Description
Plain radiographs are typically used as the first-line modality for assessment of lower extremity conditions. Computed tomography (CT) is used for evaluation of tumors, metastatic lesions, infection, fractures and other problems. Magnetic resonance imaging (MRI) is the first-line choice for imaging of many conditions, but CT may be used in these cases if MRI is contraindicated or unable to be performed.

OVERVIEW
*Conservative Therapy (musculoskeletal) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components such as rest, ice, heat, modified activities, medical devices (such as crutches, immobilizer, metal braces, orthotics, rigid stabilizer or splints, etc. and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized.

**Home Exercise Program (HEP) — The following two elements are required to meet guidelines for completion of conservative therapy: 

CT and Osteolysis — Since computed tomography scans show both the extent and the location of lytic lesions, they are useful to guide treatment decisions, as well as to assist in planning for surgical intervention when needed, in patients with suspected osteolysis after total hip arthroplasty (THA).

CT and Tarsal Coalition — This is a congenital condition in which two or more bones in the mid-foot or hind-foot are joined. It usually presents during late childhood or late adolescence and is associated with repetitive ankle sprains. Mild pain, deep in the subtalar joint and limited range of motion are clinical symptoms. Tarsal coalition is detectable on oblique radiographs, but these are not routinely obtained at many institutions. Clinical diagnosis is not simple; it requires the expertise of skilled examiners. CT is valuable in diagnosing tarsal coalition because it allows differentiation of osseous from non-osseous coalitions and depicts the extent of joint involvement as well as degenerative changes. It may also detect the overgrowth of the medial aspect of the talus that may be associated with talocalcaneal coalitions.

American Academy of Pediatrics “Choosing Wisely” Guidelines advise against ordering advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. “History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the work up of injury or pain (spine, knees and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies frequently require sedation in the young child (5 years old or less) and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient … if you believe findings warrant additional advanced imaging, discuss with the consulting orthopedic surgeon to make sure the optimal studies are ordered (AAP, 2018).”

Policy
INDICATIONS FOR LOWER EXTREMITY CT (FOOT, ANKLE, KNEE, LEG or HIP)
Plain radiographs must precede CT evaluation.

Some indications are for MRI, CT, or MR or CT arthrogram. More than one should not be approved at the same time.

If a CT arthrogram fits approvable criteria below, approve as CT.

Joint-specific provocative orthopedic examination when MRI is contraindicated or cannot be performed (See Table 1.)
Note: With a positive orthopedic sign, an initial X-ray is always preferred. However, it is not required to approve advanced imaging.

• Ankle
  • Unstable syndesmotic injury (high ankle injury)
    • With inconclusive stress X-rays (a standing CT is preferred)
    • Can have positive fibular translation, squeeze or cotton test, but imaging may be needed to confirm diagnosis
• Knee1-7
  • Any positive test listed
    • McMurray’s
    • Apley’s
    • Lachman’s
    • Anterior or Posterior Drawer sign
    • Varus or valgus stress
    • Acute mechanical locking of the knee not due to guarding⁸
• Hip
  • Anterior impingement sign (labral tear)^9,10,11
• Posterior Impingement sign (labral tear)¹²

Joint or muscle pain without positive findings on an orthopedic exam as listed above after X-ray completed and an MRI is contraindicated or cannot be performed (does not apply to young children)^3,13

• Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last six months which includes active medical therapy (physical therapy, chiropractic treatments and/or physician-supervised exercise**) of at least four weeks, OR
• With progression or worsening of symptoms during the course of conservative treatment
• Persistent hip mechanical symptoms including clicking, locking, catching, giving way or hip instability with a clinical suspicion of labral tear, with or without clinical findings suggestive of impingement^12,14

Ankle instability and suspected anterior talofibular ligament rupture (anterior and posterior drawer tests) as a result of a sprain requires initial active conservative therapy (above) and X-ray

Painful acquired or congenital flatfoot deformity in an adult after X-ray completed and MRI is contraindicated

• After failure of active conservative therapy listed above^15,16

Extremity mass

• Mass or lesion after non-diagnostic x-ray or ultrasound¹⁷ and MRI cannot be performed. CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI.¹⁸
  • Baker’s cyst should be initially evaluated with ultrasound.
  • If superficial, then ultrasound is the initial study.
  • If deep, then X-ray is the initial study.

Known cancer of the extremity^{19,20,21,22,23}

• Cancer staging
• Cancer Restaging
• Signs or symptoms of recurrence

Infection of bone or joint^24,25
Note: MRI and nuclear medicine studies are recommended for acute infection as they are more sensitive in detecting early changes of osteomyelitis.^26,27 CT is better at demonstrating findings of chronic osteomyelitis (sequestra, involucrum, cloaca, sinus tracts) as well as detecting soft tissue gas and foreign bodies.²⁸

• Abnormal X-ray or ultrasound
• Negative X-ray but with a clinical suspicion of infection
  • Signs and symptoms of joint or bone infection include:
    • Pain and swelling
    • Decrease range of motion
    • Fevers
  • Laboratory findings of infection include:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Ulcer (diabetic, pressure, ischemic, traumatic) with signs of infection (redness, warm, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment, and bone or deep infection is suspected²⁹
• Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell³⁰
• Neuropathic foot with friable or discolored granulation tissue, foul odor, non-purulent discharge and delayed wound healing³¹

Osteonecrosis (avascular necrosis [AVN], Legg-Calve-Perthes disease) when MRI is contraindicated or cannot be performed^32,33,34

• Abnormal X-ray
• Normal or indeterminate X-rays but symptomatic and high risk (e.g., glucocorticosteroid use, renal transplant recipient, glycogen storage disease, alcohol abuse,³⁵ sickle cell anemia³⁶)

For evaluation of known or suspected autoimmune disease (e.g., rheumatoid arthritis) and MRI is contraindicated³⁷

• Further evaluation of an abnormality or non-diagnostic findings on prior imaging
• Initial imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g., RF, ANA, CRP, ESR)
• To determine change in treatment or when diagnosis is uncertain prior to start of treatment
• Follow-up to determine treatment efficacy of early rheumatoid arthritis
• Follow-up to determine treatment efficacy of advanced rheumatoid arthritis if X-ray and ultrasound are equivocal or noncontributory

Crystalline arthropathy

• Dual-energy CT can be used to characterize crystal deposition disease, such as gout versus CPPD³⁸

Trauma
Bone fracture

• Suspected stress or insufficiency fracture with a negative initial x-ray^39,40,41:
  • If hips and MRI cannot be done
  • Non-hip extremities: if X-rays taken 10 – 14 days after the injury or clinical assessment are negative or nondiagnostic⁴²
  • If at high risk for a complete fracture with conservative therapy (e.g., navicular bone) and MRI cannot be performed⁴³
• Suspected acute hip fracture with initial X-rays negative or non-diagnostic^11,44
• Intra articular fractures that may require surgery (i.e., depressed tibial plateau fracture)⁴⁵
• Nonunion or delayed union as demonstrated by no healing between two sets of X-rays. If a fracture has not healed by 4 – 6 months, there is delayed union. Incomplete healing by 6 – 8 months is nonunion^46,47

Tendon or muscle rupture after X-ray and MRI is contraindicated or cannot be performed^48,49,50

• Clinical suspicion based on mechanism of injury and physical findings

Suspected ACL rupture — Acute knee injury with physical exam limited by pain and swelling with X-ray completed (Wheeless, 2018) if MRI is contraindicated⁶

• Inability to perform because of pain and swelling should be considered a red flag
• Suspicion should be based on mechanism of injury, i.e., twisting, blunt force
• Normal X-ray:
  • Extreme pain, inability to stand, audible pop at time of injury, very swollen joint, leg numbness
• Abnormal X-ray:
  • Large joint effusion on X-ray knee effusion⁵¹

Osteochondral lesions (defects, fractures, osteochondritis dissecans) and X-ray done (if MRI contraindicated or cannot be done)^{6,14,52,53,54}

• Clinical suspicion based on mechanism of injury and physical findings

Foreign body⁵⁵

• Indeterminate X-ray and ultrasound

Loose bodies or synovial chondromatosis seen on X-ray or ultrasound

• In the setting of joint pain⁵⁶

Peripheral nerve entrapment (e.g., tarsal tunnel, Morton’s neuroma) and MRI is contraindicated, including any of the following^57,58,59,60

• Abnormal electromyogram or nerve conduction study
• Abnormal X-ray or ultrasound
• Clinical suspicion and failed four weeks conservative treatment including at least two of the following (active treatment with physical therapy is not required):
  • Activity modification
  • Rest, ice or heat
  • Splinting or orthotics
  • Medication

Pediatrics
Note: Leg length discrepancy — The literature indicates that standing plain film X-rays are preferred, but there are some advantages to using a CT scanogram instead and may be preferred^61,62

• Osteoid osteoma after an X-ray is done⁶³
• Painful flatfoot (Pes planus) deformity with suspected tarsal coalition, not responsive to active conservative care⁶⁴
  • When MRI cannot be performed; OR
  • Extra-articular coalition is suspected (bony bridges around the joints); OR
  • When needed for surgical planning⁶⁵
• Slipped capital femoral epiphysis and chronic recurrent multifocal osteomyelitis — MRI is the appropriate modality, rather than CT

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation

• When imaging, physical, or laboratory findings indicate joint infection, delayed or non-healing, or other surgical/procedural complications
• Joint prosthesis loosening or dysfunction, X-rays non-diagnostic^66,67
• Trendelenburg sign or other indication of muscle or nerve damage after recent hip surgery

Table 1: Positive Orthopedic Joint Tests, Lower Extremity

References 

1. Abousayed M, Alley M, Shakked R, et al. Adult-Acquired flatfoot deformity: Etiology, diagnosis and management. JBJS Reviews. 2017 Aug; 5(8):e7.
2. American Academy of Pediatrics (AAP). Section on Orthopaedics and the Pediatric Orthopaedic Society of North America. Choosing Wisely®. http://www.choosingwisely.org/clinician-lists/aap-posna-mri-or-ct-for-musculoskeletal-conditions-in-children/. Released February 12, 2018.
3. Beaman FD, Von Herrmann PF, Kransdorf MJ, et al. American College of Radiology ACR Appropriateness Criteria® - Suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot). J Am Coll Radiol. 2017; 14:S326-S337. https://acsearch.acr.org/docs/3094201/Narrative/.
4. Bencardino JT, Stone TJ, et al. ACR Appropriateness Criteria Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol. 2017 May;14(5S):S293-S306.
5. Bennett DL, Daffner RH, Weissman BN, et al. American College of Radiology ACR Appropriateness Criteria® - Non-traumatic Knee Pain. https://acsearch.acr.org/docs/69432/Narrative/. Published 2012.
6. Bestic JM, Wessell DE, Beaman FD, et al. American College of Radiology ACR Appropriateness Criteria® - Primary Bone Tumors. https://acsearch.acr.org/docs/69421/Narrative/. Revised 2019.
7. Boas FE, Fleischman D. CT artifacts: Causes and reduction techniques. Imaging Med. 2012; 4(2): 229-240.
8. Bouchard M, Mosca VS. Flatfoot deformity in children and adolescents: surgical indications and management. J Am Acad Orthop Surg. 2014; 22(10):623.
9. Bowers S, Franco E. Chronic wounds: Evaluation and management. Am Fam Physician. 2020 Feb; 101(3):159-66.
10. Cecava ND, Dieckman S, Banks KP, et al. Traumatic knee injury: correlation of radiographic effusion size with the presence of internal derangement on magnetic resonance imaging. Emerg Radiol. 2018 Oct; 25(5):479-87.
11. Chou H, Chin TY, et al. Dual‐energy CT in gout – A review of current concepts and applications. J Med Radiat Sci. 2017 Mar; 64(1): 41–51.
12. Colebatch AN, Edwards CJ, Østergaard M, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013; 72:804-814. http://ard.bmj.com/content/72/6/804.
13. Dodwell ER. Osteomyelitis and septic arthritis in children: Current concepts. Curr Opin Pediatrics. 2013 Feb; 5(1):58–63.
14. Domkundwar S, Autkar G, Khadilkar SV, et al. Ultrasound and EMG–NCV study (electromyography and nerve conduction velocity) correlation in diagnosis of nerve pathologies. J Ultrasound. 2017 Jun; 20(2):111-122.
15. Dommett RM, Redaniel MT, Stevens MC, et al. Features of cancer in teenagers and young adults in primary care: a population-based nested case-control study. Br J Cancer. 2013; 108(11):2329. Epub 2013 Apr 25.
16. Dong Q, Jacobsen JA, Jamadar DA, et al. Entrapment neuropathies in the upper and lower limbs: Anatomy and MRI features. Radiol Res Practice. 2012; 2012:230679.
17. Donovan A, Rosenberg ZS, Cavalcanti CF. MR imaging of entrapment neuropathies of the lower extremity. Radiographics. 2010; 30(4).
18. Doral MN, Bilge O, Huri G, et al. Modern treatment of meniscal tears. EFORT Open Rev. 2018; 3(5):260-268.
19. Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: Role of CT in the emergency department. Radiographics. 2007; 27:1723-36.
20. Felten R, Pemin P, Caillard S, et al. Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism. PLOS ONE. February 22, 2019.
21. Fitzgerald JJ, Roberts CC, Daffner RH, et al. American College of Radiology ACR Appropriateness Criteria® - Follow-up of Malignant or Aggressive Musculoskeletal Tumors. https://acsearch.acr.org/docs/69428/Narrative/. Published 2015.
22. Fox MG, Chang, EY, Amini B, et al. American College of Radiology ACR Appropriateness Criteria® - Chronic Knee Pain. https://acsearch.acr.org/docs/69432/Narrative/. Revised 2018.
23. Fox MG, Graham JA, Skelton BW, et al. Prospective evaluation of agreement and accuracy in the diagnosis of meniscal tears: MR Arthrography a short time after injection versus CT arthrography after a moderate delay. Am J Roentgenol. 2016; 207:142-149. 10.2214/AJR.15.14517.
24. Fritz J, Lurie B, Miller TT, et al. MR imaging of hip arthroplasty implants. Radiographics. 2014; 34(4):E106-E132. http://pubs.rsna.org/doi/abs/10.1148/rg.344140010.
25. Fritz J, Lurie B, Potter HG. MR imaging of knee arthroplasty implants. Radiographics. 2015 Aug; 35(5).
26. Fukushima W, Fujioka M, Kubo T, et al. Nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res. 2010 Oct; 468(10):2715-24
27. Gaddey HL, Riegel AM. Unexplained lymphadenopathy: Evaluation and differential diagnosis. Am Fam Physician. 2016 Dec 1; 94(11):896-903.
28. Garras DN, Raikin SM, Bhat SB, et al. MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures: Clinical Diagnostic Criteria. Clin Orthop Relat Res. 2012 Aug; 470(8): 2268–2273.
29. Gill SK, Smith J, Fox R, Chesser TJ. Investigation of occult hip fractures: the use of CT and MRI. Sci World J. 2013; 2013:830319.
30. Glaser C. Tarsal Coalitions: A Practical Approach to a Not-So-Rare Entity. J Belgian Soc Radiol. 2016; 100(1):104. DOI: http://doi.org/10.5334/jbr-btr.1224.
31. Glaudemans AWJM, Jutte PC, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging. 2019; 46(4): 957–970.
32. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009; 2(2):105-17.
33. Guggenberger R, Pfirrmann CW, Koch PP, et al. Assessment of lower limb length and alignment by biplanar linear radiography: Comparison with supine CT and upright full-length radiography. Am J Roentgenol. 2014; 202(2):W161-W167.
34. Hananouchi T, Yasui Y, Yamamoto K, et al. Anterior impingement test for labral lesions has high positive predictive value. Clin Orthop Relat Res. 2012 Dec; 470(12):3524–3529.
35. Hesper T, Zilkens C, Bittersohl B, et al. Imaging modalities in patients with slipped capital femoral epiphysis. J Child Orthop. 2017; 11(2):99-106. http://doi.org/10.1302/1863-2548-11-160276. https://www.ncbi.nlm.nih.gov/pubmed/28529656.
36. Holzapfel K, Regler J, Baum T, et. al. Local Staging of Soft-Tissue Sarcoma: Emphasis on Assessment of Neurovascular Encasement—Value of MR Imaging in 174 Confirmed Cases. Radiology. 2015 Jan; 275(2).
37. Hussin P, Mawardi M, et al. The 'Chalky Culprit' of acute locked knee. G Chir. 2014; 35(9-10):239–240.
38. Iyer RS, Chapman T, et al. Pediatric bone imaging: Diagnostic imaging of osteoid osteoma. Am J Roentgenol. 2012; 198:1039-1052.
39. Kamegaya M, Saisu T, Nakamura J, et al. Drehmann sign and femoro-acetabular impingement in SCFE. J Ped Orthop. 2011 Dec; 31(8):853-857.
40. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368:1675-1684.
41. Kellar J, Givertz A, et al. Biphosphonate-related Femoral Shaft Fracture. Clin Pract Cases Emerg Med. 2020 Feb; 4(1):62-64.
42. Khan AN, Seriki DM, Hutchinson E, et al. Legg-Calve-Perthes Disease. Emedicine. 2011. http://emedicine.medscape.com/article/410482-overview.
43. Kircher MF, Willman JK. Molecular body imaging: MR imaging, CT, and US. Part II. Applications. Radiology. 2012; 264(2):349.
44. Kopf S, Beaufils P, Hirschmann MT, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2020; 28(4):1177-1194.
45. Laya BF, Restrepo R, Lee EY. Practical imaging evaluation of foreign bodies in children: An update. Radiol Clin North Am. 2017 Jul; 55(4):845-867.
46. Lefevre N, Naouri JF, Herman S, et al. A current review of the meniscus imaging: Proposition of a useful tool for its radiologic analysis. Radiol Res Pract. 2016; 2016:8329296.
47. Lipsky BA, Senneville E, Abbas ZG, et al. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diab Metab Res Rev. 2020 Mar; 36 Suppl 1:e3280.
48. Mandell JC, Khurana B, Smith JT, et al. Osteomyelitis of the lower extremity: Pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. Emerg Radiol. 2017.
49. Mintz DN, Roberts CC, et al. ACR Appropriateness Criteria Chronic Hip Pain. J Am Coll Radiol. 2017 May; 14(5S):S90-S102.
50. Mohankumar R, White L, Naraghi A. Review. Pitfalls and pearls in MRI of the knee. AJR Am J Roentgenol. 2014; 203:516-530. https://www.ajronline.org/doi/full/10.2214/AJR.14.12969.
51. Mohseni S, Shojaiefard A, Khorgami Z, et al. Peripheral lymphadenopathy: Approach and diagnostic tools. Iran J Med Sci. 2014 Mar; 39(2 Suppl):158–170.
52. Mordecai SC, Al-Hadithy N, Ware HE, et al. Treatment of meniscal tears: An evidence based approach. World J Orthop. 2014 Jul 18; 5(3):233–241.
53. Morshed S. Current Options for Determining Fracture Union. Adv Med. 2014; 2014:708574.
54. Mullan CP, Madan R, Trotman-Dickenson B, et al. Radiology of chest wall masses. AJR. 2011; 2011:197(3).
55. Murphey MD, Foreman KL, Klassen Fischer MK, et al. From the radiologic pathology archives imaging of osteonecrosis: Radiologic-pathologic correlation. RadioGraphics. 2014 Jul 14; 34(4)
56. Murphey MD, Roberts CC, Bencardino JT, et al. American College of Radiology ACR Appropriateness Criteria® - Osteonecrosis of the Hip. J Am Coll Radiol. 2016; 13:147-155. https://acsearch.acr.org/docs/69420/Narrative/.
57. Murphey MD, Wessell DE, et al. ACR Appropriateness Criteria Soft-Tissue Masses. J Am Coll Radiol. 2018 May; 15(Suppl 5):S189-S197.
58. Naraghi A, White LM. MRI of labral and chondral lesions of the hip. AJR Am J Roentgenol. 2015; 205(3):479-490. https://www.ajronline.org/doi/full/10.2214/AJR.14.12581.
59. National Comprehensive Cancer Network (NCCN). Imaging guidelines. 2019. https://www.nccn.org/professionals/physician_gls/default.aspx.
60. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011; 83:39-46. https://www.ncbi.nlm.nih.gov/pubmed/21888126.
61. Peck DM, Voss LM, Voss TT. Slipped capital femoral epiphysis: Diagnosis and management. Am Fam Physician. 2017 Jun 15; 95(12):779-784.
62. Peck J, Gustafson KE, Bahner DP. Diagnosis of achilles tendon rupture with ultrasound in the emergency department setting. Int J Academ Med. 2017; 3(3):205-207.
63. Pitocco D, Spanu T, Di Leo M, et al. Diabetic foot infections: A comprehensive overview. Eur Rev Med Pharmacol Sci. 2019 Apr; 23(2 Suppl):26-37.
64. Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: An update. EFORT Open Rev. 2016;1(5):225-232. doi:10.1302/2058-5241.1.000031
65. Rabinovich RV, Haleem AM, Rozbruch SR. Complex ankle arthrodesis: Review of the literature. World J Orthop. 2015 Sep 18; 6(8):602–613.
66. Rajani R, Quinn R. Synovial chondromatosis. OrthoInfo. 2016 Dec. https://orthoinfo.aaos.org/en/diseases--conditions/synovial-chondromatosis
67. Ross AB, Lee KS, Chang, EY, et al. American College of Radiology ACR Appropriateness Criteria® Acute Hip Pain–Suspected Fracture. Revised 2018. https://acsearch.acr.org/docs/3082587/Narrative/.
68. Ross AB, Lee KS, Chang, EY et al. ACR Appropriateness Criteria Acute Hip Pain-Suspected Fracture. J Am Coll Radiol. 2019 May; 16(5S):S18-S25.
69. Sabharwal S, Kumar A. Methods for Assessing Leg Length Discrepancy. Clin Orthop Relat Res. 2008 Dec; 466(12):2910–2922.
70. Sadineni RT, Psumarthy A, Bellapa NC, et al. Imaging patterns in MRI in recent bone injuries following negative or inconclusive plain radiographs. J Clin Diagn Res. 2015 Oct; 9(10):TC10–TC13.
71. Salih S, Blakey C, Chan D, et al. The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures. Strat Trauma Limb Reconstr. 2015; 10(3):149–153.
72. Scalcione LR, Gimber LH, Ho AM, et al. Spectrum of carpal dislocations and fracture-dislocations: Imaging and management. Am J Roentgenol. 2014; 203:541-550.
73. Sinha S, Peach AH. Diagnosis and management of soft tissue sarcoma. BMJ. 2010; 341:c7170.
74. Slaughter AJ, Reynolds KA, Jambhekar K, et al. Clinical orthopedic examination findings in the lower extremity: Correlation with imaging studies and diagnostic efficacy. Radiographics. 2014 Mar; 34(2).
75. Smith TO, Drew BT, Toms AP, et al. Accuracy of magnetic resonance imaging, magnetic resonance arthrography and computed tomography for the detection of chondral lesions of the knee. Knee Surg Sports Traumatol Arthrosc. 2012 Dec; 20(12):2367-79. Epub 2012 Jan 24.
76. Smith BE, Thacker D, Crewesmith A, Hall M. Special tests for assessing meniscal tears within the knee: A systematic review and meta-analysis. Evid Based Med. 2015; 20:88-97.
77. Subhawong TK, Fishman EK, Swart JE, et al. Soft-tissue masses and masslike conditions: What does CT add to diagnosis and management? AJR Am J Roentgenol. 2010 Jun; 194(6):1559–1567.
78. Taljanovic, MS, Chang, EY, Ha, AS, et al. American College of Radiology Appropriateness Criteria® - Acute Trauma to the Knee. Revised 2019. https://acsearch.acr.org/docs/69419/Narrative/.
79. Thorpe SW, Wukich DK. Tarsal coalitions in the adult population: Does treatment differ from the adolescent? Foot Ankle Clin. 2012 Jun; 17(2):195-204.
80. Tos P, Crosio A, Pugliese P, et. el. Painful scar neuropathy: Principles of diagnosis and treatment. Plast Aesthet Res. 2015; 2:156-64.
81. Turan A, Celtikci P, Tufan A, et al. Basic radiological assessment of synovial diseases: A pictorial essay. Eur J Rheumatol. 2017 Jun; 4(2):166-74.
82. Van Bergen CJA, Van den Ende KIM, Ten Brinke B, et al. Osteochondritis dissecans of the capitellum in adolescents. World J Orthop. 2016 Feb 18; 7(2):102–108.
83. Van Dijk CN, Reilingh ML, Zengerink M, et al. Osteochondral defects in the ankle: Why painful? Knee Surg Sports Traumatol Arthrosc. 2010 May; 18(5):570–580.
84. Vuurberg G, Hoorntje A, Wink LM, et.al. Diagnosis, treatment, and prevention of ankle sprains: Update of an evidence-based clinical guideline. Br J Sports Med. 2018; 52(15):956. Epub 2018 Mar 7.
85. Wali Y, Almaskan S. Avascular necrosis of the hip in sickle cell disease in oman. Is it serious enough to warrant bone marrow transplantation? Sultan Qaboos Univ Med J. 2011 Feb; 11(1):127–128.
86. Walker EA, Beaman FD, et al. ACR Appropriateness Criteria Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus. J Am Coll Radiol. 2019 Nov; 16(Suppl 11):S440-S450.
87. Wheeless III CR. Wheeless' Textbook of Orthopaedics. Duke University Medical Center's Division of Orthopedic Surgery. © 1996-2018 Data Trace Internet Publishing, LLC. Updated 2018.
88. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute achilles tendon ruptures: A quantitative systematic review of randomized controlled trials. Am J Sports Med. 2012; 40(9):2154. Epub 2012 Jul 16.
89. Zoga AC, Weissman BN, Kransdorf MJ, et al. American College of Radiology ACR Appropriateness Criteria® – Soft Tissue Masses. 2017. https://acsearch.acr.org/docs/69434/Narrative/.
90. Zollars ES, Hyer M, Wolf B, et al. Measuring lupus arthritis activity using contrasted high-field MRI. Associations with clinical measures of disease activity and novel patterns of disease Lupus. Science Med. 2018; 5:e000264. doi: 10.1136/lupus-2018-000264.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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