1. The Evolving Role of the Radiologist Assistant
Richard Danieli

2. Outline Introduction Radiology journey R.R.T. to R.A.
Education as a Radiologist Assistant student
Registered Radiologist Assistant (R.R.A.) Handbook ARRT
RA education requirements
Procedure List
Mandatory procedures
Elective procedures
Competency requirements
CR1 Forms
CR2 Forms
Summative Evaluations
Board license eligibility
Exam outline
Career outlook
Current legislation
HR 3032 Medicare Access to Radiology Care Act
Society of Radiology Physician Extenders
Interesting Case studies
Fibrin sheath port injection study
Hiatal Hernia on UGI
Loopogram obstruction
TFC tear wrist arthrogram
Questions and Answers

3. Introduction
Clark F. Miller School of Radiologic Technology at Central Maine Medical Center
Central Maine Community College
Florida Hospital College of Health Science
Currently at Quinnipiac University Masters in Health Science Radiologist Assistant
24 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

4. R.R.T. to R.A. R.R.T. license in every state for clinicals
Advance Cardiac Life Support (ACLS)
Moderate/Conscious sedation
Response to a code/anaphylaxis/allergic reaction
Cardiac rhythyms
Educational structure differences and the importance of good educators
The bridge between Radiologist and Technologist
Technician difficulties and interpretation difficulties
logistics (PACS,RIS, proper orders etc…)
Responsibilities- need to recognize pathology
RT’s have Merrills. RA’s have….. Pathology, experience, Radiologist preferences.
IR-Coagulation factors
If you don’t know about it, you don’t look for it
Radiologist-4 years undergrad, 4 years medical school, 1 year surgery/ internal medicine internship, 4 years residency, 1 year fellowship= 14 years education
RA’s- 4 years undergrad, 2 years graduate school= 6 years education
Future specialization for RA education possible

5. Q.U. Education Courses Clinical Pharmacology I
Human Anatomy
Human Anatomy Lab
Imaging Pathophysiology
Radiation Safety and Health Physics
Image Critique & Pathologic Pattern Recognition I
Image Critique & Pathologic Pattern Recognition II
Interventional Procedures I
Interventional Procedures II
Patient Assessment, Management and Education
Research Methods and Design
Clinical Seminar I
Clinical Seminar II
Clinical Seminar III
Radiologist Assistant Clinical I
Radiologist Assistant Clinical II
Radiologist Assistant Clinical III
Radiologist Assistant Clinical IV
Thesis I
Thesis II
20 courses

6. Arthrogram (radiography, CT, MR joint injection and aspirations)
Invasive Nonvascular
Arthrogram (radiography, CT, MR joint injection and aspirations)
Lumbar Puncture
Cervical, thoracic, or lumbar myelography- imaging only
Lumbar Puncture with contrast
Thoracentesis with or without catheter
Placement of catheter for pneumothorax
Paracentesis
Abscess, fistula, sinus tract study
Injection sentinel node localization
Breast needle localization
Change of percutaneous tube or drainage catheter
Thyroid biopsy
Liver biopsy
Invasive Vascular
Peripheral insertions of central venous catheter placement
Insertion of non-tunneled central venous catheter
Insertion of tunneled central venous catheter
Port injection
Extremity Venography
Post processing
Perform CT post processing
Perform MR post processing
GastroIntestinal and Chest
Esophageal study must fluoro and image the esophagus, may be with UGI
Swallow Function Study (participate in procedure and provide initial observations to radiologist
Upper GI Study
Small Bowel study- direct the study and spot TI
Small bowel study via enteroclysis tube
Enema with barium, air, or water soluble contrast
Nasogastric/enteric and orogastric/enteric tube placement-may not require image guidance
T-tube cholangiogram
Defecography
Perform chest fluoroscopy for diaphragmatic motion
Genitourinary
Antegrade urography through existing tube (e.g. pyelostography, nephrostography)
Cystography or voiding cystourethrography, with minimum of 10 bladder catheterizations
Retrograde urethrography or urethrocystography
Loopography through existing tube
Hysterosalpinography- imaging only
Hysterosalpinography- procedure and image (physian participation required)
36 procedure titles
375 mandatory, 125 elective= 500 total

7. Clinical Portfolio
The 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.

8. Form 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-2
4. 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

9. Form 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 nonvascular
Form CR-2B: GU Form CR-2D: invasive vascular
Form CR-2E: post-processing activities
2. 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

10. Summative Evaluation
The Summative Evaluation Rating Scales address five skill areas:
(1) evaluation of medical information
(2) patient communication
(3) radiation safety
(4) professionalism
(5) specific procedural skills
Used as a Clinical grade by preceptor radiologist, used as midterm and final clinical grade evaluation

11. R.R.A. Exam Board Eligibility
1. ARRT Certified and Registered in Radiography
2. One year of Acceptable Clinical Experience
3. Educational Program Completion
4. Didactic Competence Requirement

12. R.R.A. Licensing Exam Board Eligibility
5. Clinical Education Requirements
5A. Component 1: Clinical Experience Documentation and Competence Assessments
5B. Component 2: Professional Activities and Accomplishments Record
5C. Component 3: Case Studies
5D. Component 4: Summative Evaluation Rating Scales
Keeping a strict log of procedures performed.

13. R.R.A. Licensing Exam Board Eligibility
6. Baccalaureate Degree
7. ARRT Ethics Requirements
8. Application for Certification

14. Registered Radiologist Assistant Examination Content Categories
Multiple Choice:
A.Patient Communication, Assessment, and Management- 45 points
B. Drugs and Contrast Materials -30 points
C. Anatomy, Physiology, and Pathophysiology- 55 points
D. Radiologic Procedures- 40 points
E. Radiation Safety, Radiation Biology, and Fluoroscopic Operation- 15 points
F. Medical-Legal, Professional, and Governmental Standards -15 points
Total Number- 200 points
Testing Time Allowed 3.5 hours
2 Case Studies
Each case is followed by four to six essay questions worth 3 or 6 points each.
Testing Time Allowed 2.5 hours
No study guide available only Outline.

15. Career 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 ARRT
Image interpretation ( think radiology residence)
Radiology Procedures not listed (bone marrow biopsy, IVC filter placement, drainage tube insertion, port removal, radiologist comfort etc…)
Liability
United kingdom
Advanced radiographer Practitioner
Quality of service provided
Clinical training of RA vs resident, PA, NP

16. HR 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.

17. Society 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 Credits
Legislative involvement

18. References
A.R.R.T (2013). Registered Radiologist Assistant (R.R.A.) | ARRT - The American Registry of Radiologic Technologists. Retrieved January 12, 2013, from
S.R.P.E. (2013). Society of Radiology Physician Extenders Inc. Society of Radiology Physician Extenders Inc. Retrieved January 12, 2013, from

19. Port Injection
Richard Danieli

20. Patient Information 55 year old female
Right breast grade 3 infiltrating ductal carcinoma

21. Mammogram of Right Breast
Breast Cancer

22. Ultrasound of Right Breast
Breast Cancer

23. Patient History
Left sided portacatheter placed 5/23/12 in good location and functional
Portacatheter needed for chemothereapy treatment for cancer of the right breast

24. Initial post port chest x-ray on 5/23/12
Normal, surgical placed, used subclavian vein. Could be longer, tip in SVC or brachiocephalic junction.

25. Reason for the Examination
No blood return from port when accessed two days ago

26. Relevant Information
Left sided portacatheter placed to keep right side open for surgical and radiation options

27. Radiographic Procedure
Portacatheter was accessed using sterile technique
Patient was positioned supine on fluoroscopy table
Scout spot x-ray obtained
Patient was positioned in right anterior oblique
10 cc non ionic iodinated contrast was injected in the port
Live fluoroscopy and rapid sequence imaging was obtained

28. Scout fluoroscopy image 1 month post port placement
Note: Loop in catheter
Note: Distal location of catheter

29. Examination Results Malposition of the distal end of the portacatheter
Loop in middle portion of portacatheter
Fibrin sheath formation of distal portacatheter lumen

30. Port Injection Image
Note: contrast jetting superiorly and laterally from catheter.

31. Differential Diagnosis
Extravasation of contrast through fracture or hole of catheter

32. Discussion
Migration of the catheter tip superiorly with a mid-portion loop is known complication especially with left sided ports due to the vessel pathway
Fibrin sheath formation of the distal catheter lumen another known complication of portacatheters allowed a limited forward flush, but no blood aspiration

33. Suggestions Removal of current portacatheter
Replace with a new portacatheter

34. Discussion 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.

35. References
Kandarpa, 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 from
Mauro, 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

36. Esophagram Pathology
Richard Danieli

37. Patient Information 77 year old female
No known surgery to gastrointestinal tract
No weight loss

38. Patient History Dysphagia
Pharyngeal perforation, aspiration, and fistula were not clinically indicated therefore thick and thin barium contrast was used and not water soluble contrast.

39. Reason 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 aspiration
Postoperative assessment of laryngectomy
Penetrating Trauma

40. Relevant Information
Endoscopy showed antral deformity follow up with GI study recommended

41. Radiographic Procedure
Esophagram performed
Thick and thin barium used in vertical and horizontal positions
Patient positioned upright in right lateral, AP, and LPO
Patient positioned supine in RAO, AP and RPO
Images obtained of esophagus collapsed and dilated with barium
Modifications of routine exam to image visualized pathology

42. HH on CXR
The chest x-ray shows the Hiatal Hernia. Notice the circumscribed lucency behind the heart.

43. Zenckers Diverliculem
Notice the small Zenker’s diverticulm.

44. Diverticulum
Notice the distal esophageal diverticulum with barium distending distal esophagus
Image obtained in upright position

45. Distal Esophageal diverticulum
Notice distal esophageal diverticulum has barium pooling. In comparison to previous image there are tertiary contractions of the distal tortuous esophagus
Image obtained in upright position
stomach

46. Distal 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

47. Examination 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

48. Differential Diagnosis
The differentials for the hiatal hernia on the frontal chest x-ray are:
retrocardiac lung abscess
retrocardiac empyema
epiphrenic esophageal diverticulum
There 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 visualized
The zenckers diverticulum could be wrongly diagnosed as an ulcer
The distal esophageal diverticulum could be wrongly diagnosed as a large ulcer

49. Discussion
Zenker’s diverticulum correlates with the sensation of food getting stuck in the upper esophagus
Motility dysfunction which contributes to the patient’s dysphagia.
Considerable gastroesophageal reflux (suspected treatment or forgot to mention symptoms)
Asymptomatic distal esophageal diverticulum
Asymptomatic type IV complex paraesophageal hiatal hernia

50. Suggestions
Treatment 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 obstruction
No treatment for asymptomatic type IV complex paraesophageal hiatal hernia
No treatment for 77 year old asymptomatic distal esophageal diverticulum
No treatment for the Zencker’s diverticulum
No treatment for dysmotility

51. Suggestions
Upper gastrointestinal barium study to visualize the stomach and duodenum could be done for further evaluation
Small 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

52. Discussion 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 esophagram
Discuss the indications and contraindication of administering effervescent granules
Tina:
Define a Zenker’s diverticulum
Discuss another type of esophageal diverticulum

53. References
Herring 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:

54. Loopogram
Richard Danieli

55. Patient Information
A 68 year old male with history of muscle invading bladder cancer.
Post operative robotic assisted radical cystoprostatectomy
Post operative ileal conduit urinary diversion performed
Interesting case, hx bladder CA/ surgery, divert urine to ileal conduit.

56. Patient History History of bladder cancer Prior CT
Filling defects in the dilated left renal pelvis
Absence 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

57. Reason for the Examination
Recommendation from prior CT
Evaluate Ileal Conduit
Evaluate left ureter by retrograde contrast administration

58. Relevant Information History of bladder cancer
Obstructed proximal left ureter seen on prior CT

59. Radiographic Procedure
24-gauge Foley catheter inserted into stoma with 30 cc balloon inflated
Conray-60 introduced into ileal conduit by gravity infusion
Reflux into right ureter
No 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

60. Examination Results Normal right upper urinary tract
Normal ileal conduit contour
No reflux into left ureter due to obstruction at the ureteroileal junction

61. Loopogram Spot Film AP Note: No contrast in left ureter Catheter
Right ureter
Catheter balloon
Ileal conduit

62. Loopogram Spot Film Slight LPO
Note: No contrast in left ureter
Catheter
Catheter balloon
Right ureter
Ileal conduit

63. Loopogram Spot Film Steep LPO
Note: No contrast in left ureter
Right ureter
Catheter balloon
Catheter
Ileal conduit

64. Abdomen/Pelvis CT with IV Contrast Coronal Image
IV contrast in right ureter
IV contrast remained in left renal pelvis

65. Abdomen/Pelvis CT with IV Contrast Axial Image
IV contrast in right ureter
IV contrast remained in left renal pelvis

66. Differential Diagnosis
No contrast extravasated therefore obstructed
Ureteral obstruction post ileal conduit
Improperly fashioned anastomosis
Ischemia of the ureter with subsequent fibrosis and stricture
Recurrent tumor in the ureter (rare)
Infection or abscess formation with reaction
Edema
Calculus
Sloughed papilla
Adhesions or scarring.
Torsion or compression at the sigmoid

67. Discussion
No extravasation of contrast outside of the ileal conduit or the right ureter
Normal contour of ileal conduit and right ureter
No 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

68. Suggestions Renal ultrasound Renal radionuclide studies,
Percutaneous nephrogram/ureterogram
Intravenous pyelogram (IVP)
Abdomen/pelvis CT (with oral contrast, with and without IV contrast)

69. Discussion 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?

70. References
Appleby, S., & Atala, A. (2010, September 2). Urostomy and Continent Urinary Diversion. National Kidney and Urologic Diseases Information Clearinghouse. Retrieved July 7, 2012, from
Banner, M. P., Pollack, H. M., Bonavita, J. A., & Ellis, P. S. (1984). The radiology of urinary diversions. Radiographics, 4, Retrieved from
Fernbach, S., & Holland, E. (1988). Undiversion of the urinary tract: The pre-and postoperatie evaluation. Radiographics, 8, Retrieved from
Noble, 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 from
Thiruchelvam, 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

71. Right Wrist Arthrogram with Gadolinium injection
Rich Danieli

72. Clinical
19 year old female continued right wrist discomfort for four months status post surgery for fracture of 5th metacarpal due to traumatic fall
Patient continues to have pain with movement and therefore range of motion is slightly limited.

73. History
An 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.

74. Risks
Bleeding
Infection
Contrast Reaction
Joint Capsule Rupture.

75. Benefits
It assists and increases the ability to diagnose pathology within the wrist on the MRI.

76. Alternatives Do nothing MRI without gadolinium
Arthogram without gadolinium and MRI
Wrist arthroscopy.

77. Important Components 20ml syringe Gadolinium mixture
15ml saline
5ml isovue iodinated contrast
0.2ml of gadolinium.
Injection site of the wrist
radioscaphoid joint
Small patient and small joint
only 2.5ml of Gad mixture was injected.

78. End of Procedure Exercise wrist Final images obtained and recorded
Send patient to MRI

79. Differential Artifact Gadolinium injected in the wrong area
Delayed gadolinium injection time from MRI scan time

80. Triangular 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

81. Results
Partial sprain triangular fibrocartilage complex ligament at its attachment to the ulnar styloid
Internal sprain triangular fibro cartilage.
Arthrogram right wrist with contrast and gadolinium injection

82. Results
Partial sprain TFC ligament at its attachment to the ulnar styloid
Internal sprain triangular fibro cartilage.
MRI right wrist with gadolinium

83. Results
Partial sprain TFC ligament at its attachment to the ulnar styloid
Internal sprain Triangular fibro cartilage.
MRI right wrist with gadolinium

84. Radiology Report MRI
No 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.

85. Questions
John
What 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?

86. Questions
Tina
What 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?

87. Questions
Stacy
What 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?

88. References
David 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

89. Questions