Quick summary

Fluoroscopic arthrography uses direct intra-articular contrast injection to confirm needle placement before MR arthrogram or to provide diagnostic information about joint integrity. The fluoroscopic component confirms intra-articular position; MRI or CT provides the primary diagnostic images.

Indications

MR arthrogram preparation: Joint injection to distend the capsule and improve detection of internal derangement (labral tears, ligamentous injury, loose bodies)
Diagnostic arthrogram: Rotator cuff tear (full-thickness), TFCC tear (wrist), ankle ligamentous injury
Post-arthroplasty evaluation: Suspected loosening or periprosthetic infection — arthrogram + joint aspiration
Therapeutic injection confirmation: Corticosteroid or anesthetic injected under fluoroscopy for confirmed intra-articular delivery

Contraindications

Contraindication	Notes
Active joint septic arthritis	Aspiration for culture is indicated; do NOT inject contrast or gadolinium
Allergy to iodinated contrast	Use alternative approach (MRI without arthrogram, US-guided)
Overlying cellulitis or skin infection	Avoid injection through infected tissue
Coagulopathy	Relative; discuss with referring physician; aspirin/NSAIDs generally held 5 days

Joint-Specific Access and Injection Protocol

MR arthrogram mixture (all joints): 0.1 mM/mL gadolinium — practical recipe per 14 mL: 0.1 mL gadolinium (e.g., gadobutrol or gadopentetate) + 0.5 mL Omnipaque 300 + 13.4 mL normal saline. The Omnipaque allows fluoroscopic visualization of the injectate.

Needle: 22-gauge spinal needle for all joints. Confirm intra-articular position with 0.5–1 mL Omnipaque 300 before injecting the full arthrogram volume.

Joint	Approach	Key Landmark	Total Volume (MR Arthrogram)
Shoulder	Anterior (rotator interval)	Inferior glenohumeral joint; coracoid–humeral interval	12–14 mL
Hip	Anterior (femoral neck)	Junction of medial femoral neck and head; avoid femoral neurovascular bundle medially	12–14 mL
Wrist	Dorsal radiocarpal	Scapholunate interval or radioscaphoid joint; 3–4 cm distal to Lister's tubercle	3–4 mL
Ankle	Anteromedial or anterolateral	Talar dome; tibiotalar joint space	8–10 mL
Elbow	Posterior (olecranon fossa)	Olecranon fossa with elbow flexed 90°; needle directed anteriorly into trochlear notch	8–10 mL
Knee	Lateral subpatellar or medial	Subpatellar fat pad; suprapatellar for aspiration of effusion	30–40 mL

Wrist injected volume is small. The radiocarpal compartment holds only 3–4 mL — resistance is felt quickly. Stop injecting if resistance increases before target volume; overdistension causes capsular rupture and contrast extravasation that can obscure compartment communication findings.

Joint Images — Needle Placement and Post-Injection

Fluoroscopic image showing needle placement for shoulder arthrogram at the inferior glenohumeral joint — Shoulder — needle placement (anterior, rotator interval approach)

Shoulder arthrogram post-injection showing intra-articular contrast distribution in the glenohumeral joint — Shoulder — post-injection, intra-articular contrast distribution

Fluoroscopic image showing needle placement at the medial femoral neck for hip arthrogram — Hip — needle placement (anterior femoral neck approach)

Hip arthrogram post-injection showing contrast within the hip joint capsule — Hip — post-injection, joint capsule distension

Fluoroscopic image showing needle placement in the radiocarpal joint for wrist arthrogram — Wrist — needle placement (dorsal radiocarpal approach)

Wrist arthrogram post-injection showing contrast within the radiocarpal compartment — Wrist — post-injection, radiocarpal compartment

Fluoroscopic image showing needle placement at the talar dome for ankle arthrogram — Ankle — needle placement (anteromedial tibiotalar approach)

Ankle arthrogram post-injection showing contrast within the tibiotalar joint — Ankle — post-injection, tibiotalar joint

Fluoroscopic image showing posterior needle placement in the olecranon fossa for elbow arthrogram — Elbow — needle placement (posterior olecranon fossa approach)

Elbow arthrogram post-injection showing contrast within the elbow joint — Elbow — post-injection, elbow joint distension

Fluoroscopic image showing lateral subpatellar needle placement for knee arthrogram — Knee — needle placement (lateral subpatellar approach)

Knee arthrogram post-injection showing contrast within the knee joint — Knee — post-injection, knee joint distension

Intra-Articular Confirmation

Intra-articular vs. extra-articular contrast distribution is the key fluoroscopic finding. Intra-articular: contrast flows freely along articular cartilage, fills joint recesses and capsular attachments. Extra-articular: contrast pools in soft tissue planes without joint recess filling — reposition needle before injecting diagnostic volume.

Pattern	Interpretation
Free flow along articular cartilage; fills joint recesses	Intra-articular — proceed with full injection
Soft tissue pooling; irregular tracks in fascial planes	Extra-articular — reposition
Resistance to injection	Extra-articular or needle tip against cartilage/bone — withdraw slightly
Contrast flows into bursa	Bursal communication (rotator cuff full-thickness tear if subacromial; TFCC tear if DRUJ communicates with radiocarpal)

Key Diagnostic Findings

Shoulder

Finding	Fluoroscopic Appearance
Full-thickness rotator cuff tear	Contrast fills the subacromial/subdeltoid bursa = communication with glenohumeral joint through full-thickness tear
Biceps tendon sheath filling	Normal — the long head biceps tendon sheath communicates with the glenohumeral joint
Capsular adhesion (frozen shoulder)	Reduced joint volume; capsule does not distend; obliteration of axillary and subscapularis recesses
Labral tear (SLAP/Bankart)	Not diagnosed on fluoroscopy — MR arthrogram images are diagnostic

Wrist

Finding	Fluoroscopic Appearance
TFCC tear	Contrast from radiocarpal joint fills the distal radioulnar joint (DRUJ)
Scapholunate ligament tear	Contrast from radiocarpal joint fills the midcarpal compartment through the scapholunate interval
Lunotriquetral ligament tear	Contrast fills midcarpal from radiocarpal through lunotriquetral interval

Post-Arthroplasty

Finding	Significance
Contrast tracking along prosthesis-bone interface	Loosening (confirm with delayed fluoroscopy; contrast should clear in intact prosthesis)
Fistulous tract to adjacent soft tissue	Periprosthetic infection — aspirate joint fluid for culture before injecting contrast
Communication with adjacent joint or bursa	Erosion of joint capsule

Post-arthroplasty arthrogram uses iodinated contrast only — no gadolinium. Joint aspiration should precede contrast injection when infection is suspected; send fluid for cell count, Gram stain, culture, and crystal analysis.

Reporting Checklist

Joint accessed: (name, approach)
Needle: 22-gauge spinal
Intra-articular confirmation: confirmed by free contrast distribution / soft tissue injection (if occurred, note and document repositioning)
Omnipaque 300 test dose: volume used (mL)
Total arthrogram volume injected: (mL) — gadolinium/Omnipaque/saline mixture
Bursal communication (shoulder): absent / present (subacromial = full-thickness RCT)
Compartment communication (wrist): absent / present (DRUJ = TFCC; midcarpal = SL or LT)
Post-arthroplasty: prosthesis-bone interface — no contrast tracking / contrast tracking (loosening)
Joint aspiration: volume obtained / sent for: cell count / culture / crystals (if applicable)
Patient transferred to MRI / CT for arthrogram sequences

Common Pitfalls

Pitfall	How to Avoid
Extra-articular injection	Use small test dose (0.5–1 mL) under fluoroscopy before injecting full volume; confirm distribution pattern before proceeding
Shoulder: missing subacromial bursal fill	If evaluating for RCT by arthrogram, upright positioning after injection shows bursal fill better; take fluoroscopic images in multiple positions
Gadolinium overdose	Standard MR arthrogram concentration is 0.1 mM/mL (highly diluted) — do not inject undiluted gadolinium intra-articularly; causes synovitis and cartilage damage
Post-arthroplasty: contrast in cement mantle mistaken for loosening	Cement mantle may have defects that fill with contrast without true loosening; compare with prior films; delayed imaging (15 min) helps distinguish true interface tracking from cement defects
Wrist: wrong compartment	Wrist has three compartments (radiocarpal, midcarpal, DRUJ) — each must be entered separately for complete three-compartment arthrogram if indicated; inadvertent midcarpal entry misses radiocarpal pathology

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Arthrography — Interpretation and Findings