ARTHROGRAM

SINOGRAM/FISTULOGRAM
BRONCHOGRAM

Dr. Vikash Kr Gupta

Senior Resident/Lecturer
Department of Radiodiagnosis and Imaging
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 ARTHROGRAPHY
Radiological examination used to demonstrate either the articular
cartilage or the boundaries of synovial space following administration of
contrast media into the joint space followed by X-ray examination of the
joint.

Used to obtain diagnostic information regarding the

– Joint space
– Surrounding soft tissue
– Cartilage
– Lesions of the menisci
• Delineates the joint space and its surrounding structures

Why ?
The inability of plain radiography to demonstrate either the articular
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the boundaries of a synovial space
ANATOMY

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 Indications

 - Suspected injury of meniscus (tears)

 – Suspected capsular damage
 – Rupture of articular ligaments
 – Cartilaginous defects
 – Arthritic deformities (specifically TMJ)
 – Congenital luxation ( dislocation) of hip
 – Extent of damage from trauma

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 Contraindications
– Hypersensitivity to iodine

CT and MRI have largely replaced arthrography

- Noninvasive

Useful in diagnosing
– Abnormalities of the articular disc

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 Shoulder

Glenohumeral joint
 Patient is lying supine with the extended arm externally rotated.

 The transducer is placed ventrally parallel to the long axis of the

subscapular tendon.

 Local anaesthetics are not needed if needles are used with a

diameter of 21-gauge or thinner.

 one may need to use a larger bore needle due to high viscosity of
the aspirate. In such cases local anaesthetics are indicated.

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 50mm needle is used connected to a syringe containing the
contrast media, injects 15-20mL of the contrast medium.

 The needle is advanced perpendicular to the medial edge of

the humeral head, penetrating the subscapular tendon.

 No resistance to injection should be felt and one should see

the contrast flow freely into the joint.

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 Elbow
 For injection of the elbow the patient is supine with the arm in
90◦ flexion, raised and resting on a cushion. The joint space
between the radial head and the capitulum is easily palpated.

 The hand is pronated or may be turned into the thumb up

position, which is necessary to open the joint maximally.

 The transducer is placed over the joint visualizing the joint

space. The needle (22 gauge, 30 mm) on the dorsolateral side of
the joint toward the joint space aiming toward the articular
surface of the radial head.

 5-8 mL of contrast media is injected. No resistance to injection

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 Wrist

 The patient is supine with the wrist resting flexed over

45◦ sponge or a rolled-up towel.

 In some cases it may be helpful to hold the wrist in ulnar

deviation in order to open the joint space even more.

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 The space between the radius and the scaphoid is
identified on ultrasound.

 A 23-25-gauge, 30 mm needle is advanced under

ultrasound guidance into the joint directed toward
the articular surface of the radius until one feels
contact with the radius.

 After ensuring that the tip of the needle is free from

the radial cartilage 2-4 mL contrast is injected.

 The bevel of the needle is facing toward the joint

space and the contrast is seen to flow into the joint.
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 Knee
Indications for CT or MR arthrography of the knee are:-

 evaluation of the post-operative meniscus.

 Intra-articular bodies/ loose bodies.
 evaluation of the stability of osteochondral lesions
 Evaluation of articular cartilage.
 Inject medication such as corticosteroids and/or a local
anaesthetic.

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 For injection we generally do not use ultrasound guidance
but use the standard "blind" procedure introducing the
needle (21-gauge, 50 mm) behind the patella using a
lateral midpatellar approach.

 The patella is lateralized and the needle introduced from

the mid lateral side aiming toward the centre of the
patella.

 The needle is introduced horizontally aiming posterior to

the centre of the patella.

 40 mL contrast media is injected.

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 Hip
 The patient is placed supine.

 The leg is held in slight internal rotation and abduction.

 Preferably a 3.5-5 MHz curved array transducer is used, which

provides the necessary penetration depth.

 Usually a 21 gauge needle with a length of 9 cm is used for the

average adult.

 In smaller adults or children a 23-gauge, 5 cm needle might be

used.

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 Local anesthetic may be injected prior to the main injection.
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 Three-way connector between the two syringes containing
the anaesthetic and the injection fluid (contrast or
medication).

 The needle is advanced at a caudo-cranial angle along the

long axis of the transducer aiming for the anterior recess
near the junction of the femoral neck with the femoral
head.

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 The bevel of the needle should be facing toward the joint.

 When the needle makes contact with the femoral head-neck

junction it is slightly retracted.

 10-15mL contrast or medication is injected.

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 FISTULOGRAM
A Fistulogram is an radiological / imaging procedure used to view a
fistula following administration of contrast media.

An abnormal passage between two or more anatomic spaces or

organs or a pathway that leads from an internal cavity or organ to
the surface of the body.

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 SINOGRAM
A Sinogram is a radiological/ imaging procedure done to assess a sinus
following administration of contrast media.

An abnormal passage or cavity that originates or ends in one opening,

often on the skin.
Contrast material is used to help identify the start of the fistula/sinus,
its pathway and what organs are involved.

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 INDICATION
 Diagnose and assess the size and shape of fistulas and sinuses
 Prepare a treatment plan.
 Fistulas usually involve hollow organs like the intestines,
bladder, urethra and vagina.
 Fistulograms are used to assess many types of fistulas,
including those that form between: two loops of intestine the
anal canal and skin near the anus the vagina and another body
part such as the colon, rectum, small intestine or bladder.
 Used to assess abscess collections post-drainage and to
determine whether there is a persistent communication from
the collection to any surrounding structures.
 Additionally, fistulograms are used to assess deliberately
created fistulas in people receiving kidney dialysis.
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 CONTRAINDICATION

 Hypersensitivity to iodine

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 Procedure
 Performed after the drainage of an abscess to assess the size of the
cavity and any fistulous connection to bowel or sinus tracts. (Some
cavities are flushed with saline )
 
 Before performing the procedure, ask the patient about the amount of
drainage per day and check the previous sinogram to estimate cavity
size.

Equipment
 Contrast:
 Hypaque 30% (Omnique used commonly )
 
 Tubes:
 Use the existing drainage catheter/red rubber catheter or small angiocath
sheath (for fistulagrams)

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 Techniques
 Take AP and lateral scout views of the cavity area. 
 Inject Hypaque slowly and watch for the sinus tracts, fistula and size of cavity
 
 Do not over inject or forcefully inject contrast
 
 The maximum cavity capacity is reached when the following occurs:
 the patient develops pain or discomfort
 contrast tracks along the catheter onto the skin surface
 Fistulas, sinus tracts or extravasation occur
 
 Take representation radiographs to show:
 cavity size
 cavity depth from the skin
 sinus or fistula tracts
 
 At the end of the exam, aspirate all the contrast out of the cavity
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 Pearls

 Do not over-distend the cavity

 
 With fistulagrams, you can occlude the Foley catheter opening
(may inflate the balloon) to prevent contrast leakage
 
 Lateral view radiographs are important to assess cavity depth
 
 Scout radiographs are important in assessing the presence of
surgical clips or contrast from previous exams which may mimic
sinus tracts or extravasation.

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AP sinogram view of a pelvic
abscess drained. The cavity is
completely obliterated.
Lateral Orthogonal sinogram view of a
pelvic abscess. There is a sinus tract
extending anteriorly (not shown on AP
view).
 
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AP view of a sinogram of a Tubo-ovarian abscess. AP view of a sinogram of a Tubo-ovarian abscess.
Initial study shows the collapsed fallopian tube. On further distension the patient had severe pain
causing her to place her hand over the site (see
the hand).
 

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AP view with adequate filling of abscess cavity showing a fistula to the pouch (see
contrast at the tip of the Medina catheter within the pouch).

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Limitations of Fistulogram/Sinogram

 May not be possible in every patient due to medical and/or technical

reasons.
 The procedure may fail to define the presence of disease upstream or
downstream from the fistula, which may be necessary for appropriate
treatment planning.
 The procedure may fail to provide the anatomic location of the fistula
within the gastrointestinal tract.
 Edema, debris, or a large abscess may hinder fistulograms by blocking the
flow of contrast material.
 Fistulograms are not recommended if sepsis is present—a potentially life-
threatening response to infection.
 Contrast-enhanced CT may be able to identify connections from the bowel
to any surrounding structures or skin.
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 Bronchography
 Is a contrast study for demonstration of the broncho-
pulmonary tree/segment.

 Initially, it was the definitive diagnosis for bronchiectasis.

 However the advent of CT

especially high resolution CT (HRCT) had almost push
bronchography out of use recently

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 Indication
 Bronchiectasis
 Bronchial obstruction - site & extent
 Other possible indications -when other imaging
modalities are negative includes:
 Recurrent Haemoptysis Bronchopleural fistula
 Congenital lesions - agenesis & sequestration.

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 Contraindications
 Acute respiratory infection
 Poor respiratory reserve
 Others
Massive haemoptysis,
Active PTB & hx of allergy

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 Materials & Methods

Materials
Fluoroscopic
 unit with overcouch tube and Catheter
Contrast media - LOCM (lotrolan-300) 2- 3ml per lung

segment; <25ml/patient

Methods - 4 types
Catheter
Cricothyroid puncture - not for <12yr old
Bronchoscope
Dribbling contrast over the back of the tongue not
reliable and already abandoned
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Patient preparation

Chest
 physiotherapy
NPO for 6hrs prior to procedure

Pre-medications - 0.6mg Atropine & Morphine

Asthmatics should have steroid prophylaxis &

salbutamol pre-procedure

Preliminary
 films
PA & Lateral
 Technique

 Local anaesthesia agent application to the nasal, oral & larynx (including
the vocal cords) in form of lozenges and Xylocaine spray
 Depending on the method, the catheter is advanced through'the
nasal/oral cavity , through the larynx and well down the trachea
 The catheter is then secured by taping to the patient's cheek
 Each side is usually done in turns
 Upper lobe (right) - patient lies on his/her Rt side with head up. Contrast
agent is injected briskly and the pt tipped head down, then turns semi-
prone and then semi-supine
 Lower Lobe (right) - patient leans to the right and bends forward. After
contrast injection, pt will swing sideways and then backwards
 Films
 Preliminary film are repeated & then additional views - 45° RPO & LPO for
the left side
 Aftercare
 Coughing/chest physiotherapy
 NPO till anaesthesia wears out - to prevent aspiration
 Patients that used cricothyroid puncture are advised to press on the site
while coughing to make coughing effective
 24hrs post-procedure CXR to view residual contrast is usually done

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 Complications

Due to Contrast

Nausea, vomiting, pyrexia, headache,etc

Bronchospasm
Impaired respiratory fxn
Segmentalcollapse
Allergic rxn - !LOCM
Technique

Subcutaneous emphysema
Haematoma
Tracheal injury
Soft tissue injury
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Chest x-ray followed by barium
bronchogram demonstrating a
double contrast image of the
bronchial tree. Fortunately for
everyone, especially the patients,
the advent of CT has made this
bronchograms purely of historical
interest. 

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THANK - YOU

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