Unit 1 (Arthrography+)
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an invasive radiographic examination of the soft tissue structures of a diarthrodial joint by the introduction of a contrast media:
greek word for joint:
arthrography is largely being replaced by:
common joints that are examined through arthrography:
surgically viewing a joint through a scope:
name four contraindications to arthrography:
- skin infections
- anticoagulant therapy
- sensitivity to the dye
- sensitivity to the anesthetic
though unlikely, what is the most common type of reaction to arthrogram contrast:
- vasovagal response
- (other: allergy to anesthetic; inflammatory synovitis)
a nervous system (vasovagal) response can be the result of:
and the symptoms are:
- fright, pain, or trauma
- low blood pressure, nausea, perspiration, pallor
be familiar with these basic parts of an arthrogram tray:
- prep sponges
- gauze sponges
- fenestrated drape
- 1 50cc syringe
- 2 10cc syringes
- flexible connector
- hypodermic needles (18, 20, 21, 25)
- possible spinal needle
- 5ml ampule of anesthetic (xylocaine, lidocaine)
on an arthrogram tray, what usually goes in the different sized syringes?
- 50cc is usually for air
- 1 10cc each for the contrast and the local anesthetic
what images are routinely taken for an arthrogram?
- scouts are always taken
- fluoro images taken
- overhead images
swelling of a joint due to too much fluid:
three general types of contrast arthrography:
- pneumoarthrography (gaseous)
- opaque arthrography (water-soluble iodinated)
- double contrast arthrography (a combination of both gaseous and acqueous)
describe synovial fluid and its function:
- contained within synovial joints; clear, viscous fluid resembling the white of an egg
- reduces friction between the joints
name the most general indications for requiring arthrography:
- disease or traumatic injury to the soft tissue structures
- tears/ruptures of ligaments, tendons, articular cartilage, or of the joint capsule
an interarticular fibrocartilage of crescent shape located in the knee:
attach bone to bone:
attach muscle to bone:
located on weight-bearing surfaces of bones:
hyaline articular cartilage
a padlike sac or cavity found in connective tissue that reduces friction between tendon and bone, tendon and ligament, or between other structures where friction is likely
fibrous capsule that encloses the synovial joint space:
thapsulee site of nerve endings that send messages to the brain about position and movement:
connective tissue making up the inner surface of the fibrous joint capsule and produces the synovial fluid that lubricates the joint surface:
the only parts of the joint not covered by the synovial membrane:
- hyaline cartilage
- intra-articular disks
a non-traumatic pathologic process that can require a knee arthrogram:
what approaches may the doctor choos with needle placement for a knee arthrogram?
the least used method of arthrography of the knee:
a more common method of arthrography of the knee:
- (needs a fractional focal spot - .3mm)
name the method of arthrography of the knee that uses the following:
7 x 17” cassette
low small table or stand to support knee
5lb sand bag
what amount of air is commonly used in pneumoarthrogram and what is a risk specific to this procedure?
- 100-150mL of air (painful)
- risk of air embolism due to large amount of air
name the method of arthrography of the knee being described:
no greater concentration than 30%
patient is prone
stress device under femur
used to open up each side of joint space.
better distribution of contrast around meniscus
vertical ray method
for the vertical ray method of a knee arthrogram, describe how to better visualize a particular side of the knee:
- to outline medial side: stress laterally
- to outline lateral side: stress medially
describe fluoroscopy of the meniscus of the knee during arthrography:
- closely collimated views of each meniscus
- rotating leg 20 degrees between each exposure
- 9 pictures of each meniscus demonstrates the meniscus in profile throughout its diameter
how should the radiographer mark the images taken of the menisci of the knee during an arthrogram?
- M or L for medial/lateral
- right or left marker
name common projections taken for arthrography of the knee:
- 20 degree RPO
- 20 degree LPO
- intercondylar fossa
what type of contrast study is a horizontal ray method knee arthrography?
- double contrast
- 50cc low density positive medium
- 80-100cc negative medium
for the double contrast arthrogram of the medial meniscus, what is done after the 1st exposure?
rotate leg toward the supine position 30 degrees, and make six exposures for the medial side
name the arthrogram in which the following occurs.
the excess of the heavy iodinated solution drains into the dependent part of the joint. this leaves only a thin opaque coating on the gas enveloped uppermost part.
- knee arthrogram
- horizontal ray method
the ligament of the knee that originates on the anterior portion of the femur in the intercondyar notch and inserts on the posterior aspect of the tibial plateau:
name what is being imaged with the following criteria:
have patient sit with knee flexed 90 degrees over the side of the table.
a firm pillow is placed under the knee and adjusted so that forward pressure can be applied to the leg.
the patient holds a grid cassette in position and a slightly overexposed lateral projection is made.
ACL, as a part of a knee arthrogram study
name projections commonly taken during an arthrogram of the wrist:
- internal oblique
- external oblique
describe the amount and injection site of contrast for an arthrogram of the wrist:
- 1.5 - 4mL
- dorsal surface of wrist, where radius, scaphoid, and lunate join
what is the usual injection site for an arthrogram of the hip?
- 3/4" distal to inguinal crease and 3/4" lateral to palpated femoral pulse
- spinal needle used due to depth of joint
what is the most common reason for a hip arthrogram for an adult? for a child?
- adult, usually loose hip prosthesis
- child, usually for congenital hip dislocation
name a radiographic complication that can commonly occur for a hip arthrogram in an adult:
commonly for a loose prosthesis. cement, which contains barium, is usually involved. it looks like our contrast medium, so it is difficult to distinguish between the two.
name a solution to the problem of two positive agents interfering with each other during arthrography (ex. hip prosthesis containing cement):
what is the most common structure of interest in a shoulder arthrogram?
- the rotator cuff, partial or complete tear
- (also tear of glenoid labrum, persistent pain, frozen shoulder)
name the four muscles that join to form the rotator cuff of the shoulder:
- teres minor
name the contrast amount and injection site common for a shoulder arthrogram:
- single contrast: 10-12mL contrast
- double contrast: 3-4mL contrast, 10-12mL air
- 1/2" inferior and lateral to the coracoid process
- use spinal needle
how is the inferior portion of the rotator cuff best visualized during a shoulder arthrogram?
with the patient in an erect position
name the common projections taken during an arthrogram of the shoulder:
- AP internal rotation
- AP external rotation
- 30 degree AP oblique
- CT may follow arthrogram study.
what can be visualized on an arthrogram of the TMJ?
abnormalities of the articular disk (from trauma or stretched/loose posterior ligament)
name the contrast amount and injection site for an arthrogram of the TMJ:
- .5-1mL of contrast
- 1/2" anterior to tragus of the ear
name the study, position, and label:
- double contrast arthrogram of shoulder
- axillary projection
- A. coracoid process
- B. humeral head
- C. glenoid cavity
- D. opaque medium
- E. air pocket
a radiographic method used to evaluate the length or differences in length between long bones:
a premature fusion of epiphysis to shorten a bone:
name two treatment methods for length differences in long bones:
- control the growth of the normal side
- increase the growth of the shorter limb
how is epiphysiodeses accomplished?
by means of a metaphysial-epiphysial fusion at the distal femur or proximal tibia
the growing portion of the bone between the diaphysis and epiphysis:
how is the growth of a shorter limb increased?
- by surgically cutting the femur and/or tib-fib
- placing a frame around cut ends
- constant, gradual pressure separates bones
- takes a period of years
how is orthoroentgenography used for exact length of limbs?
- three exposures of each limb is made
- a taped ruler is placed between the limbs for bilateral images or beneath each limb for separate images
- center over joints and mark the area you are centering to on the skin
- do both sides for comparison mark both sides use skin marking pencil
name the three exposures made for exact limb length for the lower extremity:
- 1st exposure: Hip (center over)
- 2nd exposure: Knee
- 3rd exposure: Tibiotalar joint
- Do not move limb or ruler in between exposures.
- Change techniques from 1 joint to the other.
- Narrow collimation.
where do you mark the hip when measuring for limb length?
1-1 1/4" laterodistally at a right angle to the midpoint of an imaginary line extending from the ASIS to the symphysis
where do you mark the knee when measuring for limb length?
area below apex of patella at the level of the depression between the femoral and tibial condyles
where do you mark the ankle when measuring for limb length?
area directly below the depression, midway between the malleoli
when is orthoroentgenography not quite effective and why?
- when there is more than a slight discrepancy in lengths of limbs
- because it is not possible to place the center of the x-ray tube exactly over both knee joints or exactly over both ankle joints and make a single exposure.
what occurs when you center midway between the two joints during orthoroentgenography, to compensate for a larger discrepancy in limb lengths?
bilateral distortion due to the diverging x-ray beam
a form of orthoroentgenography that attempts to reduce magnification by putting the part close to the film and using a long SID:
where do you mark the shoulder when measuring for limb length?
the shoulder joint over the superior margin of the head of the humerus
where do you mark the elbow when measuring for limb length?
joint at 1/2 - 3/4" below the plane of the epicondyles
where do you mark the wrist when measuring for limb length?
area midway between the styloid process of radius and ulna
what are the advantages of using CT for long bone measurement (in which a scanogram/scout is used)?
- it can be more consistently reproduced
- place cursors over joints and measure from joint to joint
- radiation dose is 50-200 times less than conventional radiography
- it takes about the same amount of time
the formation of bone substance; the conversion of other tissue into bone:
shaft/body of long bones:
the ends of long bones:
primary and secondary centers of bone formation/ossification:
- primary: diaphysis (appear before birth)
- secondary: epiphysis
the space between the diaphysis and epiphysis that is made up of cartilage:
describe the progression of the epiphyseal plates of long bones:
present until skeleton growth is complete upon full maturity, which is normally at about 25 years
what is the most common radiograph taken to calculate bone age?
PA projection of the hand and wrist
in determining bone age, the degree of maturation is determined by:
the size, appearance, and differentiation of the various ossification centers
name some variations that can contribute to differing degrees of maturation among individuals:
- gender (recognized by charts)
- genetic diversity
- nutritional status
bone age protocols for ages 1-2 often include:
- a knee (usually the left)
- sometimes a foot
what is the last bony structure to ossify?
the epiphysis of the iliac crest
closure of the fontanels:
what projections are sometimes taken to demonstrate the closure of the fontanels?
AP and lateral skull
what is sometimes requested in amenorrhea to estimate developmental age?
a lateral view of the sella turcica
when a series of films is taken of various parts of the skeletal system to detect abnormalities:
name indications for a skeletal survey:
- degenerative conditions
- suspected child abuse
why should a babygram be avoided in a skeletal survey?
there is distortion because of improper centering, scatter, and underexposure and overexposure all play a part in the degradation of the image
be familiar with the projections commonly taken for a skeletal survey:
- AP and lateral skull
- AP and lateral complete spine
- AP both humeri
- AP both forearms
- PA both hands and wrists
- AP pelvis
- AP both femora
- AP both tib/fib
- AP both feet
- AP chest for ribs (table, low kVp)
- Lateral chest for ribs (table, low kVp)
any object that enters the body that is not part of the body:
only _____________ foreign bodies can be visualized.
if an object enters the mouth, it may be ___________ or ____________.
give four very basic guides for radiographing to locate a foreign body:
- images should be taken in two planes
- remove all thick wound coverings before taking images
- get permission first
- only a thin layer of gauze should be left
give the # of types of glass, which glass types might show up on radiographs, and which glass types will not show up:
- 70,000 types of glass
- might be visible: containing lime or metallic oxide (iron, gold, lead, copper)
- not visible: glass with more silicon
the simplest and most commonly used method for localizing penetrating foreign bodies:
right angle projections
_________ projections can separate overlapping structures in any body region and prove especially useful when the image of the foreign body is superimposed by bone
________ projections can demonstrate whether the object is embedded in the bone or is lodged in the adjacent soft tissues
____________ projections are useful in the evaluation of superficial foreign bodies in the limbs
name the situation in which you follow these steps:
direct the central ray exactly through the foreign body, taking right angle views
oblique projections can separate overlapping structures in any body region and prove especially useful when the image of the foreign body is superimposed by bone
smaller parts of limbs where the foreign body is often near the site of entry
in localizing a foreign body in the hand, what lateral projection is used?
straight lateral, not fan lateral
In adults the most frequent foreign body
- fragments of fish or chicken bones
- a bolus of solid food
- dental appliances
when an object enters the mouth and starts the gag reflex, what can happen instead of expulsion of the object?
the foreign object may be dislodged from the oral pharynx upward into the nasopharynx
If aspirated into air passages, a foreign
body will be located:
above the diaphragm in the neck or chest
when there is any doubt of foreign body, particularly in the case of infants and young children, the preliminary radiographic survey should include:
- the body of the patient from the level of the highest external body orifice to the lowest
- (ears to anal canal)
- include neck, chest, abdomen, pelvis
Radiolucent foreign bodies require:
a contrast medium to coat the object or localize the site of foreign body obstruction and determine the condition of soft tissues at the point where the object has lodged
Because an aspirated object can be quickly drawn into a distal branch of the airways, the initial radiographs of infants and young children should be large enough to include:
the entire respiratory system
small, aspirated foreign objects sometimes pass on to block one of the smaller bronchial branches and exact localization of the site sometimes requires:
in aspirated foreign body localization, what projection can be especially useful to examine patients who are short-necked and high-shouldered?
- lateral projection of trachea and mediastinum
- (CR to the laryngeal prominence and decrease the technique to better visualize soft tissue areas)
a procedure to locate aspirated, radiolucent foreign bodies using a contrast medium under fluoroscopic visualization:
why might you need to take an inspiration and an expiration radiograph for a foreign body?
- to determine if airflow is completely blocked to that part of the lung
- (blocked if no change in air)
what are the two most routine projections taken for a swallowed foreign body?
- RAO of esophagus
- AP of abdomen
for non-opaque foreign objects, what contrast medium is best and why?
- water-soluble iodinated contrast is best because it won't adhere to the foreign body and interfere with its removal
- barium solution contrast would make the foreign body slippery and difficult to grasp and remove with the esophagus scope
what should be done in the preliminary exam
if a young child is brought into the examining room and it’s not certain whether the foreign object has been inhaled into the respiratory system or swallowed?
- A patient’s symptoms will usually tell whether an object has been inhaled or swallowed
- but if it’s not clear, taking a preliminary radiographic survey is essential
- the survey must include the body of the patient from the level of the uppermost external orifice to the lowest
into which bronchus is an aspirated object most likely to become lodged?
the right bronchus because of its larger diameter and more vertical direction
what procedure should be followed to examine a child who swallowed a smooth foreign object?
preliminary images of the entire alimentary canal would be needed, along with follow-up radiographs at 24-hour intervals until the object has passed through the body
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