Referral Criteria for planar x-ray & fluoroscopic (including
theatres) examinations
Radiology Department
Document Control
Reference No: HEYRAD14 First published: July 2012
Version: 2 Current Version Published:
June 2019
Lead Director & IRMER Practitioner:
Drs Byass & Goldstone
Review Date: June 2022
Document Managed by Name:
Trevor Parker Ratification Committee: Plain Film and Fluoroscopy Operational Group
Document Managed by Title:
Clinical governance Radiographer
Date EIA Completed: N/A
Consultation Process
Section Managers, Lead Radiographers, MPE, Radiologists via RMT
Key words (to aid intranet searching)
Target Audience
All staff Clinical Staff Only Non-Clinical Staff Only
Managers Nursing Staff Only Medical Staff Only
Version Control
Date Version Author Revision description
June 2019 2 Craig Moore & Trevor Parker
Referral criteria taken out of HEYRAD12 to produce this stand-alone document
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1 INTRODUCTION This document is written to ensure that departmental process conforms with the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER 2017).
2 PURPOSE This document ensures the Radiology Department is compliant with regulation 6(5a) of the Ionising Radiation (Medical Exposure) Regulations 2017. It provides advice for referrers of patients for planar x-ray and fluoroscopic procedures to the Radiology Department at Hull University Teaching Hospitals.
3 SCOPE These procedures apply to all IRMER Referrers who request planar x-ray and fluoroscopic medical exposures.
4 DUTIES It is a legal requirement that the IRMER Referrer includes sufficient clinical details in the request to allow the radiation exposure to be justified and authorised by the Radiology IRMER Practitioner/Operator. The request must therefore conform to the criteria below. The IRMER Operator cannot legally perform x-ray procedures if the IRMER Referrer’s request does not conform to the criteria in this document, or if the patient and IRMER Referrer cannot be identified. Incomplete requests will be returned to the IRMER Referrer. If the request is part of a research project/clinical trial, this must be clearly indicated
on the request.
Typical radiation doses
The following referral criteria include an approximate level of patient radiation dose,
described in the table below.
Symbol Typical effective dose in mSv
Lifetime additional risk of cancer induction per
exam
˂1 Less than 1 in 20,000
1-5 1 in 20,00 to 1 in 4,000
5 - 10 1 in 4,000 to 1 in 2,000
>10 Greater than 1 in 2,000
Plain Film Referral Criteria Examination Plain Film Referral Criteria Relative Dose
Chest
Acute chest pain/central chest pain
Aortic dissection
Acute abdominal symptoms
Chronic stable angina
Pneumothorax
Sternal fracture
Pericarditis
Pleural effusion
Routine pre-operative (only on patients over 60 with significant cardiorespiratory symptoms)
Valvular cardiac disease
Pulmonary embolus
Lung cancer/metastases/pleural tumour
Pneumonia/chest infection
Pneumonia/chest infection follow up
Haemoptysis
Heart disease
Heart failure
Interstitial lung disease
Myocarditis
Hypertension
Acute exacerbation of asthma
Chronic Obstructive Pulmonary Disease
Surgical insertion or removal of device
NG tube check
Cervical rib
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Examination Plain Film Referral Criteria Relative Dose
Sternum
Abnormal isotope bone scan
Infection
Malignancy
Trauma
Abdomen
Acute abdominal pain
Obstruction
Perforation
Blunt trauma
Stab injury
Acute inflammatory bowel disease
Acute pancreatitis
Swallowed sharp or poisonous foreign body
Faecal impaction
Post-operative patient, not improving
Palpable abdominal or pelvic mass
Pre-MRI for patients who lack capacity, to eliminate pain relieving pumps/ baclofen pumps/ spinal stimulators, and renal stents being insitu.
Cervical Spine
Trauma
Fracture follow up
Osteoporotic collapse
Bone pain
Osteomyelitis
Primary bone tumour
Metastases
Myeloma
Metabolic bone disease
Osteomalacia
Arthropathy
Ankylosing Spondylitis
Atlanto-axial subluxation
Neurological deficit
Abnormal isotope bone scan
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Examination Plain Film Referral Criteria Relative Dose
Thoracic Spine
Trauma and follow-up for vertebral #
Fracture follow up
Osteoporotic collapse
Bone pain
Osteomyelitis
Primary bone tumour
Metastases
Myeloma
Metabolic bone disease
Osteomalacia
Arthropathy
Ankylosing Spondylitis
Neurological deficit
Abnormal isotope bone scan
Lumbar Spine
Trauma and follow-up for vertebral #
Fracture follow up
Osteoporotic collapse
Bone pain
Osteomyelitis
Primary bone tumour
Metastases
Myeloma
Metabolic bone disease
Osteomalacia
Arthropathy
Ankylosing Spondylitis
Neurological deficit
Abnormal isotope bone scan
Sacrum
Trauma
Fracture follow up
Abnormal isotope bone scan
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Examination Plain Film Referral Criteria Relative Dose
Sacroiliac joints
? sacroiliitis
? RA
? Uveitis
Coccyx Acute trauma
Abnormal isotope bone scan
Pelvis/Hip
Fall /inability to weight bear
? avascular necrosis
? Total Hip Replacement
? bone tumour
? osteomyelitis
? arthropathy
Painful prosthesis
Abnormal isotope bone scan
Pagets
Paediatric Pelvis
Irritable hip
Slipped capital femoral epiphysis
Perthes disease
Limping (unknown cause)
Trauma
Fracture follow up
Clicking hips
Development dysplasia of the hip
Hip
Trauma ?fracture
Fracture
Orthopaedic Referral
Complex history
Pain & OA
? bone tumour
? dislocated hip
? avascular necrosis
? osteomyelitis
?arthropathy
Abnormal isotope bone scan
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Examination Plain Film Referral Criteria Relative Dose
Femur
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Osteomalacia
Painful prosthesis
Paget’s disease
Abnormal isotope bone scan
Myeloma
Intramedullary nailing
Knee
Trauma – non weight bearing
Fracture follow up
Knee pain with locking/restricted movement
Bone tumour
Knee replacement/surgery
Effusion
Loose body
Osteomyelitis
Osteochondritis dessicans
Osteomalacia
Painful prosthesis
Abnormal isotope bone scan
Arthropathy
Tibia & Fibula
Trauma – non weight bearing/bony tenderness
Fracture follow up
Knee pain with locking/restricted movement
Bone tumour
Osteomyelitis
Osteomalacia
Painful prosthesis
Abnormal isotope bone scan
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Examination Plain Film Referral Criteria Relative Dose
Ankle
Trauma – tenderness/soft tissue swelling
Fracture follow up
Bone tumour
Osteomyelitis
Osteomalacia
Painful prosthesis
Ankle replacement/surgery
Abnormal isotope bone scan
Foot
Trauma – bony tenderness
Stress fracture
Fracture follow up
Bone tumour
Osteomyelitis
Foot surgery
Abnormal isotope bone scan
Calcaneum
Trauma
Stress fracture
Fracture follow up
Osteomyelitis
Abnormal isotope bone scan
Shoulder
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Arthropathy
Painful prosthesis
Abnormal isotope bone scan
Soft tissue calcifications (calcific tendonitis)
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Examination Plain Film Referral Criteria Relative Dose
Clavicle
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Abnormal isotope bone scan
Acromio-clavicular joint
Trauma/dislocation
Sterno-clavicular joint
Subluxation
Dislocation
Tumour
Scapula
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Abnormal isotope bone scan
Humerus
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Myeloma
Painful prosthesis
Abnormal isotope bone scan
Elbow
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Arthropathy
Abnormal isotope bone scan
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Examination Plain Film Referral Criteria Relative Dose
Forearm
? # following trauma
Follow up fracture (supported by RIS/PACS history)
? bone tumour
? osteomyelitis (must be at least
5/6 days after trauma to show/ ap view only)
Abnormal isotope bone scan
Radius & Ulna
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Abnormal isotope bone scan
Wrist
Trauma
Fracture follow up
Bone tumour
Osteomyelitis
Arthropathy
Abnormal isotope bone scan
Scaphoid
Trauma
Follow up (10-14 days)
Fracture follow up
Bone tumour
Abnormal isotope bone scan
Hand
Trauma
Fracture follow up
Bone tumour
Arthropathy
Osteomyelitis
Abnormal isotope bone scan
Bone age (DP view of non-dominant hand and wrist)
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Examination Plain Film Referral Criteria Relative Dose
Fingers
Trauma/dislocation
Fracture follow up
Arthropathy
Skull
Penetrating injury
Suspected NAI
Hydrocephalus ?shunt function
Following abnormal bone scan as indicated by radiologist
Facial Bones
Orbital Trauma –blunt injury
Middle 1/3 facial injury
Major facial trauma
Max-Fax Request OM15, OM30
Mandible
Trauma/dislocation
Fracture follow up
Osteomyelitis
Bone tumour
Dental assessment (OPT & Cephalostat)
Orbits
? Metallic FB (please read pre MRI protocol)
? Metallic FB or
? removed FB
? Glass FB
IVU
Renal Stone Disease
Analgesic Nephropathy
Medullary Sponge Kidneys
In conjunction with other imaging methods:
Haematuria. These patients need urology referral.
Recurrent urinary tract infections
Renal tract obstruction
Renal trauma
Post operative – renal tract.
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Examination Plain Film Referral Criteria Relative Dose
Sinuses
Referrals from ENT only unless authorised by a radiologist.
? Polyp
Chronic sinusitis
Clinical indication of recurrent sinusitis
? fluid levels
? malignancy
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Fluoroscopy Referral Criteria
Examination Fluoroscopy Referral Criteria Relative Dose
Barium Meal/Swallow
Dyspepsia
Gastric or duodenal ulcer
Globus
Disordered swallowing mechanism
Oesophageal pouch/web
Dysphagia
Oesophageal stricture
Carcinoma
Gastro-oesophageal reflux
Hiatus hernia
Odynophagia
Achalasia
Contrast Enema
Barium Enema clinical indications:
?Inflammatory bowel disease
?Abdominal mass
Change in bowel habit
Bleeding PR
Lower abdominal pain Water soluble contrast enema clinical indications:
?Large bowel obstruction
Post Operative Assessment
? Colonic Fistula or Leak
? malrotation after discussion with Radiologist
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Examination Fluoroscopy Referral Criteria Relative Dose
Water Soluble Enema
Any barium swallow criteria with high risk of aspiration
Gastric outlet obstruction
Post-operative assessment
Oesophageal perforation or fistula
Small Bowel Follow Through
Coeliac disease
Crohn’s disease
Obstruction
Intestinal blood loss – chronic or recurrent
Video Fluoroscopy Dysphagia
Sialogram ? Stones in salivary glands/ducts
? stricture
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Pancreatic and biliary malignancy
Choledocholithiasis
Acute or chronic pancreatitis
Pancreatic divisum
Palliative therapies
Dilatation of benign structures
Manometry
Hysterosalpingogram (HSG)
Infertility
Artificial insemination
Cystogram
Recurrent urinary tract infections
Pyelonephritis
Hydronephrosis
Bladder trauma/rupture
Stress incontinence/bladder dysfunction
Vesico-ureteric reflux
Cystocele
Bladder cancer
Bladder polyps
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Examination Fluoroscopy Referral Criteria Relative Dose
Percutaneous Transhepatic Cholangiogram (PTC)
Jaundice
Obstruction of bile duct
Hepatic carcinoma
Fluoroscopic Injections Pain relief
Cholecystotomy Empyema of gallbladder
Duodenal, Oesophageal, Colonic or Biliary Stent
Malignant obstruction
Ureteric Stent
Malignant obstruction
Inflammation
Infection
Surgical trauma
Ascitic Drain Refractory ascites secondary to portal hypertension
Palliation of malignant ascites
Respiratory embarrassment
PleurX™ Drain Long term palliation of malignant ascites
Radiologically Inserted Gastrostomy (RIG)
Compromise/disease of the upper GI tract.
Nephrostomy
Urinary tract infection
Urinary tract malignancy
Chemotherapy
Spina Bifida
Biopsy (Liver, Lung, Renal, Omental, Thyroid, Bone or Lymph node)
Collection of pathological/histological samples for analysis
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Examination Fluoroscopy Referral Criteria Relative Dose
Chest Drain
Post biopsy
Pneumothorax
Chylothorax
Empyema
Haemothorax
Hydrothorax
Arthrocentesis
Pathological/histological sample collection
Gout
Septic Arthritis
Nasojejunal Tube
Nutrition due to compromise/disease of the upper GI tract
Post RIG insertion
Inferior/Superior Vena Cava Filter
Deep vein thrombosis
Pulmonary embolus
Free floating thrombus in IVC
Prophylaxis pre-surgery
Testicular Embolisation Painful varicocele
Venogram Vein patency
Dacrocystogram Epiphoria
Arthrogram Rotator cuff tear
Evaluation of the glenoid/acetabular labrum
Lumbar (Nerve root block, facet joint injection, SI joint injection)
Lumbosacral pain syndromes (including somatic, neuropathic and visceral origin).
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Examination Fluoroscopy Referral Criteria Relative Dose
Cervical (Nerve root block, facet joint injection)
Cervical pain, occipital headache, sympathetic mediated pain
Joint injections Bursa, pain due to arthritis
Proctograms
Anismus,
Tenismus
Difficulty defecating
Obstructed defecation
Faecal incontinence
Prolapse
Anterior or posterior rectocele.
Descending Perennial Syndrome (DPS),
Chronic constipation
Incomplete emptying or capacious rectum
Rectal intussusception
Intra-anal intussusception
External rectal prolapse
Enterocele
Sigmoidocele
Incontinence and solitary rectal ulcer.
Urethorograms Trauma,
Stricture, poor bladder emptying
post-op assessment.
Myelography
Indicated where there is suspicion of pathology affecting the contents of the spinal canal - specifically the spinal cord, cauda equina and spinal nerve roots.
It is mostly indicated when MRI is contraindicated and occasionally as a problem solving investigation supplementary to MRI.
NG Tube
Nutritional support required – difficulties in performing the procedure on ward.
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Examination Fluoroscopy Referral Criteria Relative Dose
MCUG Recurrent UTI’s
Poor urine flow,
Vesico-ureteric reflux
Lumbar Puncture
Difficulties in performing the procedure on ward/day unit. o To obtain samples of cerebrospinal fluid (CSF) for diagnostic
purposes. o Measure opening pressure CSF for diagnostic purposes o Therapeutic drainage of CSF where pressure is raised and
clinical symptoms of raised intracranial pressure
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Theatre X-Ray Procedures Referral Criteria Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose
Dynamic Hip Screw Fractured hip/femur
Intramedullary Nailing Fractured femur/tibia
Manipulation under Anaesthetic
To evaluate the position of a fracture during manipulation
Open Reduction Internal/External Fixation (ORIF)(ExFix)
Reduction of fractures Check position of metalwork during operation
Temporary Pacemaker Insertion
Complete/partial heart block Arrhythmia Asystole
Retrograde Pyelogram Ureteric obstruction Filling defects (stones or tumours) Assist with percutaneous access Stent placement Haematuria Trauma Assess duplex systems
Joint Injections e.g. hip Bursa Pain due to Arthritis
Cervical- (medial branch nerve block/facet joint/epidural/stellate ganglion/RF)
Cervical pain, Occipital headache, Sympathetic mediated pain
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Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose
Lumbar-(Spinal Nerve Root Block/medial branch nerve block/Epidural/Facet joint Injection/SI joint/sympathectomy-lumbar, superior hypogastric plexus block, ganglion impar block)/piriformis injection/pudendal nerve block/psoas compartment block/Radiofrequency ablation(RF)
Lumbosacral pain syndromes, thoracic pain syndromes(including somatic, neuropathic and visceral origin)
Thoracic-paravertebral/intercostal nerve block/epidural/sympathectomy/suprascapular nerve block/RF
Lumbosacral pain syndromes, thoracic pain syndromes(including somatic, neuropathic and visceral origin)
Trigeminal Nerve Rhizotomy
Neuralgia
Removal of Metal Work/Foreign Bodies (FBD)
Location of broken screws/plates/foreign bodies/lost swabs
Hickman Line/Portacath insertion/Longline check
Difficulty in positioning of line, e.g. portacath, hickman line, for permanent IV access.
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Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose
On table Angiography – peripheral vascular
Trauma to check vascular flow, angioplasty, graft patency, embolism.
On Table Cholangiogram Query presence of stones in biliary duct.
Sacral Nerve Stimulation Fecal incontinence and overactive bladder
Retrograde pyelogram/ Cystoscopy/ On table Cystogram
Ureteric reflux, ‘STING’ (subureteral transurethral injection) procedure, stones. Disorders of urethra including posterior urethral valves. Position check for stents. Abnormalities of duplex systems.
Stent insertion/ stent removal/ stent change.
Kidney stones/obstruction of the urine flow from the kidney.
Any instrumented spinal surgery (including anterior cervical plates, corpectomy cages, arthroplasty, interspinous distraction devices, vertebroplasty)
To ascertain correct vertebral level prior and during surgery. Deformity correction (ie checking the fracture-dislocation has corrected, or the spondylolisthesis has reduced)
Transsphenoidal Adenomectomy
Removal of tumour from pituitary gland
Radiofrequency Rhizotomy
Trigeminal Neuralgia
ERCP – Endoscopic Retrograde Choledocopancreatogram +/- Stent Insertion
Acute Pancreatitis – If considered Gall stone related Pancreatic trauma Pancreatic ascites Dilated bile ducts on Ultrasound or CT Pancreatic masses or cysts Possible bile duct damage post surgery Chronic abdominal pain
Dilatation e.g. Oesophageal/Stent Ins
Oesophageal Carcinoma Benign strictures Post surgical anastamosis strictures
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