Musculoskeletal System

Common Diagnostic Tests ANA, antinuclear antibodies Detects SLE, a collagen disease Arthritis can result from SLE Normal = negative Client prep

CRP, C-reactive protein inflammation and auto-immune disorders show abnormal protein Normal = female 1-20, male 1-13mm/h Can get false negative Client Prep, usually non-fasting blood draw

Uric Acid-Blood Elevated with Gout and arthritis Normal = male , female mg/dl Client prep: usually non-fasting blood draw

Uric Acid-Urine (24 hour collection) Normal = ml/24hr Client prep

CBC Hemoglobin Increase can mean CHF Decrease can mean SLE or sarcoidosis Normal = male 14-18, female g/dl Client prep

CBC WBC elevated with infection/inflammation Normal + 5,000 – 10,000/mm3 Client prep

ESR, Erythrocyte Sedimentation Rate RBC descent in saline in 1 hour Increases with inflammation, infection, necrosis, or cancer Normal = male up to 15, female up to 20 mm/hr Client prep

RF, Rheumatoid Factor (IgM) Elevated with autoimmune disease such as Rheumatoid arthritis and SLE Normal = < 60 U/ml or negative Client prep

Serum Calcium, detects calcium metabolism Increase may indicate: metastatic bone tumor, Paget’s disease, acromegaly Decrease may indicate: rickets, osteomalacia, vitamin D deficiency Normal = 9.0 – 10.5 mg/dl < 6mg/dl may lead to tetany (cramps, convulsions, twitching) > 14mg/dl may lead to coma Client prep

Radiologic Studies Arthrogram/Arthrography-Xray with contrast dye into joint to visualize soft tissue of joints (meniscus, ligaments, cartilage)

Arthrogram Client prep

Arthrogram Procedure: Cleanse & anesthetize area Insert needle into joint space Aspirate fluid to minimize dilution of dye Leave needle in, replace syringe with dye syringe Inject contrast and remove needle ROM to distribute dye X-rays will be taken Takes about 30 minutes May experience some discomfort, pressure, tingling

Following Arthrogram: Assess for swelling Apply ice, if needed Mild analgesic May hear crepitus after test. This is normal and will disappear in 1-2 days. Instruct pt to call MD if pain or swelling occurs

CT Scan X-ray (body scanner) with contrast dye Three-dimensional cross-sectional view of tissues at various angles Can identify small differences: Detects edema, hemorrhage, blood flow, infarcts, tumors, infections, aneurysms, demyelinating disease, muscular disease, skeletal abnormalities, disk problems, causes of spinal cord compression Takes about an hour Findings as with arthrogram, but 3-D view

CT Scan Client prep

Following CT Scan Increase fluid intake to flush dye Evaluate patient for delayed reaction to dye (usually occurs within 2-6 hours) Treat with antihistamine and/or steroids, if indicated

CT Scan Procedure Patient must lie still Show picture of CT machine and discuss claustrophobia, may need antianxiety med Performed by a radiologist Takes minutes Discomfort includes lying still on a hard surface, peripheral venipuncture, mild nausea, salty taste, flushing, and warmth from dye

MRI MRI/Magnetic Resonance Imaging Magnetic field and radio waves, noninvasive Can evaluate soft & hard tissue, & blood vessels Unique d/t no exposure to ionizing radiation Advantages over CT Disadvantages

MRI Contraindications: > 300 lbs Claustrophobia Metal implants, clips, pacemaker, infusion pumps Pregnancy (long-term effects not known) If on continuous life support

Client prep: Obtain consent Can drive afterwards without assistance Assess for contraindications Show picture of machine, discuss claustrophobia Remove all metal objects from body (create artifacts, can go flying, damages credit cards) Must remain motionless in supine position Will hear thumping sound, ear plugs available Empty bladder prior to test for comfort No food or fluid restrictions prior to test Explain procedure

MRI Procedure Lie flat on hard table that slide into a tube Must lie still Can talk to or listen to staff Magnevist (contrast agent) may be used via IV Performed by radiologist Takes 30 to 90 minutes Discomfort from lying on hard surface, possible venipuncture, possible tingling in teeth (metal fillings) No postprocedural care needed

MRI Detects: edema, hemorrhage, blood flow, infarcts, tumors, infections, aneurysms, demyelinating disease, muscular disease, skeletal abnormalities, disk problems, causes of spinal cord compression

X-ray X-ray, electromagnetic radiation passes photons (light particles) through the body onto film Bone (very dense) blocks photons, appears white Air appears black Muscle, fat, and fluid appear as various shades of gray Metal and contrast block almost all photons and appear bright white

X-ray Client prep Nonfasting Position determined by area to be x-rayed Patient should be still, usually hold breath Contraindicated if pregnant May need to remove jewelry & don a gown No discomfort except r/t position Detects fractures and some joint abnormalities

Myelogram X-ray with contrast dye of spinal subarachnoid space Detects spinal tumors, herniated discs, bone spurs, cervical ankylosing spondylosis, arthritic lumbar stenosis Contraindications: Multiple sclerosis patients (may cause exacerbation), ICP, infection near lumbar puncture sight, allergy to shellfish

Myelogram Client prep

Myelogram Procedure Empty bladder A lumbar puncture is performed 15 ml CSF removed 15 ml of radiopaque dye injected Patient will be tilted up and down to spread dye (prone position) Lights are off, dye followed with fluoroscopy X-ray films taken Needle remains in place until exam concluded Done by radiologist and takes 45 minutes Discomfort varies from mild to severe

Following Myelogram Bed rest for several hours Head position varies per dye used, per MD order Monitor for bleeding, fever, headache, photophobia, seizure, VS, ability to void, reaction to dye Possible med restrictions Push fluids

Bone Scan Radioactive isotope intravenous They use a gamma camera to detect “hot spots” of activity where the isotope collects Can detect tumor, arthritis, fracture, necrosis, degenerative changes, osteomyelitis Normal = uniform distribution Abnormal = area of higher concentration Contraindicated in pregnancy, breastfeeding

Bone Scan Advantages: Disadvantages:

Bone Scan Client prep: Explain procedure, is non-fasting, no sedation required Arrive at Nuclear Medicine department 4 hours prior to test Dye given IV, takes 4 hours to travel to bones Push fluid to aid in dye distribution Empty bladder upon return to avoid artifact You may be asked to wear a gown Done in supine, prone, & lateral position, takes an hour Takes 6-24 hours for dye to leave system (push fluids) Discomfort is needle stick for dye infusion, and hard surface

Bone Mineral Density/BMD BMD Measures bone mass The only test to diagnose osteoporosis Normal is comparative to same age, sex, size. Lower density = higher risk for fractures -1 to –2, Osteopenia < -2.5, Osteoporosis Client prep: Non-fasting, non-invasive, do Q2 yrs

Other Tests Arthrocentesis Obtain synovial fluid from a joint Needle aspiration Sterile procedure Detects infections, synovitis, crystal-induced arthritis, tumors, joint degeneration Inject anti-inflammatory medications Normal= Clear, straw-colored fluid, no crystals Contraindicated if infection near joint being tested

Arthrocentesis cont’d Informed consent Explain procedure May or may not be fasting Local anesthetic Aseptic procedure Fluid may be removed, Steroid may be injected Apply pressure dressing following procedure May do venipuncture to compare chemical content Doctor office or bedside, by MD, takes 10 minutes Pain may worsen after test

Following Arthrocentesis Assess for pain, fever, swelling Apply ice Apply pressure dressing to decrease reaccumulation of fluid or hematoma Avoid strenuous use of joint for several days

Arthroscopy-used most often for knee Small incision, endoscope Examine the inside of a joint Diagnose disease, meniscus problems, torn cartilage, remove small bodies, do biopsy Advantage: allows direct visualization, can perform surgery, can monitor disease progress, can attach video camera; can examine, biopsy, or do surgery Contraindications:Infection or ankylosis in joint

Arthroscopy Client prep: Obtain consent NPO at midnight Teach crutch use for post procedure use Shave 6” above and below joint May use local or general anesthesia Pressure wrap or tourniquet Knee at 45 degree angle May have 2-3 small incision sights Sutured with dressing applied Done by orthopedic surgeon, takes 15 to 30 minutes

Arthroscopy Follow-up Asses neurologic status and circulatory status Assess for sxs of infection, for drainage Teach to elevate & ice to decrease swelling May walk with crutches if MD order Suture removal in 7-10 days