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The traditional process of imaging has been performed under a specific radiologic order from a physician. This is changing through the expansion of services through advanced nursing and physician assistant providers often described as physician extenders and other clinicians with an increasing role in primary care. In the United States, the ordering of basic/screen radiologic assessment is now often accomplished through clinicians who are not physicians. This chapter presents a recommended format for the evolving provision of diagnostic imaging.
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The starting point is always the determination of the need for imaging. An example of the challenge today is often seen in orthopedic surgery. The manual assessment reveals a positive Lachman test that has a sensitivity of approximately 90% for rupture of the anterior cruciate ligament. The patient then demands an MRI as that is what must be done in these cases. A great starting point in asking the question of imaging is: “Will the results of the imaging change the way I will treat this patient?” As we have seen a huge increase in use of certain advanced imaging modalities, better guidelines have emerged and are now available to assist the appropriate sequences in most patients. The American College of Radiology provides the Appropriateness Criteria on their Web site (www.acr.org/Quality-Safety/Appropriateness-Criteria) better enabling the recommended sequence of imaging. These criteria are easily utilized and are now the “norm” in general patient care. Also ideal is that the clinician provides context to the radiologist for the imaging, which may assist in the discernment of the imaging selected and interpretation. Today, this is typically accomplished in providing information on the imaging order and/or verbal communication between the ordering clinician and the radiologist. The radiologist reading of the imaging has great value in confirming the treating clinician’s perceptions, questioning the actual diagnosis, or the completeness of same. The timing and requirement for reading and reporting on an image or set of images by a radiologist is dictated by each jurisdiction’s practice act.
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This text uses a regional approach that is consistent with how imaging is typically described. In many situations, radiography remains the primary initial imaging modality through efficiency and cost. In general terms, clinicians ordering radiography nearly always begin with a regional series. These series at a minimum will have two images directed at 90° opposition (i.e., AP and lateral views). If the region has overlapping structures or bony presentations at differing angles, oblique or specifically selected additional angles are procured. This is nicely demonstrated in the ankle where the imaging sequence begins with the AP and lateral with additional oblique and/or mortise views to better assist in clarity of structure (Figures 2-1 to 2-3). During the past several years, clinicians have developed ordering paradigms for specific regions. The ankle is one of these with the Ottawa rules dictating the need for plain film imaging if specific things are part of the patient presentation ...