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Ortho Test 1-musculoskeletal lab/imaging*
Terms in this set (90)
What are the antibodies that attack substances found in the nucleus of cells?
Antinuclear antibodies (ANA)
Indications of antinuclear antibody (ANA) test?
test is used as a primary test to help evaluate a person for autoimmune disorders that affect many tissues and organs throughout the body (systemic) and is most often used as one of the tests to help diagnose systemic lupus erythematosus (SLE)
How is Antinuclear antibodies (ANA) testing done?
Venous blood flow
Qualitative enzyme linked immunosorbent assay (ELISA)
Detection=positive, none detected=negative.
If positive perform indirect fluorescent assay
Errors of ANA labs?
Anti-human IgG-specific conjugate since normal people have low levels of ANA-IgM
Conversion of ANA IgM to IgG generally precedes the onset of autoimmune disease states
What is rheumatoid factor (RF)?
proteins produced by your immune system that can attack healthy tissue in your body. High levels of rheumatoid factor in the blood are most often associated with autoimmune diseases, such as rheumatoid arthritis and Sjogren's syndrome
How is rheumatoid factor (RF) testing done?
Venous blood draw
Order w/ cyclic cintrullinated peptide (CCP)
Have pt fasting
Limitations of RF?
Only found in 20% of pts w/ juvenile rheumatoid arthritis
Interpretation of Rheumatoid factor (RF)?
Normal level- 0-14 IU/mL
Increased in 80% of pts w/ classic or definite rheumatoid arthritis
What is anti-cyclic citrullinated peptide (anti-CCP) antibody, IgG?
Antibody found in serum of pts w/ rheumatoid arthritis but NOT in pts w/ other joint or soft tissue diseases
How is Anti-CCP drawn?
Typically ordered w/ RF, testing for RA is much more sensitive that way.
If anti-CCP is negative, and RF is positive, how do you determine dx of RA?
S/sxs become more vital in determining the dx of RA
Errors w/ anti-ccp?
Don't use urine or plasma
Interpretation of anti-ccp?
Present in 69-83% of pts w/ rheumatoid arthritis- specificity 93-95%
May be present in the latent phase of disease, associated w/ future RA development and may predict radiographic joint destruction
What are anti-neutrophil cytoplasmic antibodies (ANCA)?
IgG autoantibodies directed against antigens found in the cytoplasmic granules of neutrophils and monocytes. ANCA testing is usually performed to help diagnose or exclude Wegener's granulomatosis and microscopic polyangiitis
Indications of anti-neutrophil cytoplasmic antibodies (ANCA)?
Help detect and dx certain forms of autoimmune vasculitis
Help distinguish UV and crohn's.
Interpretation of anti-neutrophil cytoplasmic antibodies (ANCA)?
Normal <1:20 (dilution)
Increased in >90% of pts w/ certain necrotizing systemic vasculitides and usually <5% of pts w/ collagen vascular dz or arthritis
What is uric acid, serum/plasma?
Uric acid is a product of metabolic breakdown of purine nucleotides via digestion of certain dietary proteins
What are examples of dietary sources of uric acid?
Sweetbreads- (the thymus gland or pancreas of an animal, especially as used for food.)
Organ meets (liver, kidney)
Indication of uric acid test?
Aids in dx and monitoring of gout or kidney dz
Procedure of uric acid test?
venous blood draw
Limitations of uric acid test?
Negative interference reported w/ high/over doses of acetaminophen
Assay interference (negative) possible w/ high concentrations of N-acetylcysteine (NAC) are present
What is the target serum uric acid level in gout pts?
What can increased uric acid in the blood lead to?
Crystals to form in joints leading to joint inflammation and pain characteristic of gout
Crystals/stones can damage kidneys
What is synovial (joint) fluid analysis?
a group of tests that examine joint (synovial) fluid. The tests help diagnose and treat joint-related problems
Indications of synovial fluid analysis?
Joint inflammation where gout or pseudogout may be suspected
Procedure of synovial fluid analysis?
Analyze for cell count, gram stain, culture, crystal analysis, glucose
Pt prep for synovial fluid analysis?
Informed consent, sterile prep, anesthesia, proper pt positioning
Errors of synovial fluid analysis?
Do not pass a needle into the joint through overlying cellulitis
Caution w/ pts on anticoagulation
What is seen in synovial fluid w/ gout?
Negative birefringent crystals
What is seen in joint synovial fluid w/ pseudogout?
Positive birefringent calcium pyrophosphate dihydrate crystals
Characteristics of normal synovial fluid in synovial fluid analysis?
WBC count- <200
Polymorphonuclear neutrophils (PMNs)- <25%
Glucose level- similar to that of pts serum glucose level
Characteristics of synovial fluid in non-inflammatory conditions like osteoarthritis or trauma?
Appearance- clear, yellow
WBC count- <2000
Glucose level- similar to that of pts serum glucose
Characteristics of synovial fluid in inflammatory conditions (RA, psoriatic arthritis, Lyme dz, gout, calcium pyrophosphate deposition disease (CPPD) sarcoidosis)?
Appearance- clear, cloudy yellow
WBC count- >2000
Glucose level- <serum glucose level
Characteristics of synovial fluid in septic conditions (infection, still dz)?
WBC count- >50,000
Glucose level- may be at least 25 mg/dl lower than that of pt's serum glucose level
Indications of arthrocentesis/intraarticular injections?
Dx- eval of new onset arthritis, rule out infection, persistent joint effusion
Tx- instill steroids, drain septic arthritis or tense hemarthrosis/effusion
Contraindication of arthrocentesis/intraarticular injections?
Cellulitis at injection site
Relative- bleeding disorder, pt on anticoagulants
Complications of arthrocentesis/intraarticular injections?
Post injection flare of joint pain and swelling. May occur after steroid injections and last severe days
What are materials needed for arthrocentesis/intraarticular injections?
Minor procedure tray: 18 or 20 guage needle
Ethyl chloride spray can be substituted for lidocaine
Two heparinized tubes for cell count and crystal examination
Call lab for preferred supplies for transport of fluid for exam
Syringe containing long acting corticosteroid- methylprednisolone (depo-medrol), triamcinolone (kenalog)
Step one of arthrocentesis/intraarticular injection?
Describe procedure and complications
Obtain written consent
Step two of arthrocentesis/intraarticular injection?
Determine the optimal site for aspiration
Identify landmarks and mark site w/ indentation or sterile marking pen
Avoid injecting into tendons
Step 3 of arthrocentesis/intraarticular injection?
Maintain a sterile field w/ sterile implements to minimize risk of infection
Step 4 of arthrocentesis/intraarticular injection?
Clean the area w/ chlorhexidine and let dry
Wipe the aspiration site w/ alcohol
Step 5 arthrocentesis/intraarticular injection?
Using a 25 gauge needle, anesthetize the puncture site w/ lidocaine
Do NOT inject into the joint space (lidocaine is bactericidal)
Avoid lidocaine perparations w/ epinephrine in a digit
Spray area w/ ethyl chloride (freeze spray) just before needle insertion
Step 6 of arthrocentesis/intraarticular injection?
Insert aspirating needle (18 or 20 gauge, smaller if finger or toe) applying a small amount of vacuum to syringe
When capsule is entered fluid flows easily usually
Remove as much fluid as possible (reposition syringe prn)
Step 7 of arthrocentesis/intraarticular injection?
If corticosteroid is to be injected, remove the aspirating syringe from the needle (hemostat to hold needle in place when switching syringes) which is still in joint space
Attach syringe containing corticosteroid pull back plunger to ensure the needle is not a vein and inject contents
NEVER inject steroids if there is any possibility of a joint infection
Remove the needle, apply pressure to area to prevent leakage of SQ steroids as they can cause atrophy of skin
Step 8 of arthrocentesis/intraarticular injection?
Note volume aspirated from the joint
Increased fluid inflammatory, septic or hemorrhagic arthritis
Bedside test for viscosity is to allow a drop of fluid to fall from the tip of the needle
Normal synovial fluid is highly viscous and forms a several inch long string
How much synovial fluid does a knee typically have?
What does decreased viscosity of synovial fluid indicate?
Infection or inflammatory condition
Step 9 arthrocentesis/intraarticular injection?
Send fluid for cell count and diff (purple or green top tube)
Microscopic crystal exam w/ light microscopy- normally no debris, crystals or bacteria
Glucose- red top tube
Gram stain and culture for bacteria, fungi, AFB
Cytology if malignant
Shoulder arthrocentesis, posterior approach?
Seat pt upright
Palpate spine of scapula to the acromion- identify posterolateral corner of acromion
Use 1.5 inch needle. Insert needle 1cm inferior and 1cm medial to posterolateral corner of acromion
Direct needle anterior and medial toward presumed position of coracoid process
The glenohumeral joint is located at a depth of 1.0-1.5 inches
Arthrocentesis of the knee?
Fully extend knee w/ pt supine and make sure pt and quad muscles are relaxed
Insert needle posterior to the lateral portion of patella into the patellar-femoral groove. Advance needle slightly posteriorly and inferiorly.
To inject the knee, have the pt sitting down w/ leg flexed and enter knee anteriorly over medial joint line
Arthrocentesis of the ankle?
The most accessible site is between the tibia & the talus. Position the angle of foot to leg at 90 degrees. Make a mark lateral & anterior to the medial malleolus & medial & posterior to the tibialis anterior tendon. Direct the advancing needle posteriorly toward the heel.
The subtalar ankle joint does not communicate with the ankle joint & is difficult to aspirate even for an expert.
*Be aware that "ankle pain" can originate in the subtalar joint rather than in the ankle.
Indications of dual energy x-ray absorptiometry (DEXA) scan?
Evaluation of osteoporosis by measuring bone mineral density (BMD)
What are the T scores of dexa scan?
≥-1 is normal
-1 to -2.5 is osteopenia
<-2.5 is osteoporosis
Errors w/ DEXA scan?
Pt movement and artifacts can result in falsely elevated BMD estimate
What is the T-score?
Standard deviation by which the BMD of the pt differs from the mean BMD of a young adult
What is the Z-score?
Standard deviation by which the BMD of the pt differs from the mean BMD of a person the same age as the pt
How does increased radiation exposure appear on x-ray?
Increased blackening (overexposed)
What things appear as black on x-ray?
What appears as gray-black on x-ray?
What things appear as gray on x-ray?
What things appear as white on x-ray?
Indications of x-ray?
Direct eval of bones
Indirect eval of soft tissues (gas, tumors, calcifications)
What is the minimum amount of views that should be taken in x-ray?
Minimum of 2 views at right angles to eachother
Indications of CT scan?
2 major uses:
Eval of fracture fragment position
Precise portrayal of fractures in multiple planes
Limitations of CT scan?
Radiation exposure > conventional radiography
Not recommended for pregnant women, unless absolutely necessary
What is fluoroscopy?
A live x-ray used during procedures
Indications of fluoroscopy?
Evaluation of joint motion
Used by orthopedic surgeons to monitor placement of hardware
Limitations of fluoroscopy?
Radiation exposure is variable and > than conventional radiography
Not recommended for pregnant women
Indications of MRI?
Eval of soft tissues (muscles, tendons, bone marrow, ligaments)
Pt prep for MRI?
Remove all metal
Limitations of MRI?
Don't use of ferromagnetic implants and foreign bodies are contraindicated
Errors of MRI?
The image is a recreation based on a computer's interpretation of reality so it may be off occasionally.
What is arthrography?
X-ray examination of a joint space. During arthrography, a contrast material is injected to enable the radiologist to study the joint space that appears on the x-ray image
Indication of arthrography?
Fine intra-articular detail needed
Useful in shoulder, hip, wrist and elbow
Procedure of arthrography?
Contrast agent is injected into the joint using fluoroscopic guidance
Joint is imaged using radiography, CT, MRI or a combo
Errors of arthrography?
Contrast injected outside the joint capsule
Indication of Ultrasound (US)?
Evaluate muscle, tendon, ligament, cartilage
Procedure of US?
High-frequency sound waves are transmitted into tissue and reflected
Can't transmit through bone
What is radionuclide imaging (bone scintigraphy) and what is it used for?
Aka Bone scan
a nuclear medicine imaging technique of the bone. It can help diagnose a number of bone conditions, including; cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be visible in traditional X-ray images), and bone infection
Procedure of radionuclide imaging (bone scintigraphy)?
Technicium 99m (Tc-99m)
Gamma cameras detect gamma rays emitted by injectable agent
Agent is absorbed by hydroxyapatite crystals
Limitations of radionuclide imaging (bone scintigraphy)?
Very sensitive for areas w/ increased bone turnover
Indications of positron emission tomography/CT (PET scan)?
Dx and staging of malignancy
Procedure of PET scan?
Pt is injected w/ fluorine fluorodeoxyglucose (FDG) and is is trapped w/in the cell
CT and PET scans are performed using a combo of their components, it provides CT and PET images
Limitations of PET scan?
Difficult in clinical picture of granulomatous infections (TB, fungal, sarcoidosis etc)
Some tumors have a low affinity for FDG (prostate, bronchoalveolar)
Errors w/ PET/CT scan?
Tries to measure glucose uptake in tumors
Also measure uptake in macrophages (inflammation/infection), brown adipose tissue
Hyperglycemia competes w/ FDG (DM)
Steps of radiograph interpretation?
1. choose right study/images (minimum of two)
2. provide consulting radiologists w/ hx
Check pt name, DOB FIRST
, check orientation, position, side description, look at all available views including old films
4- follow the cortex lines completely around the bone outline searching for irregularities
What is a Salter-Harris fracture?
fracture that involves the epiphyseal plate or growth plate of a bone. It is a common injury found in children, occurring in 15% of childhood long bone fractures
What are the different classifications of salter-harris fracture? (SALTR)
S- slipped (type 1)-fracture through the physeal plate
A- above (type 2)- fracture through the metaphysis and physis (most common; up to 75% of all physeal fractures)
L- lower (type 3)- fracture through the epiphysis and physis
T- through or transverse or together (type 4)- fracture through the metaphysis, physis and epiphysis
R- ruined or rammed (type 5)- crush injury involving part or all of the physis
What is the most commonly missed Salter-Harris fracture?
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