maintain position)
CHECK Pulse/MARK Femoral Artery (AVOID Injecting here)
Landmark → ANYWHERE at Prox-Mid FEMORAL NECK
The Native Hip:
You don’t need to be in the “joint”.
You only have to place the needle
tip in the joint capsule.
See how large the capsule is.
Placing the needle anywhere the
capsule is will result in success.
The depth is easy… contact bone.
Hip: (oblique entrance to avoid femoral artery)
↑
Femoral
Pulse is here
Here, C-arm rotated 5-10° laterally
Now my approach (circle) is away
from the femoral artery.
(if no C-arm, just turn patient 5-10° away)
Example: injection at lateral side of femoral neck
NEEDLE: 22g spinal needle
INJECT: Test injection, then 10cc dilute Gd
Example: Injection near center of femoral neck
↑
Femoral
Artery
Another example:
Another example:
Test Injection
3-5cc contrast
POST final injection
Hip: “the final product”
THE KNEE
The Knee:
POSITIONING
Patient Supine
Knee relaxed, slightly flexed
Palpate patella
Set landmark at Lat PF joint
This injection is done by “feel”
not directed by fluoro
Needle placed by palpation (no imaging)
Needle: short regular 20-23g drawing needle
Inject: 10-15cc (10cc should be fine)
Contrast injected during fluoro (validate within capsule)
Knee Injection:
Watch contrast flow away from needle into joint capsule
After injection exercise the joint
Needle placed by
Palpation (w/o fluoro)
Contrast flows away
From the needle tip
MR-Gad Injection: prior meniscetomy
THE ELBOW
Elbow: approach
Most patients will turn head away!!
NEEDLE: 23 or 25g butterfly
Inject: 5 – 10cc (5cc Gad likely enough)
Continued injection
Contrast 5 – 10cc volume
Needle: 23 or 25g butterfly
↑
Space for
Annular Lig
Conventional
Arthrogram
radial head partially absent
THE WRIST
Wrist injection: what NOT to do
↓↓
DO NOT INJECT
at the ligament
Need to first flex wrist
(next slide)
Wrist: Patient positioning (your choice!!)
Note that wrist is flexed over
The pad (easier access)
Sitting position not favored
(vasovagal)
Wrist arthro
Keep away from TFC & Ligaments (SLL, LTL)
• Needle best at Mid-Navicular
• Cushion under wrist mandatory!!!
Wrist Injection:
•25g Butterfly works well
•Image during injection!!
(only a few cc necessary)
•Exercise post injection
Normal:
If difficult to inject, it may be from the small size
of the wrist joint → bevel may be obstructed by
the articular cartilage.
Rotating the needle bevel may allow injection
THE ANKLE
Feel Pulse and mark with sharpie
AVOID INJECTING AT PULSE
Turn patient lateral for injection
Ankle: injection approach
If try to inject from AP view will hit bone
Use lateral projection with needle entering from AP side
Ankle: injection approach
25g needle (butterfly works well)
Capsular Volume = 5 -10cc
Initial filling Articular surfaces and Anterior/Posterior recesses
Conventional arthrogram
Ankle Arthro: tendon communication
Normal filling:
Medial side tendons 15%
-flexor digitorum longus
- flexor hallucus longus
Subtalar Joint 10%
ABNORMAL (peroneal tendons)
→ calcaneofibular lig tear
THE END
Steven R. Urbanski, M.D.
Jefferson Radiology
Hartford, Connecticut