Presentation on theme: "The Evolving Role of the Radiologist Assistant"— Presentation transcript:
1The Evolving Role of the Radiologist Assistant Richard Danieli
2Outline Introduction Radiology journey R.R.T. to R.A. Education as a Radiologist Assistant studentRegistered Radiologist Assistant (R.R.A.) Handbook ARRTRA education requirementsProcedure ListMandatory proceduresElective proceduresCompetency requirementsCR1 FormsCR2 FormsSummative EvaluationsBoard license eligibilityExam outlineCareer outlookCurrent legislationHR 3032 Medicare Access to Radiology Care ActSociety of Radiology Physician ExtendersInteresting Case studiesFibrin sheath port injection studyHiatal Hernia on UGILoopogram obstructionTFC tear wrist arthrogramQuestions and Answers
3IntroductionClark F. Miller School of Radiologic Technology at Central Maine Medical CenterCentral Maine Community CollegeFlorida Hospital College of Health ScienceCurrently at Quinnipiac University Masters in Health Science Radiologist Assistant24 Month Full time: first year classroom, second year clinicals. Clinical placement:Yale New Haven Hospital, CT.Fallon Clinic Worcester, MA.Baystate Medical Center Springfield , MA.Cooper Univerisity Hospital Camden, NJ.Uconn Medical Center Farmington, CT
4R.R.T. to R.A. R.R.T. license in every state for clinicals Advance Cardiac Life Support (ACLS)Moderate/Conscious sedationResponse to a code/anaphylaxis/allergic reactionCardiac rhythymsEducational structure differences and the importance of good educatorsThe bridge between Radiologist and TechnologistTechnician difficulties and interpretation difficultieslogistics (PACS,RIS, proper orders etc…)Responsibilities- need to recognize pathologyRT’s have Merrills. RA’s have….. Pathology, experience, Radiologist preferences.IR-Coagulation factorsIf you don’t know about it, you don’t look for itRadiologist-4 years undergrad, 4 years medical school, 1 year surgery/ internal medicine internship, 4 years residency, 1 year fellowship= 14 years educationRA’s- 4 years undergrad, 2 years graduate school= 6 years educationFuture specialization for RA education possible
5Q.U. Education Courses Clinical Pharmacology I Human AnatomyHuman Anatomy LabImaging PathophysiologyRadiation Safety and Health PhysicsImage Critique & Pathologic Pattern Recognition IImage Critique & Pathologic Pattern Recognition IIInterventional Procedures IInterventional Procedures IIPatient Assessment, Management and EducationResearch Methods and DesignClinical Seminar IClinical Seminar IIClinical Seminar IIIRadiologist Assistant Clinical IRadiologist Assistant Clinical IIRadiologist Assistant Clinical IIIRadiologist Assistant Clinical IVThesis IThesis II20 courses
6Arthrogram (radiography, CT, MR joint injection and aspirations) Invasive NonvascularArthrogram (radiography, CT, MR joint injection and aspirations)Lumbar PunctureCervical, thoracic, or lumbar myelography- imaging onlyLumbar Puncture with contrastThoracentesis with or without catheterPlacement of catheter for pneumothoraxParacentesisAbscess, fistula, sinus tract studyInjection sentinel node localizationBreast needle localizationChange of percutaneous tube or drainage catheterThyroid biopsyLiver biopsyInvasive VascularPeripheral insertions of central venous catheter placementInsertion of non-tunneled central venous catheterInsertion of tunneled central venous catheterPort injectionExtremity VenographyPost processingPerform CT post processingPerform MR post processingGastroIntestinal and ChestEsophageal study must fluoro and image the esophagus, may be with UGISwallow Function Study (participate in procedure and provide initial observations to radiologistUpper GI StudySmall Bowel study- direct the study and spot TISmall bowel study via enteroclysis tubeEnema with barium, air, or water soluble contrastNasogastric/enteric and orogastric/enteric tube placement-may not require image guidanceT-tube cholangiogramDefecographyPerform chest fluoroscopy for diaphragmatic motionGenitourinaryAntegrade urography through existing tube (e.g. pyelostography, nephrostography)Cystography or voiding cystourethrography, with minimum of 10 bladder catheterizationsRetrograde urethrography or urethrocystographyLoopography through existing tubeHysterosalpinography- imaging onlyHysterosalpinography- procedure and image (physian participation required)36 procedure titles375 mandatory, 125 elective= 500 total
7Clinical PortfolioThe Clinical Portfolio consists of the following components:(1) Clinical Experience Documentation and Clinical Competence Assessments(2) Professional Activities and Accomplishments Record(3) Case Studies(4) Summative Evaluation Rating Scales.
8Form CR-1: Summary of Clinical Experience and Competence Assessments 1. This form is completed by the student as he or she: (a) completes the requisite number of cases for the mandatory and elective procedures; and (b) is evaluated by a radiologist on the mandatory and elective procedures.2. The student records the number of cases completed for each mandatory and elective procedure he or she performs.3. The student records only the date that the competency assessment was completed. Note that the actual competence assessments are completed by a radiologist using Form CR-24. The preceptor and program director must verify and sign the bottom of Form CR-1. This form is submitted to ARRT at the time of application.A log of all procedures done
9Form CR-2: Clinical Competence Assessments (Forms CR-2A through CR-2E) 1. These forms are completed by the radiologist at the time he or she evaluates the student. There are separate evaluation forms for each class of radiologic procedures:Form CR-2A: GI/Chest Form CR-2C: invasive nonvascularForm CR-2B: GU Form CR-2D: invasive vascularForm CR-2E: post-processing activities2. The radiologist and student are required to sign the bottom of Form CR-2 for each assessment, which is subsequently reviewed and signed by the program director.3. The student must submit a minimum total of 15 assessment forms to ARRT (12 mandatory and 3 elective procedures).Comp form for each procedure
10Summative EvaluationThe Summative Evaluation Rating Scales address five skill areas:(1) evaluation of medical information(2) patient communication(3) radiation safety(4) professionalism(5) specific procedural skillsUsed as a Clinical grade by preceptor radiologist, used as midterm and final clinical grade evaluation
11R.R.A. Exam Board Eligibility 1. ARRT Certified and Registered in Radiography2. One year of Acceptable Clinical Experience3. Educational Program Completion4. Didactic Competence Requirement
12R.R.A. Licensing Exam Board Eligibility 5. Clinical Education Requirements5A. Component 1: Clinical Experience Documentation and Competence Assessments5B. Component 2: Professional Activities and Accomplishments Record5C. Component 3: Case Studies5D. Component 4: Summative Evaluation Rating ScalesKeeping a strict log of procedures performed.
14Registered Radiologist Assistant Examination Content Categories Multiple Choice:A.Patient Communication, Assessment, and Management- 45 pointsB. Drugs and Contrast Materials -30 pointsC. Anatomy, Physiology, and Pathophysiology- 55 pointsD. Radiologic Procedures- 40 pointsE. Radiation Safety, Radiation Biology, and Fluoroscopic Operation- 15 pointsF. Medical-Legal, Professional, and Governmental Standards -15 pointsTotal Number- 200 pointsTesting Time Allowed 3.5 hours2 Case StudiesEach case is followed by four to six essay questions worth 3 or 6 points each.Testing Time Allowed 2.5 hoursNo study guide available only Outline.
15Career Outlook Momentarily Difficult R.R.A. roles beyond ARRT New Profession, Myths, and Fears (lack of support)Reimbursement issues (CMS Guidelines and supervision requirements)R.R.A. roles beyond ARRTImage interpretation ( think radiology residence)Radiology Procedures not listed (bone marrow biopsy, IVC filter placement, drainage tube insertion, port removal, radiologist comfort etc…)LiabilityUnited kingdomAdvanced radiographer PractitionerQuality of service providedClinical training of RA vs resident, PA, NP
16HR 1148 Medicare Access to Radiology Care Act of 2013 To amend title XVIII of the Social Security Act to provide for payment for services of qualified radiologist assistants under the Medicare program.More senator Co-sponsorship needed.
17Society of Radiology Physician Extenders “The Society of Radiology Physician Extenders (SRPE) is a non-profit organization for the RPA and RRA sharing a common bond within the global mid-level radiology profession and medical community in general. The society holds an annual conference conducting seminars and presentations. The SRPE is an active participant with other health care professionals and organizations to educate and promote the role of the mid-level radiology extender. Our organization is committed to fostering the highest values and promoting superior lifelong success both personally and professionally.”Conferences with Continuing Education CreditsLegislative involvement
18ReferencesA.R.R.T (2013). Registered Radiologist Assistant (R.R.A.) | ARRT - The American Registry of Radiologic Technologists. Retrieved January 12, 2013, from https://www.arrt.org/Certification/Registered-Radiologist-AssistantS.R.P.E. (2013). Society of Radiology Physician Extenders Inc. Society of Radiology Physician Extenders Inc. Retrieved January 12, 2013, from
23Patient HistoryLeft sided portacatheter placed 5/23/12 in good location and functionalPortacatheter needed for chemothereapy treatment for cancer of the right breast
24Initial post port chest x-ray on 5/23/12 Normal, surgical placed, used subclavian vein. Could be longer, tip in SVC or brachiocephalic junction.
25Reason for the Examination No blood return from port when accessed two days ago
26Relevant InformationLeft sided portacatheter placed to keep right side open for surgical and radiation options
27Radiographic Procedure Portacatheter was accessed using sterile techniquePatient was positioned supine on fluoroscopy tableScout spot x-ray obtainedPatient was positioned in right anterior oblique10 cc non ionic iodinated contrast was injected in the portLive fluoroscopy and rapid sequence imaging was obtained
28Scout fluoroscopy image 1 month post port placement Note: Loop in catheterNote: Distal location of catheter
29Examination Results Malposition of the distal end of the portacatheter Loop in middle portion of portacatheterFibrin sheath formation of distal portacatheter lumen
30Port Injection ImageNote: contrast jetting superiorly and laterally from catheter.
31Differential Diagnosis Extravasation of contrast through fracture or hole of catheter
32DiscussionMigration of the catheter tip superiorly with a mid-portion loop is known complication especially with left sided ports due to the vessel pathwayFibrin sheath formation of the distal catheter lumen another known complication of portacatheters allowed a limited forward flush, but no blood aspiration
33Suggestions Removal of current portacatheter Replace with a new portacatheter
34Discussion Questions John: Stacy: Tina: 1. What are the indications for a central venous port?2. What are the indications for a left chest port placement?Stacy:1. If a large symptomatic venous air embolism is caused, in what position do you place your patient?2. What is the treatment for a large symptomatic venous air embolism?Tina:1. What are the post op port placement instructions for patients?2. Describe the details involved with using tissue plasminogen activator to treat fibrin sheaths or clots at the catheter tip.
35ReferencesKandarpa, K., & Machan, L. (2011). Handbook of interventional radiologic procedures (4th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.Kessel, D., Robertson, I., & Sabharwal, T. (2011). Interventional radiology: A survival guide (3rd ed.). Edinburgh: Churchill Libingstone/Elsevier.Kim, F. M., Burrows, P. E., Hoffer, F. A., & Chung, T. (1996). Interpreting the results of pediatric central venous catheter studies. Radiographics, 16, Retrieved fromMauro, M. (1998). Delayed complications of venous access. Techniques in Vascular and Interventional Radiology, 1(3), doi: /S (98)Slaby, J., & Navuluri, R. (2011). Chest Port Fracture Caused by Power Injection. Seminars in Interventional Radiology, 28(3), doi: /s
37Patient Information 77 year old female No known surgery to gastrointestinal tractNo weight loss
38Patient History Dysphagia Pharyngeal perforation, aspiration, and fistula were not clinically indicated therefore thick and thin barium contrast was used and not water soluble contrast.
39Reason for the Examination The patient stated “food gets stuck in my throat”Other clinical reasons for performing an esophagram include:Dysphagia (difficulty swallowing)Odynophagia (painful swallowing)Globus (sensation of a lump in the throat)Suspected aspirationPostoperative assessment of laryngectomyPenetrating Trauma
40Relevant InformationEndoscopy showed antral deformity follow up with GI study recommended
41Radiographic Procedure Esophagram performedThick and thin barium used in vertical and horizontal positionsPatient positioned upright in right lateral, AP, and LPOPatient positioned supine in RAO, AP and RPOImages obtained of esophagus collapsed and dilated with bariumModifications of routine exam to image visualized pathology
42HH on CXRThe chest x-ray shows the Hiatal Hernia. Notice the circumscribed lucency behind the heart.
43Zenckers Diverliculem Notice the small Zenker’s diverticulm.
44DiverticulumNotice the distal esophageal diverticulum with barium distending distal esophagusImage obtained in upright position
45Distal Esophageal diverticulum Notice distal esophageal diverticulum has barium pooling. In comparison to previous image there are tertiary contractions of the distal tortuous esophagusImage obtained in upright positionstomach
46Distal Esophageal diverticulum Notice the location of the diaphragm, clearly showing a Type IV complex paraesophageal hiatal hernia.Image obtained supine notice difference in appearance from prior images done upright showing or movement of the hernia
47Examination Results of Radiology Report Results:Multiple tertiary contractions of the esophagus are seen associated with prominence of the cricopharyngeus sphincter. 5mm in diameter Zenkers diverticulum is noted. No aspiration or penetration is seen. Large Hiatal hernia is seen with the majority of the stomach herniated into the chest cavity. There is considerable gastroesophageal reflux. A 2cm diameter outpouching is noted of the distal aspect of the esophagus compatible with distal esophageal diverticulum.Impression: Prominence of the cricopharyngeal sphincter associated with small Zenkers diverticulum. Significant motility dysfunction of the esophagus. Diverticulum of the distal esophagus as described. Large hiatal hernia. See above
48Differential Diagnosis The differentials for the hiatal hernia on the frontal chest x-ray are:retrocardiac lung abscessretrocardiac empyemaepiphrenic esophageal diverticulumThere are no differentials for the esophagram images. They could potentially be wrongly diagnosed.The stomach could be wrongly diagnosed as a volvulus or malrotation if the interpreter did not notice the level of the diaphragm, but these diagnosis should be done on an UGI where the duodenum is visualizedThe zenckers diverticulum could be wrongly diagnosed as an ulcerThe distal esophageal diverticulum could be wrongly diagnosed as a large ulcer
49DiscussionZenker’s diverticulum correlates with the sensation of food getting stuck in the upper esophagusMotility dysfunction which contributes to the patient’s dysphagia.Considerable gastroesophageal reflux (suspected treatment or forgot to mention symptoms)Asymptomatic distal esophageal diverticulumAsymptomatic type IV complex paraesophageal hiatal hernia
50SuggestionsTreatment for the reflux would be recommended such as Prilosec (an antacid).Surgery of hiatal hernia only necessary if hernia causes strangulation which cuts off the blood supply or causes an obstructionNo treatment for asymptomatic type IV complex paraesophageal hiatal herniaNo treatment for 77 year old asymptomatic distal esophageal diverticulumNo treatment for the Zencker’s diverticulumNo treatment for dysmotility
51SuggestionsUpper gastrointestinal barium study to visualize the stomach and duodenum could be done for further evaluationSmall bowel follow through with barium could also be done to further evaluate potential areas of obstruction.CT with oral contrast of the abdomen and pelvis could be performed to further evaluate the anatomy
52Discussion Questions John: Stacy: Tina: What are the four types of Hiatal Hernias?What are two properly named diapragmatic hernias?Stacy:Discuss the indications and contraindications of using a barium tablet during an esophagramDiscuss the indications and contraindication of administering effervescent granulesTina:Define a Zenker’s diverticulumDiscuss another type of esophageal diverticulum
53ReferencesHerring M.D., W. (2007). Recognizing Tumors, Tics, and Ulcers: Radiology of the Gastrointestinal Tract. In Learning Radiology Recognizing the Basics. (1st ed.). (pp ). Philadelphia, Pennsylvania: Mosby Elsevier.Houston M.D., J. D., & Davis M.D., M. D. (2001). Pharyngeal and Esophageal Examinations. In Fundamentals of Fluoroscopy. (1st ed.). (pp ). Philadelphia, Pennsylvania: W.B. Saunders Company.Mettler,JR., M.D., F. A. (2005). Gastrointestinal System. In Essentials of Radiology. (2nd ed.). (pp ). Philadelphia, Pennsylvania: Elsevier Saunders.Pretorius,M.D., E. S., Solomon,M.D., J. A., & Rubesin,M.D., S. E. (2011). Upper Gastrointestinal Tract. In Radiology Secrets Plus. (3rd ed.). (pp ). Philadelphia, Pennsylvania: Mosby Elsevier.Sandstrom,M.D., C. K., & Stern, M.D., E. J. (2011). Diaphragmatic Hernias: A Spectrum of Radiographic Appearances. Current Problems in Diagnostic Radiology, 40(3), doi:http://dx.doi.org/ /j.cpradiol ,
55Patient InformationA 68 year old male with history of muscle invading bladder cancer.Post operative robotic assisted radical cystoprostatectomyPost operative ileal conduit urinary diversion performedInteresting case, hx bladder CA/ surgery, divert urine to ileal conduit.
56Patient History History of bladder cancer Prior CT Filling defects in the dilated left renal pelvisAbsence of contrast opacification of the left ureter,Recommend direct inspection of the left collecting system with cystoscopy and ureteroscopy.Interval worsening of the left hydroureteronephrosis.Anastomotic stricture at the junction between the ureter and ileal conduit cannot be excluded
57Reason for the Examination Recommendation from prior CTEvaluate Ileal ConduitEvaluate left ureter by retrograde contrast administration
58Relevant Information History of bladder cancer Obstructed proximal left ureter seen on prior CT
59Radiographic Procedure 24-gauge Foley catheter inserted into stoma with 30 cc balloon inflatedConray-60 introduced into ileal conduit by gravity infusionReflux into right ureterNo contrast entered the left ureter despite various positional changes and delayed imaging.Patient vomited possibly due to relative over distention of the ileal bladder in attempts to induce left ureteral reflux
60Examination Results Normal right upper urinary tract Normal ileal conduit contourNo reflux into left ureter due to obstruction at the ureteroileal junction
61Loopogram Spot Film AP Note: No contrast in left ureter Catheter Right ureterCatheter balloonIleal conduit
62Loopogram Spot Film Slight LPO Note: No contrast in left ureterCatheterCatheter balloonRight ureterIleal conduit
63Loopogram Spot Film Steep LPO Note: No contrast in left ureterRight ureterCatheter balloonCatheterIleal conduit
64Abdomen/Pelvis CT with IV Contrast Coronal Image IV contrast in right ureterIV contrast remained in left renal pelvis
65Abdomen/Pelvis CT with IV Contrast Axial Image IV contrast in right ureterIV contrast remained in left renal pelvis
66Differential Diagnosis No contrast extravasated therefore obstructedUreteral obstruction post ileal conduitImproperly fashioned anastomosisIschemia of the ureter with subsequent fibrosis and strictureRecurrent tumor in the ureter (rare)Infection or abscess formation with reactionEdemaCalculusSloughed papillaAdhesions or scarring.Torsion or compression at the sigmoid
67DiscussionNo extravasation of contrast outside of the ileal conduit or the right ureterNormal contour of ileal conduit and right ureterNo contrast filling into the left ureter during the loopogram.Left ureter not evaluated from retrograde contrast administration via loopogram or antegrade contrast administration via CT
68Suggestions Renal ultrasound Renal radionuclide studies, Percutaneous nephrogram/ureterogramIntravenous pyelogram (IVP)Abdomen/pelvis CT (with oral contrast, with and without IV contrast)
69Discussion Questions John: Stacy: Tina: 1. Where are post operative ileal conduit obstructions most common?2. Besides obstruction, what is the other most common abnormality post operative ileal conduit surgery.Stacy:1. Describe pseudoobstruction (conduit malfunction) and the cause.2. What is a mucus plug in reference to a loopogram?Tina:1. Describe two renal complications of an ileal conduit.2. What risks are associated with an excessive length of an ileal conduit?
70ReferencesAppleby, S., & Atala, A. (2010, September 2). Urostomy and Continent Urinary Diversion. National Kidney and Urologic Diseases Information Clearinghouse. Retrieved July 7, 2012, fromBanner, M. P., Pollack, H. M., Bonavita, J. A., & Ellis, P. S. (1984). The radiology of urinary diversions. Radiographics, 4, Retrieved fromFernbach, S., & Holland, E. (1988). Undiversion of the urinary tract: The pre-and postoperatie evaluation. Radiographics, 8, Retrieved fromNoble, J., Amin, Z., Kessel, D., & Rickards, D. (1994). Recurrent upper tract urothelial tumours: the use of loopography following cystectomy for bladder cancer. British Journal of Radiology, 67(803), Retrieved fromThiruchelvam, N., Harrison, M., & Page, A. C. (2007). The double wire technique: an improved method for treating challending ureteroileal anastomotic strictures and occlusions. British Journal of Radiology, 80, Retrieved from
71Right Wrist Arthrogram with Gadolinium injection Rich Danieli
72Clinical19 year old female continued right wrist discomfort for four months status post surgery for fracture of 5th metacarpal due to traumatic fallPatient continues to have pain with movement and therefore range of motion is slightly limited.
73HistoryAn evaluation of patient and patients chart shows no contraindication for arthrogram or MRI (not pregnant, not claustrophobic, non-ferrous orthopedic hardware, no other metallic hardware, normal coagulations, no infection, and no known allergies.
75BenefitsIt assists and increases the ability to diagnose pathology within the wrist on the MRI.
76Alternatives Do nothing MRI without gadolinium Arthogram without gadolinium and MRIWrist arthroscopy.
77Important Components 20ml syringe Gadolinium mixture 15ml saline5ml isovue iodinated contrast0.2ml of gadolinium.Injection site of the wristradioscaphoid jointSmall patient and small jointonly 2.5ml of Gad mixture was injected.
78End of Procedure Exercise wrist Final images obtained and recorded Send patient to MRI
79Differential Artifact Gadolinium injected in the wrong area Delayed gadolinium injection time from MRI scan time
80Triangular Fibrocartilage Complex homogenous structure composed of articular disc, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament, and the sheath of the extensor carpi ulnaris
81ResultsPartial sprain triangular fibrocartilage complex ligament at its attachment to the ulnar styloidInternal sprain triangular fibro cartilage.Arthrogram right wrist with contrast and gadolinium injection
82ResultsPartial sprain TFC ligament at its attachment to the ulnar styloidInternal sprain triangular fibro cartilage.MRI right wrist with gadolinium
83ResultsPartial sprain TFC ligament at its attachment to the ulnar styloidInternal sprain Triangular fibro cartilage.MRI right wrist with gadolinium
84Radiology Report MRINo prior MRI available for comparison, intra-articular injection performed prior to patient’s arrival to the MRI center.. There is normal marrow signal in the distal radius and ulna, carpal bones and the base of the metacarpal bones. There is no eveidence of fracture or bone contusion. There is a partial tear of the triangular fibrocartilage ligament at it attachment to the ulnar styloid. There is a sprain of the scapholunate ligament. There is no evidence of vascular necrosis of the scaphoid. Surrounding soft tissue structures are unremarkable. There is no joint effusion. The median nerve has a proper signal characteristic in the caudal tunnel. There is no abnormal fluid collection. There is metal artifacts along the diaphysis of the fifth metacarpal. Posterior rotation of the distal ulna and a shallow ulnar notch of the distal radius suggesting distal radial ulnar instability.
85QuestionsJohnWhat is the specific components of the patient’s orthopeadic hardware made of that make it compatible with MRI?What are the typical sequences used for an MRI of the wrist with Gadolinium?
86QuestionsTinaWhat are the pros and cons of patient positioning when performing an MRI of the wrist between having the wrist above the head (superman position) or having the wrist by the patient’s side?If the patient was pregnant, what would have been the best diagnostic test to perform?
87QuestionsStacyWhat is a patient assessment test to check for triangular fibrocartilage complex injury and how is it performed?Was an MRI with Gadolinium necessary for this patient to determine her diagnosis?
88ReferencesDavid W. Stoller, The wrist, Seminars in Roentgenology, Volume 30, Issue 3, July 1995, Pages , ISSN X, /S X(05)80015-X. Houston,MD, J., & Davis, MD, M. (2001). Musculoskeletal Examinations. In Fundamentals of Flouroscopy. (1st ed.). (pp ). Philadelphia, PA: W.B. Saunders Company. Luis Cerezal, Faustino Abascal, Roberto García-Valtuille, Francisco del Piñal, Wrist MR Arthrography: How, Why, When, Radiologic Clinics of North America, Volume 43, Issue 4, July 2005, Pages , ISSN , /j.rcl Robinson, P. (2005). MR imaging of the wrist. Current Orthopaedics, 19(3), Usha Chundru, Geoffrey M. Riley, Lynne S. Steinbach, Magnetic Resonance Arthrography, Radiologic Clinics of North America, Volume 47, Issue 3, May 2009, Pages , ISSN , /j.rcl