11. Procedures

Question 1

In joint procedures, the target is the capsule, not the joint itself. What is the goal of the procedure?

Answer 1

To touch a bone within the capsule without causing contamination or damaging adjacent structures

Avoid putting air in the joint to prevent susceptibility artifact.

Question 2

What are the general steps for a hip joint procedure?

Answer 2

• Mark the femoral artery
• Internally rotate the hip to localize the femoral head-neck junction
• Clean and numb the skin
• Advance a 20-22 gauge spinal needle into the joint
• Inject a small amount of contrast to confirm position
• Put the rest of the contrast in

Contrast should flow away from the tip; if it stays, it’s not in the capsule.

Question 3

What is the trivia about the capsule in hip procedures?

Answer 3

Capsule is widest at the head-neck junction

The cocktail injected is around 14 cc total (4 cc Lidocaine, 10 cc Visipaque, and only about 0.1 cc Gd).

Question 4

What are the general steps for a shoulder joint procedure?

Answer 4

• Supinate the hand
• Clean and numb the skin
• Advance a 20-22 gauge spinal needle into the joint
• Pull back 1 mm and turn the bevel towards the humeral head
• Inject a small amount of contrast to confirm position
• Put the rest of the contrast in

Contrast should flow away from the tip; if it stays, it’s not in a space.

Question 5

What is the trivia about the cocktail injected in shoulder procedures?

Answer 5

The cocktail injected is around 12 cc total (4 cc Lidocaine, 8 cc Visipaque, and only about 0.1 cc Gd)

This is crucial for confirming the position of the needle.

Question 6

What are the three main reasons for putting a needle in a joint?

Answer 6

• Needs Arthrogram to Evaluate the Labrum
• Needs Steroid / Lidocaine Injection for Pain Management
• Possible Joint Infection - Needs Aspiration

Only the arthrogram will be imaged; the others just require correct needle placement.

Question 7

What should you do if a patient is allergic to Gd but needs an arthrogram?

Answer 7

Try a CT Arthrogram using Visipaque and Lidocaine

This avoids the use of Gd.

Question 8

What is the alternative if a patient is allergic to CT Contrast but needs a steroid joint injection?

Answer 8

Inject air into the joint to confirm placement, then inject the steroid

This method avoids the use of CT Contrast.

Question 9

If a patient is allergic to CT Contrast but needs an arthrogram, what are the options?

Answer 9

• Pre-medicate the patient
• Use the force and hope to get in the joint without confirming positioning with fluoro

Injecting air is not an option due to potential complications.