MUSCULAR SKELETAL SYSTEM

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MUSCULAR SKELETAL SYSTEM
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ARTHROGRAPHY

• Exam of joints and soft tissue using contrast
  medium and x-ray
• Includes hip, knee, ankle, shoulder, elbow,
  wrist, TMJs
• Technique is basically same for all areas
• Shoulder and knee most common

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Synovial Joints

• Permit free movement of joints
• Synovial Fluid- lubricant
• Resembles egg white
• Nourishes Hyaline cartilage
• Joint space enclosed in joint capsule

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KNEE ARTHROGRAM( pp. 754- 757)

• Pathological Indications
• Joint capsule injuries/ cartilage tears
• Meniscus tears
• Ligaments tears ( cruciate and collateral)
• Loose bodies

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• Bakers cyst- Nontraumatic pathology, cyst in
  posterior region
• Contraindications
• Contrast allergy
• Anethesia allergy
• Somewhat replaced by Arthroscopy and MRI

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Contrast Agents

• Double contrast arthrograms- best method
• Smaller amounts of both contrast used
• Negative- provides background
• Positive- coats joint space, outlines anatomy w/o
  obscuring pathology

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• Patient Prep
• Explain the procedure
• Have consent form signed
• Sterile technique used
• Area will be cleaned w/ antiseptic

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Equipment

• Arthrogram Tray (disposable)
• Fenstrated drape
• 1- 50 ml syringe
• 2- 10 ml syringes
• Flexible connector
• 18,20,21,25 gauge needles, local anesthetic,
  gauze
• Sterile gloves
• Contrast
• Ace bandage

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NEEDLE PLACEMENT AND INJECTION

• Retropatellar, lateral or medial area ( doctors
  preferrence)
• Needle inserted
• 10 ml syringe fluid from joint aspirated
• If normal appearance- discarded
• If abnormal (cloudy)- sent to lab to assess

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• Inject positive contrast and air if double
  contrast ( patient may feel a fullness)
• Once injection finished, needle is removed
• Ace bandage wrapped around distal femur used to
  provide lateral and medial stress to open up
  joint to see meniscus

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• Fluoro and rotate leg 20 degrees between each
  image
• Meniscus seen on all 9 exposures
• Field is collimnated and meniscus centered

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• Radiographs taken w/ horizontal beam
• Leg rotated 30 degrees between each exposure
• 6 views of a meniscus
• Demonstrated in different profiles

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SHOULDER ARTHROGRAM(pp. 758, ch. 23)

• Demonstrates joint capsule
• Rotator cuff (formed by conjoined tendons of 4
  major shoulder muscles)
• Biceps muscle (tears)
• Foreign bodies

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Equipment Needed

• Fluoroscopy
• Contrast ( water- soluble)
• 2 ½ to 3 ½ in. Spinal needle ( depth of joint
  space)

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NEEDLE PLACEMENT AND INJECTION

• Site prepared
• Fluoro guidance for needle placement
• Area anesthetized
• Small amount contrast injected to check bursa
• Full injection and filming begins

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• Contrast
• Single or double contrast
• Needle removed
• Positioning
• PA erect or supine
• AP
• Int/ext rotation, axillary, glenoid fossa

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• If there is a normal appearance, patient told to
  exercise shoulder and films repeated
• Caudal 15-23 degree angle may be used on AP

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LAMINECTOMY(pp. 645-648)

• What are Lamina?
• Where are the Lamina?
• Where are the Pedicles?
• Failure of Lamina is called what?

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• Lamina (2)
• Posterior and medially from pedicle
• Broad flate plates
• Meet in back to complete arch
• Spina Bifida

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• Surgical procedure to alleviate pain from
  impingement (nerve)
• Removal of bone or herniated disk
• Gives nerve root more space
• Depending on vertebrae , spinal fusion may be
  necessary (why?)

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• Titanium cages may be inserted to maintain disk
  space
• Spinal stenosis- degenerative change that causes
  a narrowing in the spinal canal
• Pressure on nerves

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• Equipment used is C-arm or x-table spine films
• Role of radiographer- confirm level for
  laminectomy or guidance for placement of hardware

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VERTEBROPLASTY( p. 714)

• Treatment for vertebral pain
• Instability from osteoporosis
• Spinal metastasis
• Compression fractures
• Tumors

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• Injection of acrylic cement into vertebral body
  under fluoro
• When the cement left in container hardens ( the
  cement hardened inside)

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KYPHOPLASTY(p. 715)

• Modification to vertebroplasty technique
• Small incision made
• Balloon inserted into collapsed vertebral body to
  restore height
• Cement injected to stabilize body

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RISKS AND COMPLICATIONS

• Leakage of cement
• PE caused by migration of cement into
  perivertebral veins
• Kyphoplasty has less complications due to less
  cement and more controlled injection

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BONE AGE(p. 654)

• Left PA hand and wrist
• Presence or absence of ossification centers
• Configuration/ fusion of epiphysis
• Various carpals and parts of radius and ulna can
  take years to develope

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METASTATIC SURVEY(p. 142)

• Skeletal metastasis can develop without symptoms
• Nuclear medicine study bone scan- is the first
  step
• IV injection of radionuclide followed by body
  scan reveals hot spots

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• Areas of increased activity indicate abnormal
  lesion ( x-rays adjunct)
• SPECT can be used to locate lesions within the
  joints
• Radiographs for bone survey include skull, long
  bones, spine

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DEXA SCAN(p. 777-783)

• DEXA scanning (Dual Energy X-ray Absortiometry)
• Method used to assess bone mineral density (BMD)
• Aids in diagnosis of osteoporosis
• Can show bone loss in early stages
• Assess fracture risk
• Early detection can decrease healthcare costs

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• Candidates for DEXA scan
• People w/ bone disease
• Estrogen deficient
• Vertebral abnormalities
• Long term steroid users
• Hyperparathyroid
• Monitor of drug therapy for osteoporosis

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• Bone is living tissue and changing constantly
• Young- bone is actively growing
• Age 35- more bone is removed than replaced
• Increased age- bones are thinner and weaker
• Bone mineral content (BMC) measure of quantity
  or mass of bone
• BMD is the ratio of BMC to area

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• The amount of energy measured is related to bone
  mass
• DEXA popular method
• Documents small changes in bone mass
• Flexible can measure spine and extremities
• Less expensive
• Less radiation
• Can gauge changes from drug therapy

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• Use of the dual energy x-ray attenuation to bone
  and soft tissue
• Soft tissue number is subtracted from bone and
  numbers compared to T and Z score data

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• T-Score- compares the patient w/ an average
  young, healthy individual with
• Peak bone mass
• Z-Scores- compares patient w/ an average person
  of the same age and sex

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• Patient lies supine on table
• Machine similar to C-arm
• Considered low radiation dose / benefits high
• Scout done (positioning and artifacts)

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• Site analyzed and mineral report collected
• Bone mineral image
• Bone density measurements
• Standard readings
• Pt. info.
• Quality control data

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• Drug therapy recommended
• T- score of -2 without other risk factors
• T- Score of lt -1.5 if other risk factors present
• Drugs used
• Inhibitors to bone resorption
• Stimulation of bone formation

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Other Methods

• Quantitative Computed Tomography (QCT)
• Costs more
• Shows trabecular and cortical bone
• Allows 3-D volumetric analysis

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• Quantitative Ultrasound ( QUS)
• Non-ionizing
• Assess BMD in peripheral sites
• Used where minimal soft tissue covering like os
  calcis

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• Precision or Reproducibility important
• Influenced by
• Pt. motion
• Body habitus
• Pt. positioning
• Placement of region of interest