| D. Musculoskeletal system | |||||||
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CLINICAL/DIAGNOSTIC PROBLEM |
INVESTIGATION |
RECOMMENDATION (GRADE) |
COMMENT |
DOSE |
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Osteomyelitis
|
XR |
Indicated (C) |
Initial investigation. |
I |
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|
MRI |
Specialised investigation (C) |
MRI accurately demonstrates infection, especially in the spine. |
0 |
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|
CT |
Specialised investigation (C) |
CT is valuable for demonstration of sequestra. |
II |
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|
US |
Indicated (C) |
US may be valuable in acute
osteomyelitis to demonstrate subperiosteal abscess, but there is a false
negative rate. |
0 |
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|
NM |
Specialised investigation (C) |
The two- or three-phase
skeletal scintigram is more sensitive than XR in detecting suspected
focal osteomyelitis. If osteomyelitis is suspected but there are
no localising signs or symptoms, a skeletal scintigram is useful.
Findings on a skeletal scintigram are not specific and further
specialist NM imaging with alternative agents may be required, White
cells: the use of Tc-99m-HMPAO or In-111-labelled white cells may be
useful in confirming infection in bone or joint. False negative
results may be encountered in the spine. |
II-III |
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| Primary bone tumour | XR | Indicated (B) | XR should be carried out where there is bone pain that is not resolving | I | |||
| MRI | Specialised investigation (B) | If
the XR appearances are suggestive of primary bone tum6ur, referral to a
specialist centre should not be delayed.
MRI is the investigation of choice for local staging. |
0 | ||||
| NM | Indicated (B) | If the XR appearances are suggestive of primary bone tumour, the acquisition of skeletal scintigraphy should not delay referral to a specialist centre. The scintigram may overestimate local tumour extent. The role of FDG-PET remains to be clarified. | II | ||||
| CT | Specialised investigation (B) | CT
may improve diagnostic information in some tumours, such as osteoid
osteoma, and demonstrate intratumoral calcification and ossification. CT-guided biopsy of primary bone tumours
should be carried out in specialised bone tumour centres where
histological expertise and knowledge of surgical approach is available. |
II | ||||
| US | Specialised investigation (B) | US-guided biopsy of certain superficial primary bone tumours should be carried out in specialised bone tumour centres where histological expertise and knowledge of surgical approach is available. | 0 | ||||
| Known primary tumour, skeletal metastases | MRI | Indicated (B) | More sensitive and specific than NM, MRI is the primary investigation of choice, particularly in the axial skeleton. May underestimate some peripheral lesions. | 0 | |||
| NM | Indicated (B) | A
sensitive test, but correlative imaging is required to increase
specificity.
NM is useful for assessing the presence and extent of skeletal metastases in patients with known primary cancers. The skeletal scintigram is insensitive in assessing the extent of myeloma. It may also be used to assess response to treatment, although the flare phenomenon may suggest disease progression if performed too soon after systemic therapy. It is usually only appropriate to repeat a skeletal scintigram within 6 months if there are new symptoms. |
II | ||||
| XR skeletal survey | Not indicated (C) | XRs are indicated only for specific focal symptomatic areas or for correlation with a NM examination. | II | ||||
|
Soft tissue mass tumour |
MRI |
Indicated (B) |
Provides best local staging and can provide a tissue diagnosis in a proportion of patients |
0 |
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|
US |
Indicated (C) |
US can answer specific questions (e.g. cystic/solid) and can monitor progress of benign masses such as haematomas |
0 |
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Bone pain
|
XR |
Indicated (C) |
Local view of the symptomatic area. |
I |
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|
MRI |
Indicated (C) |
MRI is appropriate if pain persists with normal XR or apparently normal NM. If pain is diffuse, MRI is not always practicable (depends on technical capabilities of the MRI unit). MRI may also provide further information when XR and/or NM findings are abnormal. |
0 |
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|
NM |
Indicated (C) |
If pain persists with normal XR or equivocal and abnormal XR in specific circumstances (e.g. suspected osteoid osteoma, osteomyelitis, or metastases). |
II |
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|
CT |
Specialised investigation (C) |
To define bony anatomy in areas of abnormality on XR/MRI/NM, especially if bone biopsy is indicated. |
II
|
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Myeloma |
MRI |
Specialised investigation (B) |
Sensitive, limited to spine, pelvis, and the proximal femora. Particularly useful in non-secretory myeloma or in the presence of diffuse osteopenia. Can be used for tumour mass assessment and follow-up. |
0 |
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|
XR skeletal survey |
Indicated (C) |
For staging and identifying lesions which may benefit from radiotherapy. Survey can be limited to specific areas for follow-up. |
I-II
|
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|
NM |
Not indicated (B) |
Skeletal scintigraphy is often negative and underestimates disease extent; consider bone marrow studies. |
II |
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|
Metabolic bone disease
|
NM |
Indicated (C) |
Skeletal scintigraphy may be useful in differentiating causes of hypercalcaemia, e.g. metastases and hyperparathyroidism, and of raised alkaline phosphotase, e.g. Paget's disease and metastases. |
II |
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|
XR |
Indicated (C) |
May be helpful in differentiating new from old vertebral fractures or identifying a different cause of pain unrelated to osteoporosis. Correlation with NM will be required |
II |
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|
DEXA |
Indicated (A) |
Measurement of bone density. DEXA or quantitative CT provides objective measurements of bone mineral content. |
II |
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|
Osteomalacia
|
XR |
Indicated (B) |
Localised XR to establish cause of local pain or equivocal lesion identified on NM |
I |
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|
NM |
Specialised investigation (C) |
Can show increased activity and some local complication, such as pseudo-fractures. |
II |
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| Pain: Osteoporotic collapse | Lateral XR thoracic and lumbar spine | Indicated (B) | Lateral views will demonstrate compression fractures. NM or MRI more useful in distinguishing between recent and old fractures and can help exclude pathological fractures |
I-II |
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|
Arthropathy: presentation |
XR affected joint |
Indicated (C) |
May be helpful to determine cause, although erosions are a relatively late feature. |
I |
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| XR hands/feet | Indicated (C) | IN patients with suspected rheumatoid arthritis, XR feet may show erosions even when symptomatic hand(s) appear normal. |
I |
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| XR multiple joints | Indicated only in specific circumstances (C) | Symptomatic joints only. |
II |
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| US/NM/MRI | Specialised investigation (C) | All can show acute synovitis. NM can show distribution. MRI can show articular cartilage and early erosions. |
0/II/0 |
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| Arthropathy: follow-up | XR | Indicated only in specific circumstances (C) | May be needed by specialist to assist management decisions. | I | |||
| Painful shoulder | XR | Not indicated initially (C) | Degenerative changes in acromioclavicular joints and rotator cuff are common | I | |||
| Shoulder impingement syndrome | XR | Indicated only in specific circumstances (B) | Pre-operative investigation | I | |||
| MRI | Specialised investigation (B) | Has value in the demonstration both of bursal inflammatory change and the aetiology of associated abnormalities. Dynamic MRI or MRI in the abducted position may be diagnostic value in subacromial impingement syndrome. | 0 | ||||
| US | Specialised investigation (B) | Clinical diagnosis can be aided by US findings | 0 | ||||
| Shoulder instability | CT/MRI | Specialised investigation (B) | Glenoid labrum and synovial cavity are well delineated by both techniques. Some gradient echo MRI techniques can show labrum well without arthrography. Arthrography (with or without CT), US, and MRI may all be used in the diagnosis | II/0 | |||
| Rotator cuff tear | Arthrography/US/MRI | Specialised investigation (C) | MRI
has the advantage of providing a global assessment of structures around
the shoulder and when combined with arthrography has the highest
accuracy.
US valuable for demonstrating complete tears. |
I/0/0 | |||
| Sacroiliac joint lesion | XR sacroiliac joints | Indicated (B) | May help in investigation of sero-negative arthropathy. Sacroiliac joints are usually adequately demonstrated on AP XR lumbar spine or pelvis | I | |||
| MRI/CT/NM | Specialised investigation (C) | MRI or CT or perhaps NM when XR is equivocal; MRI can detect earlier than XR. Dynamic contrast enhancement may be useful. MRI is particularly useful in children and adolescents. | 0/II/II | ||||
| Hip
pain: full or limited movement
(For children see section M) |
XR pelvis | Indicated only in specific circumstances (C) | XR and MRI only if symptoms and signs persist or there is a complex history | I | |||
| MRI | Indicated only in specific circumstances (C) | MRI is useful to demonstrate inflammation and MR arthrography for evaluation of acetabular labral tears or loose bodies. Intra-articular local anaesthetic injections have still to be evaluated properly | 0 | ||||
| NM | Not indicated initially (B) | May
be helpful if XR is normal.
This recommendation does not apply to children. |
II | ||||
| Hip pain: avascular necrosis | XR pelvis | Indicated (B) | Abnormal in established disease | I | |||
| MRI | Indicated (B) | MRI is the most sensitive in the detection of early avascular necrosis and will demonstrate its extent. | 0 | ||||
| NM/CT | Specialised investigation (B) | The use of pinhole collimator or SPECT is important | II/II | ||||
| Knee pain without locking or restriction of movement | XR | Indicated only in specific circumstances (C) | Symptoms frequently arise from soft tissues and these will not be demonstrated on XR. Osteoarthritis changes are common. XR is needed when considering surgery. | I | |||
| Knee pain with locking | XR | Indicated (C) | To identify radio-opaque loose bodies | I | |||
| Knee pain | MRI | Specialised investigation (B) | MRI is only appropriate where there is a specific clinical management decision, e.g. arthroscopy being considered. MRI may also be required in defining the extent of rheumatological disorders, e.g. rheumatoid arthritis. Even in patients with definite clinical abnormalities warranting intervention, some surgeons find pre-operative MRI helpful in identifying unsuspected lesions. | 0 | |||
| Painful prosthesis | XR | Indicated (B) | XR is useful to detect established loosening | I | |||
| NM | Indicated (B) | Two-
to three-phase skeletal scintigraphy is useful for diagnosing and
differentiating infection and loosening. A normal NM study excludes most
late complications. Further specialised NM studies can help distinguish
loosening from infection.
It may be difficult to differentiate post-surgical changes from pathology in the early stages. If infection is suspected, further, more specific imaging may be required. Combined leukocyte and marrow imaging is currently the technique of choice for peri-prosthetic infection. |
II-III | ||||
| Arthrography (aspiration/biopsy) | Specialised investigation (B) | Aspiration in conjunction with arthrography is useful when findings are equivocal, when there is a high clinical suspicion of infection, or when a cause of pain is not established | II | ||||
| US | Specialised investigation (C) | Accurate for detection of peri-prosthetic abscess or superficial infection. | 0 | ||||
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| Hallux valgus | XR | Indicated only in specific circumstances (C) | Useful for assessment before surgery. | I | |||
| Heel pain: plantar fasciitis or calcaneal spur | NM/US/MRI | Indicated only in specific circumstances (B) | Calcaneal spurs are common incidental findings. The cause of pain is rarely detectable on XR. Other imaging, NM, US, and MRI, are more sensitive in showing inflammatory change and should be used selectively. The majority of patients should be managed on the basis of clinical findings without imaging | II/0/0 | |||
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