Plain X-Ray & Ultrasound

Who to refer:

Please see individual pathways and the Primary Care Management section on Who to Refer

Referral for x-rays are governed by Ionising Radiation (Medical Exposure) Regulations 2018 and these are the responsibility of the Referrer.

For all Radiology requests: Referrers accept responsibility for dealing with the result(s) and informing the patient as necessary.

How to refer:

Plain x-rays: The majority of referrals for Plain x-rays should be made via SCI Gateway using the Radiology Plain X-ray protocols under the specific location where the x-ray is to take place. In certain practices where there has been appropriate training they are able to use the ICE Ordering system to order Plain X-rays

(If this is not possible, such as in the event of significant IT failure, please use the appropriate paper X-ray department form. These should be sent via internal mail and when advising patients to phone to arrange the x-ray, allow 48 hours for form to arrive.)

After referral all plain x-ray requests need to be scheduled in by the patient phoning the appropriate department using the guidance above.

Ultrasound: All referrals for Ultrasound should be made via SCI Gateway using the Radiology – Ultrasound referral form.

Guidance re Specific Plain x-ray and Ultrasound Investigations

Head and Neck – Skull

Who to refer (x-ray):

X-ray for palpable vault abnormality which feels bony

Who not to routinely refer for x-ray:

Headache – see guidance re CT Head, see also Neurology – Headache guidance

Headache suspicious of cancer – see guidance re Brain and Central Nervous System Cancers

Head Injury – if any concerns re intracranial injury, i.e. loss of consciousness, neurological defect, significant laceration, or haematoma – patient should be referred as an emergency to A&E

Note: Imaging departments may undertake skull X-ray as part of their imaging protocol for specific clinical problems e.g. skeletal survey for myeloma, but referral should specify the clinical indication for imaging.

Head and Neck – Face

Who to refer (x-ray):

X-ray for trauma to facial skeleton or mandible, not requiring attendance at A&E

X-ray for trauma to orbits including ?metallic foreign body, not requiring attendance at A&E

Who not to routinely refer for x-ray:

Middle or inner ear symptoms

Nasal trauma

Sinus disease

Temporal Mandibular Joint (TMJ) Dysfunction

Head and Neck – Neck soft tissues

Who not to routinely refer:

Suspected thyroid mass/goitre – refer directly to Endocrinology for all suspected thyroid disease. GPs should NOT refer for prior imaging.

Vascular/Carotid problems – refer to Stroke service for specialist assessment

Ultrasound for Salivary Glands

Chest

Who to refer (x-ray):

CXR Urgent Suspicion of Cancer (Remember to choose USC priority on the SCI GW Referral) as per SRGC and RefHelp Lung Cancer guidance

Any unexplained haemoptysis

Unexplained and persistent (more than 3 weeks): change in cough or new cough, breathlessness, chest/shoulder pain, loss of appetite, weight loss, chest signs, hoarseness, fatigue

Examination findings: focal chest signs, supraclavicular lymphadenopathy, New or not previously documented finger clubbing

Persistent or recurrent chest infection

Cervical and/or persistent supraclavicular lymphadenopathy

Thrombocytosis where symptoms and signs do not suggest other specific cancer

CXR Other indications:

Night sweats, fevers

Chronic respiratory conditions with unexplained change in symptoms

Unexplained increased CRP

Unexplained erythema nodosum

Strong suspicion of suspected underlying malignancy without obvious clinical primary (see additional RefHelp guidance here)

Post pneumonia follow up as advised by Radiology (Please see here for the Radiology Pneumonia Follow up protocol)

TB screening for new entrants to the UK from countries with a high prevalence of TB

Who not to routinely refer:

Chest trauma e.g. suspicion of rib fracture

COPD  / Asthma follow up

Heart failure / hypertension without clinical change (Please see guidance on diagnosis of Heart failure where prior to referral a CXR is considered ‘Helpful but not essential’)

Infection / cough / wheeze in children

Pre-operative assessment

Routine follow-up in the absence of clinical deterioration (unless advised by radiologist)

Medical screening – unless employment related risk

Upper respiratory tract infection

Suspected costochondritis

CXR for patients requiring admission – Included here for info, these conditions require admission, and investigations will be arranged by Secondary Care

Acute respiratory distress

Suspected pulmonary embolus (rule out other pathology prior to CTPA)

Chest trauma – severe / penetrating injury

Acute severe chest pain

Suspected acute decompensated heart failure

Suspected pneumothorax

Suspected chest sepsis

Sepsis of unknown origin

Testes

Please see guidance on the Scrotal Conditions page for advice on when to refer for testicular ultrasound

Abdomen

Who to refer (ultrasound):

Palpable abdominal mass (indicate if mass is lower or upper abdomen as patient preparation may be different)

Jaundice

Suspected gallbladder disease

Suspected pancreatic disease

? Abdominal aortic aneurysm

Post cholecystectomy pain

? Hepatic metastases

Persistent unexplained abnormal LFTS – see RefHelp guidance on when to refer

Who not to routinely refer:

Constipation – (although AXR may be useful in frail elderly, psychiatric and patients with intellectual impairment)

Non-specific abdominal pain

Abdominal bloating

Dysphagia – See RefHelp Dysphagia guidance

Heartburn / hiatus hernia / dyspepsia –- See RefHelp Dyspepsia guidance

Intestinal blood loss – See RefHelp GI guidance

Suspected small bowel disease – See RefHelp GI guidance

Suspected colonic pathology – See RefHelp GI guidance

For abdominal wall masses see section on soft tissue/MSK Lumps and bumps

Suspected hernia should be referred to the Surgical Service without prior imaging

Renal Tract

Who to refer (ultrasound):

CKD

? Hydronephrosis

? Urinary retention not requiring admission

? Renovascular hypertension

? Renal mass

Recurrent UTI as per RefHelp Urology Recurrent UTIs guidance

Nonvisible haematuria as per RefHelp Urology NVH guidance

Trauma and haematuria not requiring admission

Loin pain where renal calculi not suspected

Loin pain in women <40 years

Who to refer (CT KUB):

Acute renal colic not requiring admission

Who not to refer:

Visible haematuria – see RefHelp Urology Visible Haematuria guidance

Plain film KUB – except for long term follow up of at-risk patients – spinal injury/previous lithotripsy

?Prostatic malignancy – for specialist referral

Gynaecology

Who to refer (ultrasound):

Palpable pelvic mass

Post menopausal bleeding (PMB) – please use the PMB referral protocol on SCI Gateway so that these scans can be arranged promptly, as outlined in the RefHelp PMB page

Irregular menstrual bleeding/ inter-menstrual bleeding (not mid-cycle ovulatory bleeding)

Menorrhagia as indicated by Gynae Flowchart

Cyclical pelvic pain

Lost IUCD

Who not to routinely refer:

? PCOS (not routinely required -see guidance on RefHelp PCOS page re diagnosis of PCOS)

Menorrhagia without additional features suggesting ultrasound is required, as per Gynae Flowchart

Incidental finding of endometrial thickening in absence of PMB

Simple ovarian cysts where follow up not advised by Gynae / Radiology flow chart

MSK: Overall

Who to refer (x-ray)

Bone pain – symptomatic area only

? Myeloma – skeletal survey

? New arthropathy – x-ray affected joint only + hands/feet (single view) if RA suspected. For suspected OA (diagnosis confirmation) ensure symptoms >6 weeks; no previous x-ray.

? Osteomalacia – for local pain

? Osteomyelitis + Nuclear medicine – particularly in early disease when X-ray may be negative

Painful prosthesis – X-ray will not exclude all causes, if concerns with or without x-ray changes then refer to Orthopaedics urgently

Palpable bony mass – particularly if new/enlarging/painful and/or concerns re Primary bone tumour – this should be requested urgently and guidance in Sarcoma pathway followed

? Stress fracture

Trauma ?fracture not requiring attendance at A&E

Who not to routinely refer:

Routine Arthropathy follow up

Nonspecific musculoskeletal pain

Metabolic bone disease – biochemical tests usually suffice

Soft tissue mass – see guidance on suspected soft tissue sarcoma – imaging prior to referral not usually advised

MSK: Spine – Cervical spine

Who to refer (x-ray):

X-ray for ?Atlanto-axial subluxation (e.g. Down’s Syndrome, rheumatoid arthritis)

X-ray for ?Cervical Spondylosis with nerve root signs (MR preferred but not currently available as direct access)

X-ray for Injury with pain if not requiring admission

Who not to routinely refer:

Acute torticollis

? Cervical Spondylosis in absence of nerve root signs

Degenerative change

Dizziness / headaches

Whiplash injury without clinical findings

X-ray for injury with neurological deficit – these patients need A&E referral

MSK: Spine – Dorsal Spine

Who to refer (x-ray):

Injury with pain if not requiring admission

? infection

? Myeloma – ask for skeletal survey

? Osteoporotic vertebral collapse

? Primary malignancy – localised bone pain (Nuclear medicine may also be required)

Who not to routinely refer:

Acute back pain with no history of trauma (unless vertebral collapse suspected)

Degenerative change

? Metastatic bone disease (Nuclear medicine more sensitive)

Osteoporosis (unless vertebral collapse suspected)

Injury with neurological defect– these patients need A&E referral 

MSK: Spine – Lumbar Spine

Who to refer (x-ray):

? Ankylosing spondylitis

? Spondylolisthesis

First onset back pain in older patients (>55 years) and younger patients (<20)

Injury with pain if not requiring admission

? Myeloma – ask for skeletal survey

? Osteoporotic vertebral collapse

? Primary malignancy – localised bone pain (Nuclear medicine may also be required)

Who not to routinely refer:

Acute back pain in adults – symptoms may settle, six-week rule – thereafter referral to the NHS Lothian integrated back pain service is advised NHS Lothian Integrated Back Pain Pathway

Chronic back pain in adults with no pointers to infection or neoplasm

? Osteoporosis (vertebral collapse

Back pain with red flag signs – Plain films can be misleadingly normal and arranging them can therefore delay appropriate investigation with CT / MRI. Secondary care referral as per the linked guidance should be arranged.

Injury with neurological defect– these patients need A&E referral   

MSK: Spine – Whole Spine

Who to refer (x-ray):

Curvature of spine ?scoliosis or ?kyphosis (age 16-40)

Who not to routinely refer:

See reasons listed under individual guidance for cervical, dorsal, and lumbar spine

Patients younger than 16 and older than 40

MSK: Shoulder

Who to refer (x-ray):

? Rotator cuff calcification

Shoulder pain > 3 months

Trauma / dislocation – not requiring attendance at A&E

Who not to routinely refer:

? Impingement – specialist request

? Instability– referral to the Shoulder Physiotherapy Service is advised

? Rotator cuff injury – x-ray unhelpful for most rotator cuff problems – referral to the Shoulder Physiotherapy Service may be indicated

Shoulder pain – referral to the Shoulder Physiotherapy Service may be indicated

Shoulder ultrasound can’t be ordered directly by GPs in NHS Lothian, but may be requested by the Shoulder Physiotherapy Service if indicated

MSK: Pelvis and Hips

Who to refer (x-ray):

SI Joint problems

Trauma with inability to weight bear or persisting pain – not requiring attendance at A&E – if any risk of missed #NOF, please follow Radiology guidance re location of x-ray request

Suspected malignancy and hip pain

Clinical diagnosis of OA and no previous X-Ray

Unexplained undiagnosed hip pain >6 weeks and no previous X-Ray

? Avascular necrosis of the femoral head – if suspected then should refer for urgent Pelvic x-ray AND to Orthopaedics urgently as per guidance

Who not to routinely refer:

Hip pain – unless symptoms persist >6 weeks, risk of avascular necrosis or surgery considered

Trauma to coccyx

MSK: Knee

Who to refer (x-ray):

Knee pain with locking, restricted movement, or effusion

Knee pain when surgery considered

Trauma with physical signs – not requiring attendance at A&E

Suspected malignancy in patient with knee pain

Clinical diagnosis of OA and no previous X-Ray (symptoms >6 weeks and patient willing to undergo surgery)

Who not to routinely refer:

Knee pain without locking or restricted movement

? Osgood Schlatter’s disease

Trauma when physical signs are minimal

? Baker’s cyst – neither is ultrasound referral indicated to confirm the diagnosis

MSK: Ankle and Foot

Who to refer (x-ray):

Most general indications for bone and joint imaging apply (see Overall section above)

Who not to routinely refer:

Hallux valgus – except for pre-operative assessment

X-Ray for ? plantar fasciitis ? calcaneal spur

Trauma without: localised bony tenderness/ inability to weight bear/ significant soft tissue swelling

? Morton’s neuroma – refer to Foot/Ankle Service in the first instance

? Plantar fasciitis – refer to Foot/Ankle Service in the first instance

Discrete palpable mass ? ganglion/fibromatosis – refer to Foot/Ankle Service in the first instance

*Foot / Ankle ultrasound can’t be ordered directly by GPs in NHS Lothian, but may be requested by the Foot/Ankle Service if indicated*

Lumps and Bumps

Who not to routinely refer:

Lumps & Bumps should, in general, be referred to GP led Minor surgery or to General Surgery.

Suspected soft tissue cancer should be directed to the Orthopaedic Sarcoma clinic at RIE

Suspected hernia can be referred to the Surgical Service

Diffuse soft tissue swelling not suspicious of soft tissue cancer

Obviously, benign pathologies

Skin lumps and lesions

Clinical subcutaneous lipoma

Clinical sebaceous cyst

Mass <5cm diameter unless rapidly enlarging

Baker’s cysts: this is a clinical diagnosis. Referral is not indicated unless atypical and an alternative diagnosis is suspected

Breast lumps: All patients with suspected breast lumps, whether male or female, should be referred to the Breast Unit for assessment