Synonym/Acronym
Joint study.
Rationale
To assess and identify the cause of persistent joint pain and monitor the progression of joint disease. Commonly performed on shoulder, elbow, wrist, hip, knee, ankle, temporomandibular joint.
Patient Preparation
There are no food, fluid, activity, or medication restrictions unless by medical direction.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Pediatric Considerations: Young children may need to be sedated in order to remain still during the procedure. Parents should be encouraged to ask about preparation for sedation prior to the procedure, including any ordered medications or restrictions regarding medications, diet, and activity.
Normal Findings
- Normal bursae, menisci, ligaments, and articular cartilage of the joint. (Note: The cartilaginous surfaces and menisci should be smooth, without evidence of erosion, tears, or disintegration.)
Study type: X-ray, special/contrast; related body system: Musculoskeletal system.
An arthrogram evaluates the cartilage, ligaments, and bony structures that compose a joint. After a local anesthetic is administered to the area of interest, a fluoroscopically guided small-gauge needle is inserted into the joint space. Fluid in the joint space is aspirated and sent to the laboratory for analysis. A water-based iodinated contrast or air-contrast medium is injected into the joint space to outline the soft tissue structures and the contour of the joint (direct arthrography). After a brief exercise of the joint, radiographs, computed tomography (CT), or magnetic resonance images (MRIs) are obtained.
Arthrography is instrumental in evaluating ongoing joint pain or dysfunction, damage from recurrent dislocations of a joint, visualizing synovial cysts, and identifying acute or chronic tears in the soft tissue of the joint. Arthrography can also be used therapeutically to remove fluid in the joint space or to inject medications for pain relief.
Pediatrics:Arthrography is usually performed on young athletes with a suspected chronic joint injury or acute joint trauma. Hip arthrography is performed most often in children to evaluate congenital hip dislocation, hip dysplasia, or Perthes disease, before and after treatment.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with infection in the joint of interest.
Patients with active arthritis.
Patients with bleeding disorders receiving an arthrogram, because the injection site may not stop bleeding.
Patients with metal in their body, such as shrapnel or ferrous metal in the eye, and who will be having associated MRI studies.
Patients with cardiac pacemakers and who will be having associated MRI studies, because the pacemaker can be deactivated by MRI.
Factors That May Alter the Results of the Study
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the joint being examined.
- Explain that the procedure takes about 30 to 60 min and is usually performed in the radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain to the patient having an MRI that earplugs will be provided to block out the loud, banging sounds that occur during the MRI. Advise that communication with the technologist is available at all times during the MRI examination via a microphone within the scanner.
- Discuss how focused and controlled breathing assist with relaxation during the procedure.
- Explain that taking slow, deep breaths can help relieve nausea that may occur during the procedure. Usually an ordered antiemetic drug can be administered as needed. Easy access to an emesis basin should be available for use.
Procedural Information
- Preparation for the procedure entails aseptically cleaning and anesthetizing the skin surrounding the joint.
- Positioning for this procedure is determined in accordance with procedures ideally suited for the joint being examined after placement on the examination table.
- Baseline vital signs are recorded and monitored throughout the procedure.
- A small-gauge needle is inserted into the joint space during the procedure so that any fluid in the space can be aspirated and sent to the laboratory for analysis.
- Contrast medium is inserted into the joint space with fluoroscopic guidance as is appropriate to the imaging study.
- The joint is exercised to help distribute the contrast medium. X-rays, CTs, or MRIs are then taken of the joint.
- Explain that there will be monitoring for complications related to the procedure (e.g., allergic reaction, infection, pain).
- Continuous monitoring is performed to assess for complications related to the procedure (e.g., allergic reaction, etc.).
- Once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.
- Protocols may vary among facilities.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Possible complications include bleeding, infection, and pain.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Advise the patient to immediately report symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting to the appropriate HCP.
- Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
- Advise notifying the HCP if fever, increased pain, drainage, warmth, edema, or swelling of the joint occurs.
- Explain that noises from the joint after the procedure are common and should disappear 24 to 48 hr after the procedure.
- Advise avoiding strenuous activity, showering, and use of a hot tub or heating pad until approved by the HCP.
Treatment Considerations
- Follow post-procedure vital sign and assessment protocol.
- Observe and assess the joint for swelling after the test.
- Assess pain characteristics, location, duration, and intensity.
- Institute pain management modalities that fit with the patient’s view of appropriate pain management.
- Instruct in the use of an ordered mild analgesic (aspirin, acetaminophen) for discomfort. Note that narcotics may be ordered for severe pain.
- Discuss how the appropriate use of an ice pack can relieve pain and reduce swelling (i.e., ice bag wrapped in a small towel and filled with crushed ice).
- Explain how crushed ice easily conforms to the body site, and a towel helps protect the skin from the ice cold temperature.
- Advise that medicating for pain 30 min prior to activity can maximize self-care opportunities and decrease pain.
- Use rest periods to decrease joint aggravation.
- Discuss self-care activities that may require assistance, and collaboratively develop a plan to meet those needs.
- Assist patient in meeting activities of daily living.
- Encourage participation in self-care as much as possible.
- Assess the severity of mobility limitations.
- Explore the use of assistive devices to support mobility and range of motion exercises for the affected side.
- Review and adapt environment to physical limitations to prevent injury.
- Teach the patient to perform circulation exercises and to elevate the affected limb, as ordered and appropriate, to prevent swelling and formation of blood clots related to pooling of blood during lengthy periods of inactivity.
Nutritional Considerations
- Consider diet modification if excess body weight places stress on affected joints.
Clinical Judgement
- Consider why some individuals refuse to use assistive devices to improve mobility and ensure safety, and how to convince them otherwise.
Follow-Up and Desired Outcomes
- Acknowledges contact information provided for the American College of Rheumatology (www.rheumatology.org) or the Arthritis Foundation (www.arthritis.org).
- Recognizes the value of rehabilitation in accomplishing a full recovery.
- Agrees to participate in a home-based exercise program or physical therapy to assist in recovering strength and range of motion.
- Acknowledges that a balanced exercise regime during recovery that avoids both excessive and insufficient use of the affected muscles will provide the best outcome. Excessive use can cause inflammation, pain, and swelling, and insufficient use can cause stiffness and atrophy. Agrees to avoid strenuous activity until approved by the HCP.