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Generic Joint Procedures (Fluoro)

June 2014 - Donna Magid, M.D., M.Ed.

JOINT PROCEDURES: 3 general categories, all (mis)posted as 'ARTHROGRAMS"; slight modifications of set-up:

  • ASPIRATION (r/o infection) 
  • PAIN STUDIES
  • GADOLINIUM for MRI or CONTRAST for CT

REFER to separate HIP and SHOULDER documents for positioning tips, etc.  MSK Radiology coverage (Faculty, Fellow) listed on weekly MSK Schedule, Sharepoint.

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Hip Procedures

Nov. 2012 - Donna Magid, M.D., M.Ed.

(‘ARTHROGRAM”: persisting common misnomer)

Hip‘arthrography’ is a vague term used to refer to multiple studies: Injection of Gad or radiographic contrast for MR or CT respectively, aspiration to r/o infection, or injection of Marcaine/steroids to test pain relief. MAKE SURE you know what is really requested.

*ASPIRATION requires culture material; joint fluid (>1 ml in Port-a-Cult); ‘dry taps’ require second attempt, injecting 5-10 cc nonbacteriostatic saline to both(hopefully) loosen up existing fluid and/or wash over affected surfaces before being re-aspirated..

*PAIN studies, inject 7-10 cc of (9 cc’s bupivacaine .5%, up to 2 cc Kenalog 40 (ie max of 80 mg in syringe, meaning less goes into patient—data supports risk of ostenecrosis at +100mg), 4-5 cc sterile water) .  Post-injection allow the patient to relax while you clean up the prep tray (remove needles, dispose of betadyne-stained gauze-- pts. mistake it for heme and get light-headed), then assist patient upright, let them sit there a moment to make sure not tachycardic, light-headed, etc (keep hands on pt’s upper arms, make eye contact, size up); assist off table, and ask him/her to ambulate around the room and to report their perception of change (remind them “Better or the same, test has no wrong answers”).  Ask them to make note of when, hours or days later, the hip returns to the usual baseline of pain, ‘like you felt yesterday”.

*MR Goal is “1:200” Gad:Dilutant” in syringe—actual concentration at MR once injected depends on how much joint effusion or other injected fluids (ie radiographic contrast from localizing) is already in the joint. About .1 cc Gad (in TB syringe) will be injected into tip of 20 cc syringe holding (7 cc Marcaine, 13 cc sterile water; or all sterile water).

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Shoulder Procedures

June 2014 - Donna Magid, M.D., M.Ed.

SHOULDER PROCEDURES include 4 different studies:

  • ASPIRATION to R/O Infection (most likely to be encountered overnight)
  • PAIN STUDY: Bupivacaine and Kenalog injection to test response
  • MRI or CT: gadolinium (immediately pre-MRI) or contrast (pre-CT)


ASPIRATION for Possible Infection:

“R/O P. Acnes” must be handwritten BIG on all forms—fastidious ‘bug’, special handling/10 day culture necessary.

BASIC:

  • 1.5" 25 gg needle (NOT the standard 5/8")                      
  • Basic Tray
  • 20 gg spinal needle (yellow)
  • 50 cm tubing
  • Lidocaine 2 % (drawn into 5 cc syringe—10 cc if huge patient)
  • 10 cc Omni or Hypaque w/ tubing attached and contrast run through to tube tip (tube = de facto ‘label’, distinguishing between clear fluids on table)
  • Betadyne in one of the two prep cups on standard tray
  • 16 gg purple needle to draw up meds and contrast
  • (2nd 5 cc syringe and yellow (20) gg needle-- to use if aspirate fluid obtained for culture)
  • IF PAIN STUDY ADD: Bupivacaine (~9 cc), Kenalogue 40 (one 1-cc bottle, ie 40 mg, shaken well), sterile water