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Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae

Variant: 1   Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography area of interest Usually Appropriate Varies
Bone scan whole body with SPECT or SPECT/CT area of interest May Be Appropriate (Disagreement) ☢☢☢
US area of interest Usually Not Appropriate O
MRI area of interest without and with IV contrast Usually Not Appropriate O
MRI area of interest without IV contrast Usually Not Appropriate O
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies
CT area of interest without IV contrast Usually Not Appropriate Varies

Variant: 2   Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI area of interest without IV contrast Usually Appropriate O
Radiography area of interest repeat in 10-14 days May Be Appropriate Varies
Bone scan whole body with SPECT or SPECT/CT area of interest May Be Appropriate ☢☢☢
CT area of interest without IV contrast May Be Appropriate Varies
US area of interest Usually Not Appropriate O
MRI area of interest without and with IV contrast Usually Not Appropriate O
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 3   Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI area of interest without IV contrast Usually Appropriate O
US area of interest Usually Not Appropriate O
Radiography area of interest repeat in 10-14 days Usually Not Appropriate Varies
MRI area of interest without and with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT area of interest Usually Not Appropriate ☢☢☢
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies
CT area of interest without IV contrast Usually Not Appropriate Varies

Variant: 4   Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate “need-to-know.” Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI area of interest without IV contrast Usually Appropriate O
Bone scan whole body with SPECT or SPECT/CT area of interest May Be Appropriate (Disagreement) ☢☢☢
CT area of interest without IV contrast May Be Appropriate Varies
US area of interest Usually Not Appropriate O
Radiography area of interest repeat in 10-14 days Usually Not Appropriate Varies
MRI area of interest without and with IV contrast Usually Not Appropriate O
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 5   Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI area of interest without IV contrast Usually Appropriate O
Bone scan whole body with SPECT or SPECT/CT area of interest May Be Appropriate ☢☢☢
CT area of interest without IV contrast May Be Appropriate Varies
US area of interest Usually Not Appropriate O
Radiography area of interest repeat in 10-14 days Usually Not Appropriate Varies
MRI area of interest without and with IV contrast Usually Not Appropriate O
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 6   Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI area of interest without IV contrast Usually Appropriate O
CT area of interest without IV contrast Usually Appropriate Varies
Radiography area of interest repeat in 10-14 days May Be Appropriate Varies
US area of interest Usually Not Appropriate O
MRI area of interest without and with IV contrast Usually Not Appropriate O
CT area of interest with IV contrast Usually Not Appropriate Varies
CT area of interest without and with IV contrast Usually Not Appropriate Varies

Panel Members
William B. Morrison, MDa; Diane Deely, MDb; Michael G. Fox, MD, MBAc; Donna G. Blankenbaker, MDd; Julie A. Dodds, MDe; Cristy N. French, MDf; Matthew A. Frick, MDg; Shari T. Jawetz, MDh; Bharti Khurana, MDi; Molly Kresin, DOj; Nicholas C. Nacey, MDk; Charles Reitman, MDl; Nicholas Said, MD, MBAm; J. Derek Stensby, MDn; Eric A. Walker, MD, MHAo; Eric Y. Chang, MDp.
Summary of Literature Review
Introduction/Background
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
B. CT area of interest with IV contrast
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
C. CT area of interest without and with IV contrast
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
D. CT area of interest without IV contrast
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
E. MRI area of interest without and with IV contrast
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
F. MRI area of interest without IV contrast
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
G. Radiography area of interest
Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
H. US area of interest
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
B. CT area of interest with IV contrast
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
C. CT area of interest without and with IV contrast
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
D. CT area of interest without IV contrast
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
E. MRI area of interest without and with IV contrast
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
F. MRI area of interest without IV contrast
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
G. Radiography area of interest repeat in 10-14 days
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. Next imaging study.
H. US area of interest
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
B. CT area of interest with IV contrast
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
C. CT area of interest without and with IV contrast
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
D. CT area of interest without IV contrast
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
E. MRI area of interest without and with IV contrast
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
F. MRI area of interest without IV contrast
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
G. Radiography area of interest repeat in 10-14 days
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. Next imaging study.
H. US area of interest
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
B. CT area of interest with IV contrast
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
C. CT area of interest without and with IV contrast
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
D. CT area of interest without IV contrast
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
E. MRI area of interest without and with IV contrast
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
F. MRI area of interest without IV contrast
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
G. Radiography area of interest repeat in 10-14 days
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate "need-to-know.” Radiographs negative or indeterminate. Next imaging study.
H. US area of interest
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
B. CT area of interest with IV contrast
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
C. CT area of interest without and with IV contrast
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
D. CT area of interest without IV contrast
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
E. MRI area of interest without and with IV contrast
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
F. MRI area of interest without IV contrast
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
G. Radiography area of interest repeat in 10-14 days
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. Next imaging study.
H. US area of interest
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
A. CT area of interest with IV contrast
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
B. CT area of interest without and with IV contrast
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
C. CT area of interest without IV contrast
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
D. MRI area of interest without and with IV contrast
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
E. MRI area of interest without IV contrast
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
F. Radiography area of interest repeat in 10-14 days
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). Next imaging study.
G. US area of interest
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

·        ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

·        ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

·        ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

·        ACR Manual on Contrast Media

·        ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.