Musculoskeletal System (section 4)

CLINICAL PROBLEM

INVESTIGATION

RECOMMENDATION
{GRADE}

COMMENT
Osteomyelitis D01 XR Indicated [C] Initial Investigation
MRI Specialised investigations [C] MRI accurately demonstrated infection, especially in the spine
CT Specialised Investigation [C] CT is valuable for demonstration of sequestra
US Indicated [C] US may be valuable in acute osteomyelitis to demonstrate subperiosteal abscess, but there is a high false negative rate
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, as 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 Tx-99m-HMPAO or In-111-labelled white cells may be useful in confirming infection in the bone or joint. False negatives may be encountered in the spine.

?Primary bone tumour

(see also L44, L55)

 D02 XR Indicated [B] XR should be carried out when there is bone pain that is not resolving.
MRI Specialised investigations [B] If the XR appearances are suggestive of primary bone tumour, referral to a specialist centre should not be delayed.

MRI is the investigation of choice for local staging.

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 role of FDG-PET remains to be clarified
CT Specialised Investigation [B] CT may improve diagnostic information in some tumours, such as osteoid osteoma and demonstrate intratumoural calcification and ossification.

CT-guided biopsy of primary bone tumours should be carried out in  specialist bone tumour centres where histological expertise and knowledge of surgical approach is available. 

US Specialised Investigation [B] US-guided biopsy of superficial primary bone tumours should be carried out in specialised bone tumour centres where histological expertise and knowledge of surgical approach is available.
Known primary tumour ?Skeletal metastases D03 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 mets 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.
XR Skeletal survey Not indicated [C] XRs are only for specific focal symptomatic areas of correlation with a NM examination.
MRI Indicated [B] MRI more sensitive and specific than NM, MRI is the primary investigation of choice, particularly within the axial skeleton. May underestimate some peripheral lesions.
Soft tissue mass
?tumour		 D04 MRI Indicated [B] Provides best local staging and can provide a tissue diagnosis in a proportion of patients.
US Indicated [C] US can answer specific questions e.g. cystic/solid and can monitor progress of benign masses such as haematomas.
Bone pain D05 XR Indicated [C] Local view of symptomatic areas only.
NM Indicated [C] If pain persists with normal XR or equivocal and abnormal XR in specific circumstances (e.g. suspected osteoid osteoma, osteomyelitis or mets)
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 MRI unit). MRI may also provide further information when XR and/or NM findings are abnormal
CT Specialised Investigation [C] To define bony anatomy in areas of abnormality on XR/MRI/NM, especially if bone biopsy is indicated.
?Myeloma D6 XR Skeletal survey Indicated [B] For staging and identifying lesions which may benefit from radiotherapy. Survey can be very limited for follow-up.
NM Not indicated [B] Scintigraphy underestimates disease extent and is often negative. Consider bone marrow studies.
MRI Specialised investigation [B] Sensitive, limited to spine, pelvis and 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.
Metabolic bone disease D07 NM Indicated [C] Skeletal scintigraphy may be useful in differentiating causes of hypercalcaemia, e.g. mets and hyperparathyroidism and of raised alkaline phosphate e.g. pagets' disease and mets
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.
DEXA Indicated [A] Measurement of bone density. DEXA or quantitative CT provides objective measurements of bone mineral content.
Osteomalacia

(see also D09)

 D08 XR Indicated [B] Localised XR to establish cause of local pain or equivocal lesion on NM.
NM Specialised investigation [C] NM can show increased 'activity' and some local complications such as Pseudo-fractures
Pain :
osteoporotic collapse    (see also D08)		 D09 XR lateral 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.
Arthropathy: presentation D10 XR affected joint Indicated [C] May be helpful to determine cause although erosions are a relatively late feature.
XR hands / feet Indicated [C] In patients with suspected rheumatoid arthritis, XR feet may show erosions even when symptomatic hand(s) appear normal.
XR multiple joint(s) Indicated only in specific circumstances [C] Symptomatic joints only
US / NM / MRI Specialised investigations [C] All accurately show acute synovitis. NM can show distribution. MRI can show articular cartilage and early erosions
Arthropathy: follow-up D11 XR Indicated only in specific circumstances [C] XRs needed by specialists to assist management decisions.
Painful shoulder D12 XR Not indicated initially [C] Degenerative changes in the acromio-clavicular joints and rotator cuff are common.
Shoulder impingement D13 MRI Specialised investigation [B] Has value in the demonstration of both bursal inflammatory change and the aetiology of associated abnormalities. Dynamic MRI or MRI in the abducted position may be of diagnostic value in subacromial impingement syndrome
XR Indicated only in specific circumstances [B] Pre-operative investigation
US Specialised investigation [B] Clinical diagnosis can be aided by US findings.
Shoulder instability D14 CT arthrography MR arthrography Specialised investigation [B] Glenoid labrum and synovial cavity are well delineated by both techniques. Some gradient echo MR techniques can show labrum well without arthrography. Arthrography (with or without CT), US and MRI may all be used in the diagnosis
Rotator cuff tear D15 Arthrography or US or 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 is valuable in demonstrating complete tears.
Sacroiliac joint lesion D16 XR SI joints Indicated [B] May help in investigation of sero-negative arthropathy. SI joints usually adequately demonstrated on AP XR lumbar spine or pelvis.
MRI or NM or CT Specialised investigation [C] MRI or CT or perhaps NM when plain XRs equivocal; MRI can detect earlier than XR. Dynamic contrast enhancement may be useful. MRI is particularly useful in children and adolescents.
Hip pain: full or limited movement


(For Children see Section 13)		 D17 XR Pelvis Indicated only in specific circumstances [C] XR and MRI only if symptoms and signs persist or there is a complex history
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 injection still have to be evaluated properly.
NM Not Indicated Initially [C] May be helpful if XR is normal

N.B. This recommendation does not apply to children.               (for hip pain in children see 1318, 1321)
Hip pain: ?avascular necrosis D18 XR Pelvis Indicated [B] Abnormal in established disease.
MRI Indicated [B] MRI is the most sensitive in the detection of early avascular necrosis and will demonstrate its extent
NM/CT Specialised Investigation [B] The use of pinhole collimator or SPECT is important
Knee pain: without locking or restriction in movement D19 XR Indicated only in specific circumstances [C] Symptoms frequently arise from soft tissues and these will not be demonstrated on XR. OA changes common. XRs needed when considering surgery.
Knee pain: with locking. D20 XR Indicated [C] To identify radio-opaque loose bodies.
Knee pain: D21 MRI Specialised investigation [B] MRI is only appropriate when 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.
Painful Prosthesis D22 XR Indicated [B] XR is useful to detect loosening
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. Combines Leukocyte and marrow imaging is currently the technique of choice for peri-prosthetic infection.
Arthrography (aspiration/biopsy) Specialised Investigation [B] Aspiration 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.
US Specialised Investigation [C] Accurate for detection of peri-prosthetic abscess or superficial infection.
Hallux valgus D23 XR Indicated only in specific circumstances [C] For assessment before surgery.
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, MRI, are more sensitive in showing inflammatory changes and should be used selectively. The majority of patients should be managed on the basis of clinical findings without imaging.

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