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Upper Extremities

27 Arthrography

Anatomy & Pathology

Arthrography is the radiographic study of synovial joints and surrounding soft tissues (ligaments, menisci, labrum, articular cartilage, bursae, and joint capsules). The most frequently examined joints are:

  • Shoulder – glenohumeral joint, rotator cuff tendons, biceps tendon, and glenoid labrum
  • Knee – menisci, cruciate and collateral ligaments, and joint capsule
  • Hip – femoral head, acetabular labrum, and prosthesis interface
  • Wrist and Elbow – intercarpal and interosseous ligaments, joint capsule
  • Ankle – tibiotalar joint and associated ligaments

Common Pathologies and Indications:

  • Tears or ruptures of the menisci, ligaments, labrum, or rotator cuff
  • Baker’s cysts (knee) communicating with the joint capsule
  • Chronic joint pain, instability, or limited mobility
  • Evaluation of prosthetic joint loosening or suspected infection
  • Pediatric hip dislocation or post-reduction assessment

Radiographer Responsibilities

Radiographic arthrography requires both technical precision and strict aseptic technique. The radiographer plays a critical role in ensuring the safety, comfort, and cooperation of the patient throughout the procedure.

Patient Preparation

  • Confirm patient identity, procedure type, and correct joint to be imaged.

  • Verify completion of informed consent and screen for contraindications such as allergy to iodinated contrast or local anesthetic, infection at the injection site, or acute inflammation.

  • Explain the procedure clearly, including the sensation of pressure or fullness during contrast injection, and stress the importance of remaining still during fluoroscopy.

Room and Equipment Preparation

  • Prepare the fluoroscopic suite or digital radiography room with a sterile arthrogram tray, appropriate contrast agents (positive, negative, or both), spinal needles, and sterile drapes.

  • Ensure availability of local anesthetic, syringes for aspiration, and appropriate contrast dose per protocol.

  • Have sterile gloves, masks, and a sterile field ready prior to the physician’s arrival.

  • Confirm that image receptor placement, collimation, and exposure settings are ready before contrast injection to minimize fluoroscopy time and radiation dose.

Contrast and Safety Considerations

  • Check expiration dates and concentration of contrast materials.

  • Record type, volume, and lot number of contrast agent used in the patient’s record.

  • Monitor the patient for any signs of contrast reaction or vasovagal response during and after injection.

  • Use lead shielding and proper collimation to minimize dose to the patient and staff.

Post-Procedure Duties

  • Assist with removal of sterile drapes and cleanup of the area.

  • Ensure that all spot and overhead images are correctly labeled with side markers and weight-bearing indicators, if applicable.

  • Provide the patient with post-procedure instructions, including avoiding strenuous activity for 24 hours and monitoring for increased swelling, redness, or pain.

Contrast Types and Selection

Contrast Type Description Commonly Used Joints Key Advantages Limitations / Considerations
Positive Contrast Iodinated, water-soluble contrast media that appear radiopaque (white) on the image. Shoulder, hip, wrist, TMJ Excellent capsule and ligament delineation; easily visualized under fluoroscopy. May obscure fine intra-articular detail if excessive volume used; contraindicated in iodine allergy.
Negative Contrast Gas (usually room air or CO₂) introduced into the joint to provide radiolucent (dark) background. Knee, shoulder (in double-contrast), hip Enhances visualization of articular surfaces and synovial membranes. May be absorbed quickly; limited soft-tissue contrast; risk of air embolism if injected improperly.
Double-Contrast Combination of positive and negative media—typically iodinated contrast followed by air. Knee (most common), shoulder Provides optimal soft-tissue and surface detail; demonstrates tears or small defects clearly. More complex technique; requires precise timing and patient cooperation for even contrast coating.

Radiographer Awareness

Radiographers performing arthrographic procedures should be able to recognize normal contrast distribution patterns to ensure complete coverage of the joint capsule and to identify any technical issues that could compromise diagnostic quality.

  • Be alert to incomplete contrast coating, air bubbles, or contrast leakage that might result from improper injection technique or patient movement.

  • If abnormal contrast flow or unexpected findings are observed during fluoroscopy, the radiographer should notify the radiologist immediately rather than attempting to interpret the appearance.

  • Radiographers are responsible for image labeling, including side, projection, and contrast indicators (e.g., “Post-Injection,” “AP – External Rotation”), to ensure accurate image documentation and diagnostic efficiency.

Projections and Imaging Protocols

Knee Arthrography

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine, with knee slightly flexed
  • Adjustments: Site prepared and anesthetized; contrast injected via medial, lateral, or retropatellar approach; knee gently flexed post-injection to distribute contrast
  • CR: Perpendicular to the joint space
  • Pt. Instructions: Remain still; minimal movement during fluoroscopy
  • Exposure: Digital fluoroscopy or spot images; nine images per meniscus (rotating leg ~20° each)

Evaluation Criteria

  • Coverage: Meniscus seen in profile throughout its diameter on sequential images
  • Rotation checks: Medial or lateral meniscus centered in collimated field
  • Motion checks: No motion blur; fine detail of contrast coating visible
  • Technique checks: Adequate contrast penetration; menisci outlined by thin, even contrast layer
  • Clinical aim: Detect meniscal or ligamentous tears, joint capsule rupture, or cyst communication

Shoulder Arthrography

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine or upright with shoulder in neutral position
  • Adjustments: Needle inserted approximately 1.3 cm inferior and lateral to coracoid process under fluoroscopic guidance; 10–12 mL contrast injected (single or double contrast)
  • CR: Centered to glenohumeral joint
  • Pt. Instructions: Suspend respiration during imaging; gently rotate arm as instructed
  • Exposure: Scout AP internal and external rotation, 30° AP oblique, axillary, and tangential

Evaluation Criteria

  • Coverage: Joint capsule, biceps tendon, and rotator cuff visualized
  • Rotation checks: Internal rotation shows lesser tubercle in profile; external rotation shows greater tubercle in profile
  • Motion checks: Sharp delineation of capsule and contrast without pooling or leakage
  • Technique checks: Even coating of contrast along articular surfaces; adequate soft-tissue detail
  • Clinical aim: Evaluate rotator cuff tear, labral tear, adhesive capsulitis, or chronic instability

Hip Arthrography

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine
  • Adjustments: Needle inserted 1.9 cm distal to the inguinal crease and 1.9 cm lateral to the femoral pulse under fluoroscopic guidance
  • CR: Centered to the hip joint
  • Pt. Instructions: Remain still; suspend breathing during injection
  • Exposure: Spot or subtraction imaging (digital or photographic)

Evaluation Criteria

  • Coverage: Femoral head, acetabulum, and joint capsule clearly visualized
  • Technique checks: Contrast evenly distributed; no air bubbles or streaking
  • Clinical aim: Evaluate prosthesis loosening, infection, or hip impingement

Protocol Customization 

Arthrography technique should be customized to the joint and clinical indication.

  • Knee: May be performed with single- or double-contrast technique. The double-contrast method provides better meniscal edge definition.
  • Shoulder: Single contrast is used for general evaluation; double contrast enhances visualization of rotator cuff tears and labral pathology.
  • Hip: Primarily for prosthesis evaluation or pediatric dislocation reduction verification; subtraction techniques may be used for prosthetic joints.
  • Wrist, Elbow, Ankle: Indicated when specific ligamentous or capsular pathology is suspected; fluoroscopy assists in precise injection.

Arthrography Comparison Table

Category Knee Arthrography Shoulder Arthrography Hip Arthrography Wrist Arthrography
Primary Indication Meniscal tears, ligament rupture, or Baker’s cyst Rotator cuff or labral tear, chronic pain or instability Prosthesis loosening, infection, or congenital dislocation (pediatric) Intercarpal ligament tear or TFCC evaluation
Contrast Type Usually double-contrast (iodinated + air) Single- or double-contrast (positive only or positive + air) Single-contrast iodinated; subtraction used for prosthetics Single-contrast iodinated
Needle Placement Medial, lateral, or retropatellar approach into joint capsule 1.3 cm inferior and lateral to coracoid process 1.9 cm distal and 1.9 cm lateral to femoral pulse Radial side of dorsal wrist, at radiocarpal joint
Imaging Views Nine spot images, rotating leg ~20° between; AP & lateral “overheads” Scout AP (internal/external), oblique, axillary, tangential Spot or subtraction images, AP hip PA, lateral, and oblique fluoroscopic views
Key Evaluation Criteria Menisci clearly profiled; thin, even contrast coating Joint capsule and tendons evenly outlined; no leakage Clear visualization of capsule and prosthesis interface Contrast outlines intercarpal ligaments and joint capsule
Clinical Notes Most common site for double-contrast method; meniscal tears easily demonstrated Most frequent arthrogram performed today; may precede MRI Often performed under fluoroscopy in surgery suite; used post–hip replacement Performed under fluoroscopy for small-joint evaluation; rarely done standalone

Modern Practice 

In contemporary medical imaging, arthrography is primarily used as a guided contrast phase preceding CT or MRI, rather than as a standalone diagnostic study.

  • Fluoroscopic arthrography remains vital for confirming accurate intra-articular needle placement and ensuring proper contrast distribution before transferring the patient for cross-sectional imaging.

  • CT arthrography is preferred when MRI is contraindicated (e.g., pacemaker, metal implants, or claustrophobia) or when assessing osseous and prosthetic detail.

  • MR arthrography provides superior evaluation of soft-tissue structures such as the labrum, rotator cuff, and menisci, and has largely replaced conventional double-contrast methods.

  • Ultrasound guidance may be used for injection in patients with limited joint mobility or altered anatomy.

Although the frequency of traditional radiographic arthrography has declined, it remains an essential interventional imaging skill, allowing radiographers to support physicians in performing accurate, safe, and diagnostically useful joint injections across a wide range of clinical indications.

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Hows & Whys of Arthrography

Anatomy

  • Why is arthrography considered a study of soft tissue rather than bone?
    Because it outlines ligaments, cartilage, tendons, and the joint capsule using contrast rather than depicting bone density.
  • Why is the shoulder the most common joint studied with arthrography?
    Because soft-tissue tears, particularly rotator cuff and labral injuries, are frequent and diagnostic imaging of these structures is challenging without contrast enhancement.

Positioning

  • Why is fluoroscopic guidance required for needle placement?
    To ensure accurate intra-articular injection and avoid extravasation of contrast.
  • Why is the patient’s knee flexed after injection in knee arthrography?
    Gentle flexion helps distribute contrast evenly across joint surfaces and menisci.
  • Why should the shoulder be rotated during imaging?
    To assess the capsule and tendons from multiple angles and identify partial tears that may not appear in one position.
  • Why is the patient positioned upright for AC or shoulder joint imaging when possible?
    Upright positioning helps demonstrate separation, gravity-dependent contrast layering, and natural joint relationships.

Technique & Image Evaluation

  • How can you verify that contrast distribution is adequate?
    A uniform, thin coating of contrast outlines all intra-articular structures without pooling or voids.
  • How can you tell if contrast has leaked from the capsule?
    Extracapsular streaking or irregular borders suggest capsular tear or injection outside the joint.
  • How can you confirm the correct meniscus was examined during knee arthrography?
    The meniscus under study (medial or lateral) should be marked and centered in the collimated field, indicated by “M” or “L” lead markers.
  • How can you differentiate between single- and double-contrast images?
    Double-contrast studies show a thin bright coating of positive agent surrounded by radiolucent air for superior definition of soft tissues.

Clinical Applications

  • Why is conventional arthrography still occasionally performed when MRI or CT is available?
    It can be used when MRI or CT contrast agents are contraindicated, when aspiration is needed, or for evaluation of prosthetic joints and postoperative complications.
  • Why is arthrography contraindicated in patients allergic to iodinated contrast or local anesthetic?
    Because both substances are used in the procedure and could trigger severe hypersensitivity reactions.
  • How does arthrography complement MRI or CT?
    Fluoroscopic arthrography confirms joint access and contrast distribution before the patient is transferred for high-resolution cross-sectional imaging.

 

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Radiographic Procedures Review Guide Copyright © 2025 by Carla M. Allen and Taylor M. Otto. All Rights Reserved.

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