SIERRA NEVADA MEDICAL ASSOCIATES, INC. (IPA)
UTILIZATION GUIDELINES
RADIOLOGY GUIDELINES
EXTREMITIES - GENERAL
MODALITY
Nuclide Scans
Nuclide scans are neither specific nor
sensitive and are not indicated.
Ultrasound
Results are very much operator
dependent.
CT
CT is useful when MRI is
contraindicated or unavailable.
MRI
MRI is best for the evaluation and
staging of bone and soft tissue tumors.
It is the preferred method to diagnose
stress fractures.
RAD - EXTREMITIES
INDICATIONS
 Selected cases of synovitis.
 May help to localize lesions for CT
or MRI
 May be helpful in stress fractures
and occult bone injury.
 Follow-up bone metastatis.
 Selected cases of RSD.
 Selected cases of Paget’s Disease.
 Evaluation of joint effusions,
especially popliteal and soft tissue
collections of fluid.
 Certain disorders of tendons.
 Periarticular soft tissues.
 Indications for MRI when MRI is
contraindicated.
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Suspected or known tumor of the
bone or soft tissue.
Staging of known bone or soft
tissue malignancy.
Suspected stress fracture.
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EXTREMITIES - ANKLES
MODALITY
Nuclide Scan
Radionuclide scans have limited value
here.
CT
CT offers no advantage over MRI when
MRI is available except in detection of
loose bodies and evaluation of
complex fractures.
MRI
MRI will usually provide, within one
study, information that might require
multiple other studies.
RAD - EXTREMITIES
INDICATIONS
 May be helpful in detection of stress
fractures and occult bony injury.



Suspected fractures not diagnoses
by plain radiographs.
Suspected bony injuries.
Suspected tendon disruptions.
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EXTREMITIES - HIPS
MODALITY
Nuclide Scans
Radionuclide scans have little value
except screening the skeleton or region
for infections or metastases.
Ultrasound
CT
CT is useful for the evaluation of
fractures which are visualized only
suboptimally on plain radiographs.
MRI
MRI is best for evaluation of potential
avascular necrosis. It is also best for
the anatomic definition of chronic
arthritis if surgery is being considered.
It is contraindicated post hip
replacement or ORIF.
Arthrography
RAD - EXTREMITIES
INDICATIONS
 Suspected infectious process.
 Suspected metastasis.
 Occult femoral neck fracture.
 Suspected ischemic necrosis in the
setting of recent hip fracture.
 Suspected occult hip fracture if MRI
not available.
 Evaluate neonatal hip dislocation..
 Clarification of possible or complex
fractures.
 Congenital hip dislocation.
 Suspected loose body in joint.
 Suspected avascular necrosis of
femoral head.
 Possible total joint arthroplasty,
depending on findings.
 Suspected osteomyelitis or septic
arthritis.
 Suspected stress fracture.
 Evaluate occult femoral neck
fracture (i.e. Perthes,
spondyloepiphysial dysplasia
 Evaluation of possible loosening of
prosthesis.
 R/O septic arthritis.
 Evaluation of femoral
head/acetabular morphology.
Page 3 of 6
EXTREMITIES - KNEES
MODALITY
Nuclide Scans
Radionuclide scans have limited value
here
Ultrasound
CT
CT has no value here.
MRI
MRI has replaced arthrograms and
diagnostic arthroscopy for the
evaluation of the knee. It is the best
way to evaluate knee cartilage and
ligaments for both acute injuries and
chronic dysfunction. It can also detect
subarticular abnormalities not visible at
arthroscopy such as subarticular stress
fractures or bone bruises.
RAD - EXTREMITIES
INDICATIONS

Evaluation of popliteal cyst (Baker’s
cyst) with or without dissection into
calf.

Suspected internal derangement of
knee.
Suspected subarticular stress
fracture or bone bruise.
Ischemic necrosis of bone.
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
Page 4 of 6
EXTREMITIES - SHOULDERS
MODALITY
INDICATIONS
CT
CT offers no advantage over MRI when
MRI is available.
Ultrasound
Ultrasound has little usefulness.
MRI
 Suspected impingement syndromes
or rotator cuff tears.
 Suspected capsular tears or labral
tears.
 Recurrent dislocation.
 Septic joint.
Arthrography
May be indicated (alone or with CT) in
selected cases to evaluate the rotator
cuff or cartilage. Arthrography is the
gold standard for the diagnosis of
rotator cuff tear.
RAD - EXTREMITIES
Page 5 of 6
EXTREMITIES - WRIST
MODALITY
Nuclide Scan
Radionuclide scans have little value
here.
CT
CT may have a role in inexpensively
screening carpal canals in populations
with a high incidence of carpal tunnel
syndrome.
MRI
MRI is the most sensitive and specific
modality for evaluation of the wrist. It
will often show findings not evident on
plain films or sooner than they would
be evident on plain films.
The quality of wrist MRI is highly
dependent on the generation of
scanner, surface coil and software.
INDICATIONS
Arthrography

RAD - EXTREMITIES





Suspected median nerve
entrapment in the carpal tunnel.
Suspected scaphoid (navicular)
fracture.
Evaluation of fractures in the elderly
or as a result of multiple trauma.
Evaluation of the unstable wrist.
Suspected fibrocartilage tears
associated with the distal ulna.
Selected cases of ligament
disruption.
Page 6 of 6