Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. In general, MRI may be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several studies have shown that MRI has higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases. Despite the high sensitivity of breast MRI, it is not indicated as initial imaging in a patient with pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53]. Currently, there is no relevant literature for the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET in the evaluation of a male or female patient with pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60]. Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings. A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Sestamibi MBI There is no relevant literature to support the use of molecular breast imaging (MBI) in the evaluation of a male or female patient with pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Mammography Diagnostic The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Either mammography or US may be used as the initial imaging modality, on the basis of institutional preference and case-by-case consideration. However, mammography has its value in detecting suspicious microcalcifications, given the high incidence of patients with DCIS presenting with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. US Breast The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Hence, US may be useful as the initial imaging modality, with mammography added when necessary.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Ductography Ductography may demonstrate small lesions and localize the duct responsible for the nipple discharge. Ductography is minimally invasive, may be uncomfortable, and can be time-consuming. The procedure is technically challenging with 10% to 15% of cases resulting in inadequate or incomplete results [41,42]. The discharge must be present on the day of ductography so that a cannula can be placed in the appropriate duct. Failure to cannulate the discharging duct may lead to a false negative [43]. Ductography is not recommended in lactating women or patients with active mastitis. Known hypersensitivity to iodinated contrast agents is a relative contraindication. Findings on ductography suggestive of malignant or papillary lesions include intraductal filling defect, partial or complete obstruction of a duct, duct expansion or distortion, and duct wall irregularity [1].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. In patients with pathologic nipple discharge and a negative mammogram and US, Morrogh et al [44] reported the PPV and NPV of ductography for the detection of cancer and high-risk lesions to be 19% and 63%, respectively. In the setting of negative standard evaluations, ductography localized 76% of otherwise occult malignant/high-risk lesions and 91% of benign lesions [39]. When the standard evaluation is positive, ductography facilitated preoperative localization of the causative lesion in 78% of cases [39]. For detection of cancer in patients with pathologic nipple discharge, 2 studies showed the sensitivity, specificity, PPV, and NPV of ductography to be 75% to 100%, 6% to 49%, 16% to 18%, and 93% to 100%, respectively [16,23]. For detection of high-risk lesions, Adepoju et al [16] reported the sensitivity, specificity, PPV, and NPV of ductography to be 75%, 53%, 22%, and 92%, respectively.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Ductography is more sensitive than mammography and US but has a lower specificity than both modalities. A negative ductogram does not reliably exclude an underlying cancer or high-risk lesion, with the false-negative rate reported to be as high as 20% to 30% [44]. As such, the primary value of ductography is to localize intraductal lesions and assist in surgery [45]. A study found that patients who underwent ductography-guided operations or any other surgical procedure with image guidance of the lesion were significantly more likely to have a specific underlying lesion identified than patients who underwent central duct excision alone [23,42].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. At this time, there is no relevant literature available for use of ductography for evaluation of a male patient with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Contrast-enhanced breast MRI has a high sensitivity for detecting benign papillary lesions as well as in situ and invasive carcinoma [3]. Furthermore, MRI allows for the identification of index lesions in peripheral ducts that are beyond the area normally encompassed by terminal duct excision, ductography, or targeted US [44]. Index or synchronous lesions found on MRI alone can be percutaneously biopsied with MRI guidance to allow for single- stage definitive surgical management (if malignant) or potentially to avoid unnecessary surgical excision for some benign lesions.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. In general, MRI should be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge studies have shown that MRI has a higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. At this time, there is no relevant literature available for use of MRI for evaluation of a male patient with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53]. Currently, there is no relevant literature for the use of FDG-PET in the evaluation of a male or female patient with pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60]. Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings. A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathological nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathological nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in the evaluation of a male or female patient with pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise in assessing the symptomatic breast [35,36].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Ductography There is no relevant literature to support the use of ductography for the evaluation of male patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. MRI Breast There is no relevant literature to support the use of MRI for the evaluation of male patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for the evaluation of male patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of core biopsy for the evaluation of male patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for the evaluation of male patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for the evaluation of male patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging. The probability of a woman developing breast cancer over the next decade increases with age; the risk is 1 in 1,681 at 20 years of age, 1 in 232 at 30 years of age, and 1 in 69 at 40 years of age [62]. Breast cancer is rare in women <30 years of age, with the exception of those with a genetic predisposition or prior mantle radiation to the chest. In a study by Seltzer et al [66] on the significance of age in patients with nipple discharge, malignancy was found in 1 of 10 patients <30 years of age. However, caution should be exercised interpreting these results given a very small sample size and the possible inclusion of high-risk patients.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Mammography Diagnostic Most breast lesions in young women are not visualized on mammography [67,68] because of the low incidence of breast cancer (0.4% or lower) in women <30 years of age. US is most useful for initial imaging in this population; however, diagnostic mammography may be useful when US shows a suspicious finding.


Evaluation of Nipple Discharge


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge US Breast Yue et al [69] studied 955 women <25 years of age who presented with breast symptoms including palpable mass, pain, and nipple discharge. US was performed in 692 patients and was normal/negative in 671 patients and indeterminate in 21 patients. No cancer was found in this group via biopsy or clinical follow-up. However, it is unknown how many of these patients had pathologic or physiologic discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Ductography There is no relevant literature to support the use of ductography in women <30 years of age with symptoms of pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. MRI Breast There is no relevant literature to support the use of MRI in women <30 years of age with symptoms of pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET in women <30 years of age with symptoms of pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy in women <30 years of age with symptoms of pathologic nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA in women <30 years of age with symptoms of pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in women <30 years of age with symptoms of pathologic nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36].


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Ductography There is no relevant literature to support the use of ductography for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. MRI Breast There is no relevant literature to support the use of MRI for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy for evaluation of transgender patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for evaluation of transgender patients with nipple discharge.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of core biopsy for evaluation of transgender patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy.


Evaluation of Nipple Discharge


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. Evaluation of Nipple Discharge


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. 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.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Evaluation of Nipple Discharge

Evaluation of Nipple Discharge


Assessment of Gravid Cervix

Assessment of Gravid Cervix. In addition to CL screening for those at risk for PTB, other clinical scenarios may arise in which imaging assessment of the gravid cervix may be of interest. These include suspected preterm labor, induction of labor, and active term labor. Additional clinical scenarios, which may require a focused assessment of the gravid cervix, include suspected abnormal placentation including placenta previa, vasa previa, and lower uterine segment and/or cervical fibroids that may impede progression of labor and potential umbilical cord prolapse.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. 3-D Transvaginal US Three-dimensional TVUS acquires a volumetric data set that can be reformatted and analyzed in any plane. Three- dimensional TVUS may eventually be of benefit for certain clinical scenarios; however, there is currently insufficient data to recommend its routine use.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Reprint requests to: publications@acr.org


Assessment of Gravid Cervix

Assessment of Gravid Cervix

Assessment of Gravid Cervix. Assessment of Gravid Cervix


Assessment of Gravid Cervix

Assessment of Gravid Cervix. US Elastography Cervix US elastography is an imaging technique that assesses tissue stiffness. Although the available data suggest that US elastography may be beneficial in evaluating the gravid cervix [14-17], technical standards and normal reference values are lacking, and the technique remains investigational. As such, there is currently insufficient data to recommend its use in routine screening for PTB in low-risk and high-risk women, suspected preterm labor, and predicting successful induction of labor [18-22].


Assessment of Gravid Cervix

Assessment of Gravid Cervix. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be a complementary method to transabdominal US in certain clinical situations, such as large body habitus or when incomplete distention of the bladder limits transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, although inadequate visualization of the cervix has been reported in up to 22% of patients [26]. An inability to adequately assess the cervix via the transperineal approach may result from shadowing from the symphysis pubis and rectal gas and stool. Adequate assessment by transperineal US is also dependent on sonographer experience.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Transperineal assessment of the gravid cervix has been shown to be comparable to TVUS by several studies. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid cervix patients at each trimester, and the accuracy improves as the pregnancy progresses [27]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved via the transperineal and transvaginal approaches, although there was a clear preference expressed by the interpreting physician for the latter. CLs were found to be comparable after 20 weeks gestational age, and CL measured between 14 and 20 weeks gestational age were statistically shorter via the transperineal approach. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported transperineal CL comparable to those obtained transvaginally.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Standard second and third trimester transabdominal US evaluation may inadequately visualize the cervix or demonstrate findings suspicious for shortening. In such cases, transvaginal or transperineal US have been recommended for further evaluation [23]. If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. If transperineal US is performed, the above caveats regarding CL in the early second trimester should be noted.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. US Cervix Transvaginal TVUS allows for the most complete assessment of the cervix, yet its use in universal screening of low-risk women remains controversial. Supportive evidence for universal screening comes from two studies evaluating the rates of PTB before and after implementation of a universal transvaginal cervical screening program [29,30]. Following implementation of their screening program, Son et al [29] demonstrated statistically significant decreases in the rates of spontaneous PTB <37 weeks (4.8% versus 4.0%), <34 weeks (1.3% versus 1.0%), and <32 weeks (0.7% versus 0.5%). Temming et al [30] demonstrated similar findings following implementation of their screening program; however, statistically significant decreases only were observed in the rates of spontaneous PTB <28 weeks (2.0% versus 0.7%) and <24 weeks (1.5% versus 0.35%).


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Other studies demonstrate no clear benefit to transvaginal screening, thereby calling into question its appropriateness. In one study evaluating a CL screening program in nulliparous women, no statistical difference was observed in the rate of spontaneous PTB in patients who underwent screening compared with those who did not [31]. In a separate study of nulliparous women, the predictive accuracy of serial TVUS for spontaneous PTB


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33].


Assessment of Gravid Cervix

Assessment of Gravid Cervix. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be useful in certain clinical scenarios, such as large body habitus or when incomplete distention of the bladder limits the transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, and transperineal assessment of the gravid cervix has been shown to be comparable to TVUS [27]. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid patients at each trimester [26-28]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved with both transperineal and transvaginal approaches, noting a clear preference expressed for the latter. CL was found to be comparable after 20 weeks gestational age; however, CL measured between 14 and 20 weeks gestational age was statistically shorter via the transperineal approach. Given the apparent difference in accuracy of transperineal CL in the early second trimester, the authors suggested performing transvaginal imaging when short CL are obtained transperineally in the early second trimester. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported satisfactory transperineal visualization of the cervix in approximately 80% of cases. CLs obtained by the transperineal approach during this gestational age were also comparable to those obtained transvaginally.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. TVUS is the preferred approach for assessment of the gravid cervix in high-risk patients, but there may be instances in which TVUS is not possible because of patient discomfort or preference. If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. In such instances, transperineal US would be indicated, noting the above caveats regarding CL in the early second trimester.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix. The transvaginal approach affords the shortest distance between transducer and cervix, and TVUS transducers typically offer higher frequency evaluation and greater detailed evaluation. The combination of these features allows for complete visualization of the cervix, including the internal os where changes increasing the risk of PTB first occur. Lastly, transvaginal imaging is a highly reproducible test.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Several studies have demonstrated that identification of a short CL by TVUS decreases the rate of PTB by directing patients to appropriate interventions. In a randomized placebo-controlled study by Fonseca et al [6], women with a sonographically short cervix who received progesterone demonstrated a 44% reduction in the rate of PTB <34 weeks, as well as a 41% decrease in neonatal morbidity. A separate randomized placebo-controlled study confirmed the benefit of progesterone administration and found a 45% decrease in PTB <33 weeks and a 50% decrease in PTB <28 weeks [8]. Reduction in PTB rates was also observed in patients undergoing cervical pessary placement [7]. When compared with patients undergoing expectant management, pessary placement was associated with a 78% reduction of PTB <34 weeks. Lastly, short CL treated by cerclage has been found to decrease PTB. In a meta- analysis of 5 trials of high-risk patients with short CL, cerclage placement resulted in a 30% decrease in PTB <35 weeks with significantly decreased rates of PTB seen before 37, 32, 28, and 24 weeks [5].


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Given the availability of several effective interventions for the prevention of PTB, TVUS cervical screening for high-risk patients is recommended. Routine TVUS screening is also supported by the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine [36,37].


Assessment of Gravid Cervix


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Cervical Cerclage Patients who have undergone history-indicated cerclage for cervical insufficiency represent a subset of high-risk patients. In these patients with a history of one or more second trimester losses, cerclage placement may be offered during the early second trimester. In one recent study screening cerclage patients by TVUS until 26 weeks, a shorter CL below the cerclage and cervical funneling were shown to be associated with a higher rate of PTB [38]. In a separate study evaluating postcerclage patients between 18 and 24 weeks, cervical funneling was the only variable independently associated with increased risk of PTB before 34 weeks [39]. Although these and other studies suggest that short CL and cervical funneling are associated with higher rates of PTB in patients with cerclage, the Society for Maternal-Fetal Medicine does not recommend routine surveillance for this subset of high-risk patients because there is insufficient data supporting a clinical benefit to screening [37]. If assessment of the cerclage is performed, additional measurements irrespective of approach (eg, transabdominal, transvaginal, or transperineal) may include the total length of closed cervix regardless of cerclage sutures, and if funneling is present, the length of closed cervix from the level of cervical funneling to the level of the cerclage sutures.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Variant 3: Assessment of gravid cervix. Suspected preterm labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix for suspected preterm labor.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix. In one study, adequate visualization of the cervix was achieved in 82% of patients in preterm labor with good agreement of transperineal and transvaginal measurements with an intraclass correlation coefficient of 0.83 [40]. The mean difference in cervical measurements between transperineal and transvaginal approaches was 1.5 mm, with transperineal US underestimating CL in most cases. No significant disagreement between both methods was observed above or below a length of 25 mm. A study by Dimassi et al [41] also reported a strong correlation in CL obtained by both methods as well as a low mean difference in cervical measurements (0.38 mm).


Assessment of Gravid Cervix

Assessment of Gravid Cervix. TVUS would be preferred for assessment of the cervix in cases of suspected preterm labor. Nevertheless, transperineal US would be an adequate alternative in the event that TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes).


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix because it allows for complete visualization of the cervix, including the internal os where changes of PTB first occur. Transvaginal imaging is highly reproducible.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Taken together, the data demonstrate that although TVUS has limitations in its predictive ability in identifying those who will progress to PTB, its greatest value is its high negative predicative value. As such, transvaginal assessment of the gravid cervix would be the preferred approach in cases of suspected preterm labor.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. Variant 4: Assessment of gravid cervix. Induction of labor or active term labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix prior to induction of labor or during active term labor.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. However, a meta-analysis of 31 studies demonstrated limited value in predicting the outcome of induced labor [49]. Studies that are more recent also report conflicting data. In one study, a shorter CL prior to induction was associated


Assessment of Gravid Cervix

Assessment of Gravid Cervix. 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.


Assessment of Gravid Cervix

Assessment of Gravid Cervix. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Assessment of Gravid Cervix

Assessment of Gravid Cervix

Assessment of Gravid Cervix. Assessment of Gravid Cervix


Major Blunt Trauma

Major Blunt Trauma. Trauma is the leading cause of mortality for people in the United States who are <45 years of age, and it is the fourth leading cause of death overall [3]. Polytrauma can be defined as an injury to at least two body parts, including the head, neck, chest, abdomen, pelvis, and at least one extremity, with any one or a combination of these injuries being potentially fatal.


Major Blunt Trauma

Major Blunt Trauma. MR urography (MRU) is also tailored to improve imaging of the urinary tract system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic signal from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory


Major Blunt Trauma

Major Blunt Trauma. Reprint requests to: publications@acr.org


Major Blunt Trauma

Major Blunt Trauma. Major Blunt Trauma phase. Similar to CTU, hydration or low-dose furosemide can improve urinary tract distension and study quality. Thin slice acquisition and multiplanar imaging should be obtained. MRU is most commonly performed at 1.5T, but imaging at 3T has become more widely used; however, comparison of 3T MRU and CTU has not been published in the literature.


Major Blunt Trauma

Major Blunt Trauma. Discussion of Procedures by Variant Variant 1: Major blunt trauma. Hemodynamically unstable. Initial imaging. CT Whole Body There is limited literature to support the use of WBCT in patients who are hemodynamically unstable [6,7]. Patients who remain hemodynamically unstable despite initial attempts at resuscitation and who have positive signs for abdominal trauma (eg, a positive FAST) should proceed directly to exploratory laparotomy, with CT imaging deferred until after operative intervention. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [9,10]. Extended-FAST has been found to be effective in ruling out pneumothorax [11]. Although ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. FAST has been found to have a high false-negative rate in patients with pelvic fractures [12].


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs in the unstable patient typically consist of portable radiographs of the chest and pelvis. A portable anteroposterior (AP) chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4].


Major Blunt Trauma

Major Blunt Trauma. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI in the initial evaluation of the unstable trauma patient. MRI is not performed because of the time required in the emergent setting.


Major Blunt Trauma

Major Blunt Trauma. Variant 2: Major blunt trauma. Hemodynamically stable. Not otherwise specified. Initial imaging. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no survival benefit [15]. Meta-analyses have yielded conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain WBCT versus selective CT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above, include high-velocity (>35 mph) motor vehicle collision (MVC), MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC- pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. MRI Abdomen and Pelvis There is no relevant literature to support the initial use of MRI in patients who are hemodynamically stable, not otherwise specified.


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude injuries to these areas [5].


Major Blunt Trauma

Major Blunt Trauma

Major Blunt Trauma. Major Blunt Trauma


Major Blunt Trauma

Major Blunt Trauma. Fluoroscopy Retrograde Urethrography There is no relevant literature to support the use of retrograde urethrography in patients with major blunt trauma who are hemodynamically stable, not otherwise specified. Refer to Variant 6 if there is suspicion of urinary tract injury.


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body The decision regarding which patients should receive WBCT versus selective CT imaging for blunt trauma will depend on factors beyond facial injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series In the setting of blunt facial trauma, facial and cervical lateral radiographs may also be part of the initial trauma series radiographs, which also typically consists of portable radiographs of the chest and pelvis. Single cervical radiographs can rapidly evaluate for severe fracture, abnormal alignment, and prevertebral swelling, but it may miss nondisplaced fractures that are evident on CT. The portable AP chest radiograph helps screen for immediately life- threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4].


Major Blunt Trauma

Major Blunt Trauma. Variant 4: Major blunt trauma. Hemodynamically stable. Suspected extremity trauma. Initial imaging. The body regions covered in this clinical scenario are the upper extremity and lower extremity.


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma, and extremity injuries alone will not determine which is


Major Blunt Trauma

Major Blunt Trauma. appropriate. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma


Major Blunt Trauma

Major Blunt Trauma. CT Extremity In certain cases, CT may be appropriate for fracture characterization, detection of radiographically occult fractures, or operative planning.


Major Blunt Trauma

Major Blunt Trauma. CTA Extremity CT angiography (CTA) of an upper or lower extremity injury may also be considered and could be obtained during the same acquisition period to evaluate for extremity arterial injury when clinically suspected [24].


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage regardless of extremity injuries; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5].


Major Blunt Trauma

Major Blunt Trauma. Radiography Extremity Single-view radiographs of the traumatized extremity take little time and are frequently included in this setting.


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis and/or cross table cervical spine. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Radiographs of the suspected injured extremity are the first-line examination to be obtained.


Major Blunt Trauma

Major Blunt Trauma. Variant 5: Major blunt trauma. Hemodynamically stable. Suspected bowel trauma. Initial imaging. CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with arterial phase images as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided when possible because of its lower sensitivity for detecting both visceral organ and vascular injuries [19].


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body Currently, there is no consensus for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma with concern for bowel injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or


Major Blunt Trauma

Major Blunt Trauma

Major Blunt Trauma. Major Blunt Trauma


Major Blunt Trauma

Major Blunt Trauma. FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]


Major Blunt Trauma

Major Blunt Trauma. CTA Abdomen and Pelvis CT in the arterial phase may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. If 3-D reconstructions are included, then it is considered a CTA study to more closely evaluate the arterial structures for findings such as pseudoaneurysm. CTA of the abdomen has been shown to detect more splenic vascular injuries than that of CT of the abdomen in the portal venous phase alone [26]. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage, which can be accurately diagnosed by CTA and may require either surgical or vascular interventional treatment [27].


Major Blunt Trauma

Major Blunt Trauma. MRI Abdomen and Pelvis Blunt abdominal trauma is not typically evaluated by MRI because of the time of acquisition. However, some sites are moving toward the use of MRI in selected patients [28].


Major Blunt Trauma

Major Blunt Trauma. US Abdomen Although US may be able to diagnose certain abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude abdominal injuries [29]. Bowel injury is a specific setting for which US is limited because of bowel gas.


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. US is not well suited for evaluation of bowel injury because significant fluid trapped in the mesentery may not be detected by FAST.


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. There is no literature to support the use of trauma series radiographs in the detection of bowel injury.


Major Blunt Trauma

Major Blunt Trauma. Variant 6: Major blunt trauma. Hemodynamically stable. Suspected urinary system, including urethra trauma. Initial imaging. CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase, 70 seconds after contrast administration for ideal characterization of solid organ injury, including the genitourinary system. This may be obtained in conjunction with CTA if there is a concern for renal infarction or arterial injury, as well as delayed imaging of the abdomen and pelvis if perinephric fluid suggests renal pelvis or ureteral trauma. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided if there is no contraindication to IV contrast because of its lower sensitivity for detecting both visceral organ and vascular injuries [19].


Major Blunt Trauma

Major Blunt Trauma. CT Urography There is no relevant literature to support the use of CTU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma.


Major Blunt Trauma

Major Blunt Trauma. CT Pelvis with Bladder Contrast (CT Cystography) Gross hematuria in the setting of blunt traumatic injury necessitates further evaluation with CT cystogram [30]. Urinary bladder injury typically occurs because of trauma to a distended urinary bladder and may or may not be accompanied by pelvic fractures. The absence of gross hematuria generally excludes the possibility of urinary bladder injury [31]. Deck et al [32,33] reported sensitivities of 95% overall but only 78% for intraperitoneal rupture. In another study with 100% sensitivity and 99% specificity for intraperitoneal bladder rupture, the specific sites of


Major Blunt Trauma

Major Blunt Trauma. dome injuries in 4 of 18 patients were identified only with multiplanar reconstructed images [34]. A bladder contusion may not be visible by CT cystography. Routine CT, using excreted contrast only, cannot be relied on entirely to diagnose bladder rupture, even with a urethral catheter inserted and clamped [35-37]. CT performed with excreted contrast only can demonstrate intraperitoneal or extraperitoneal fluid, but it cannot differentiate urine from ascites. However, the absence of pelvic ascites is strong evidence against an intraperitoneal bladder rupture [38,39]. As with IV urography (IVU), the bladder is usually inadequately distended to cause extravasation through a bladder laceration or perforation during routine abdominal and pelvic studies. A negative study does not exclude bladder injury [40]. Although CT is not the technique of choice for urethral injuries, it is performed so frequently that urethral injuries are often identified when CT is performed for pelvic trauma.


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. CTA Abdomen and Pelvis CTA of the abdomen and pelvis may be performed to assess for active arterial bleeding. CTA of the abdomen has been shown to detect splenic vascular injuries more often than CT of the abdomen in the portal venous phase alone [26]. However, arterial phase imaging without 3-D reformations can also detect bleeding. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27].


Major Blunt Trauma

Major Blunt Trauma. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI of the abdomen and pelvis in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma.


Major Blunt Trauma

Major Blunt Trauma. MR Urography There is no relevant literature to support the use of MRU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma.


Major Blunt Trauma

Major Blunt Trauma. US Abdomen and Pelvis Although US may be able to diagnose certain abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude abdominal injuries [29,41,42]. Extraperitoneal and genitourinary injuries are more likely to be missed than intraperitoneal injuries [41,42].


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude injuries to these areas, particularly extraperitoneal or genitourinary injuries [5,41,42]. In a series of 128 acute trauma patients, 11 of 19 injuries that were missed by emergent US involved the genitourinary system [41]. The detection of peritoneal fluid in the presence of normal viscera or the failure to visualize the bladder after the transurethral introduction of saline is considered highly suggestive of bladder rupture [35]. As a practical matter, US is not definitive in bladder or urethral trauma and is almost never used for this indication.


Major Blunt Trauma

Major Blunt Trauma. Radiography Intravenous Urography There is no relevant literature to support the use of IVU in patients who are hemodynamically stable with suspected urinary system or urethral trauma. IVU has a low accuracy, on the order of 15% to 25% [43]. In one study, an


Major Blunt Trauma

Major Blunt Trauma

Major Blunt Trauma. Major Blunt Trauma


Major Blunt Trauma

Major Blunt Trauma. accurate diagnosis of bladder rupture was made with IVU in only 5 of 23 (22%) patients [44]. Carroll and McAninch [45] found an accurate diagnosis for only 5 of 32 (16%) patients, and Werkman et al [46] found an accuracy rate for only 4 of 11 (36%) patients.


Major Blunt Trauma

Major Blunt Trauma. Fluoroscopy Retrograde Urethrography In a male, gross blood at the urethral meatus may indicate a urethral injury, which warrants further evaluation with a retrograde urethrogram to evaluate urethral integrity [47].


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. A pelvic injury is associated with genitourinary trauma. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13].


Major Blunt Trauma

Major Blunt Trauma. Variant 7: Major blunt trauma. Hemodynamically stable. Suspected chest trauma. Initial imaging. CT Chest Noncontrast CT of the chest can detect most injuries, including rib fractures, pneumothorax, hemothorax, and pulmonary contusion, but has a lower sensitivity for detecting vascular injuries [20]. Contrast-enhanced CT of the chest is the preferred imaging workup of suspected chest trauma. Regardless of contrast administration, CT is more sensitive and specific for chest trauma than conventional radiographs [48,49]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective chest CT imaging for blunt trauma with concern for a chest injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20].


Major Blunt Trauma

Major Blunt Trauma. CTA Chest CT of the chest is warranted in the arterial phase primarily when there is a concern for aortic or other major vessel injury [20]. A delayed scan may be obtained, depending on the findings on the arterial phase CT.


Major Blunt Trauma

Major Blunt Trauma. US Chest There is no relevant literature to support the use of non-US FAST of the chest in patients who are hemodynamically stable with suspected chest trauma. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury [49].


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for a comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury.


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. In a patient with suspicion of chest trauma, a rapid assessment with chest radiographs plays a key role in initial workup. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and


Major Blunt Trauma

Major Blunt Trauma. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Compared with CT, pelvic radiographs also have lower sensitivity for detecting injury. In a study of 509 consecutive trauma patients, the sensitivity of the AP pelvic radiographs was 77% using CT as the reference standard [53]. The most common injury misses were the ones to the sacrum, sacroiliac joints, and loose bodies in the hip joints.


Major Blunt Trauma

Major Blunt Trauma. MRI Chest There is no relevant literature to support the use of MRI for the initial evaluation of blunt chest trauma. It is not routinely performed because of the time required in the emergent setting. Use of MRI is mainly reserved for problem solving of findings identified on initial imaging studies.


Major Blunt Trauma

Major Blunt Trauma. Variant 8: Major blunt trauma. Hemodynamically stable. Pregnant patient. Initial imaging. CT Abdomen and Pelvis For blunt trauma in a pregnant woman, CT of the abdomen and pelvis with IV contrast may still be recommended when there is a life-threatening concern for the mother or fetus. The study is typically performed in the portal venous phase, 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with CTA as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided because of its lower sensitivity for detecting both visceral organ and vascular injuries [19].


Major Blunt Trauma

Major Blunt Trauma. CT Whole Body Risks and benefits must be specifically weighed regarding CT imaging of the pregnant patient. No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies in nonpregnant patients have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.


Major Blunt Trauma

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].


Major Blunt Trauma

Major Blunt Trauma. CTA Abdomen and Pelvis CTA may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. CTA of the abdomen has been shown to detect more splenic vascular injuries than CT of the abdomen in the portal venous phase alone [26]. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27].


Major Blunt Trauma

Major Blunt Trauma

Major Blunt Trauma. Major Blunt Trauma


Major Blunt Trauma

Major Blunt Trauma. CTA Chest CTA of the chest is warranted in the arterial phase primarily to assess for aortic or other major vessel injury, in addition to other injuries within the chest [20]. Noncontrast CT of the chest should be avoided because of its lower sensitivity for detecting vascular injuries [20].


Major Blunt Trauma

Major Blunt Trauma. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI abdomen and pelvis in patients who are hemodynamically stable and pregnant.


Major Blunt Trauma

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage with added usefulness in the setting of pregnancy; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention and avoidance of CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. US is less sensitive for detecting traumatic abdominal injury in the pregnant patient compared with the nonpregnant patient [54].


Major Blunt Trauma

Major Blunt Trauma. US Pelvis In pregnant patients with blunt abdominal trauma, both the health of the mother and fetus are of concern. The pelvic US can assess the uterus and evaluate the amniotic fluid level and measure the biophysical profile, as well as assess the extent of fetal injury and demise [55]. US can also assess for the presence of free fluid and retroplacental hemorrhage, although the sensitivity for detecting abruption may not exceed 40% to 50% [55]. The gravid uterus is at increased risk of rupture from blunt trauma and is a life-threatening emergency.


Major Blunt Trauma

Major Blunt Trauma. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4].


Major Blunt Trauma

Major Blunt Trauma. 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.


Major Blunt Trauma

Major Blunt Trauma. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Introduction/Background Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). The incidence of traumatic shoulder injuries is difficult to determine because some injury types, such as low-grade acromioclavicular separations or acute rotator cuff tears, are likely under-reported because patients do not seek immediate medical treatment. However, as with many traumatic injuries, traumatic shoulder pain tends to disproportionately involve young adults and male patients [1,2].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. The etiology of traumatic shoulder pain can often be made based on clinical examination, radiographs, and mechanism of injury. Traumatic shoulder injuries can generally be separated into injuries requiring acute surgical management and injuries in which conservative management can be attempted prior to considering surgical treatment. Unstable or significantly displaced fractures and joint instability are injuries most likely requiring acute surgical treatment. Most soft-tissue injuries (such as labral tears and rotator cuff tears) can undergo a period of conservative management prior to considering surgery. However, in addition to the specific imaging findings related to a traumatic injury, indications and timing of surgical treatment of many traumatic shoulder injuries are dependent on patient age, comorbidities, current activity level, and expected activity level.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Discussion of Procedures by Variant Discussion of Procedures by Variant Variant 1: Traumatic shoulder pain. Any etiology. Initial imaging. Radiography Shoulder Radiographs are the preferred initial study performed in the setting of traumatic shoulder pain. They can delineate shoulder malalignment and most shoulder fractures [4,5]. A standard set of shoulder radiographs for trauma should include at least three views: anterior-posterior (AP) views in internal and external rotation and an axillary or scapula-Y view. Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries as acromioclavicular and glenohumeral dislocations can be misclassified on AP views [6,7]. Radiographs provide good delineation of bony anatomy to assess for fracture and appropriate shoulder alignment, which are the two primary concerns in management of acute traumatic shoulder pain. Radiographs should also be performed upright since malalignment of the shoulder can be under-represented on supine radiographs [4]. Additional views, such as the Bernageau view, have been shown to be effective in demonstrating the degree of bone loss of the glenoid or humeral head [8].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Shoulder Computed tomography (CT) is better able than radiographs to characterize fracture patterns [9-11]. However, radiographs are preferred over CT for initial evaluation because radiographs are able to diagnose displaced


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Reprint requests to: publications@acr.org


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. fractures and shoulder malalignment, which are the primary concerns in the initial assessment of shoulder trauma. CT is considered inferior to MRI for diagnosing essentially all soft-tissue shoulder injuries.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Arthrography Shoulder CT arthrogram, although not the initial study of choice, has the advantage of characterizing both bony lesions and significant soft-tissue injuries. CT arthrograms have been shown to be comparable to magnetic resonance (MR) arthrography in diagnosing Bankart, Hill-Sachs, superior labral anterior-to-posterior (SLAP), and full-thickness rotator cuff tears, but inferior to MR arthrography for diagnosing partial-thickness rotator cuff tears [12], including bursal-sided tears. CT arthrography has also only demonstrated modest agreement between observers in diagnosing anterior capsular laxity of the shoulder [13].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MRI Shoulder Noncontrast MR imaging (MRI) has been shown to be effective in assessing bony morphology and bone loss in patients with traumatic shoulder injuries [14-18], and noncontrast MRI is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries [17,19,20].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MR Arthrography Shoulder MR arthrography is considered the gold standard for imaging traumatic shoulder pain [4,17,19,21]. MR arthrography is comparable to noncontrast MRI in assessment of extra-articular soft tissues, and MR arthrography has been shown to be superior to noncontrast MRI in diagnosing intra-articular pathology like SLAP tears, labroligamentous injuries, and partial rotator cuff tears [17,19]. MR arthrography is comparable to CT in evaluating traumatic osseous lesions, such as bony Bankart and Hill-Sachs lesions [12,18]. However, the need for an invasive procedure makes MR arthrography a suboptimal initial study.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. US Shoulder Ultrasound (US) has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. US is comparable to MRI in evaluating full-thickness rotator cuff tears and rotator cuff atrophy [17,22,23]. However, US is inferior to MRI in evaluating partial-thickness rotator cuff tears and other intra-articular pathology [17,24]. Diagnosis of proximal humerus fractures by US has been described [25], but US is not generally considered a preferred imaging modality for assessing osseous pathology, which are of primary concern in initial assessment of traumatic shoulder pain.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. FDG-PET/CT Skull Base to Mid-Thigh Positron emission tomography (PET) (usually using the fluorine-18-2-fluoro-2-deoxy-D-glucose [FDG] tracer) imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT (FDG-PET/CT) is sensitive for identifying fractures, and it has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in the assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies, such as fracture, rotator cuff tear, or adhesive capsulitis [30]. Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and it can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft-tissue injuries of the shoulder have not been well described [33].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Variant 2: Traumatic shoulder pain. Nonlocalized shoulder pain. Negative radiographs. Next imaging study. Appropriately positioned radiographs can exclude shoulder dislocation and most displaced fractures as the etiology for post-traumatic shoulder pain. In the setting of normal shoulder radiographs, the most common causes of post-traumatic shoulder pain are soft-tissue injuries such as rotator cuff and labral tears.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MRI Shoulder Noncontrast MRI is a reasonable imaging study in the setting of acute nonlocalized traumatic shoulder pain and noncontributory radiographs. In the acute trauma setting, noncontrast MRI may be preferred to MR arthrography, as acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MR Arthrography Shoulder MR arthrography has been found to be superior to noncontrast MRI in the diagnosis of labroligamentous and partial-thickness rotator cuff tears [17,19]. In the acute trauma setting, however, noncontrast MRI may be preferred to MR arthrography because acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. US Shoulder US has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. In the post-traumatic setting, US has been shown to detect abnormalities, including proximal humeral fractures [25]; however, recent studies on US performed for nonspecific shoulder pain have had conflicting results. US for persistent shoulder pain after trauma has been found to diagnose significant pathology, primarily fractures and rotator cuff tears, in 90% of patients [25]. However, 40% of patients presenting with nonspecific shoulder pain were found to have no significant pathology on US [38]. Additionally, US has been demonstrated to be inferior to MRI in assessment of labroligamentous, osseous, and rotator cuff pathology [17]. US can be considered as a screening tool in patients with persistent nonspecific shoulder pain after trauma, particularly in an older patient population in whom rotator cuff tears are more common. However, a low threshold should be maintained for performing additional imaging in the setting of a noncontributory shoulder US examination.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Shoulder CT Shoulder CT has virtually no usefulness in diagnosing common traumatic soft-tissue injuries such as rotator cuff tears, labroligamentous injuries, and muscle tears. Although CT is the gold standard for diagnosing and characterizing fractures, MRI has been shown to be equivalent to CT in diagnosing the nondisplaced fractures that are typically missed on radiographs.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Arthrography Shoulder CT is inferior to MRI and US in diagnosing virtually all extra-articular traumatic soft-tissues injuries. CT is considered the gold standard in identifying fractures. However, MRI has shown to be equivalent to CT in assessing bone loss [12,18], and MRI is usually adequate for diagnosing the nondisplaced fractures that are typically missed on conventional radiographs. CT arthrography is able to reliably evaluate for glenohumeral cartilage injury, SLAP tears, and labroligamentous injuries [12,39] but is generally considered inferior to MRI in diagnosing rotator cuff and soft-tissue Bankart lesions [12].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities, although, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT is sensitive for identifying fractures, and it has been shown to be reliable in differentiating


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies such as fracture, rotator cuff tear, or adhesive capsulitis [30]. Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft- tissue injuries of the shoulder have not been well described [33].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Variant 3: Traumatic shoulder pain. Radiographs show humeral head or neck fracture. Next imaging study. Proximal humerus fractures of the head and neck are relatively common. These fractures have a bimodal age distribution, occurring in young patients as the result of high-energy trauma and older patients with low-energy trauma, such as falls from a standing position. The most commonly used classification for humeral head fractures is the Neer classification system. A complete tear of at least one rotator cuff tendon can be seen in up to 40% of humeral head fractures [40]. However, a delay in repair of rotator cuff tears by up to 4 months has not been shown to have adverse outcomes on rotator cuff repair [41], and immediate diagnosis and treatment of soft-tissue injury in the setting of a proximal humerus fracture may not be required.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Shoulder Nondisplaced fracture planes and complex bony anatomy can result in underappreciation of the extent of proximal humeral fractures on radiographs. Poor agreement between observers has been shown on grading of humeral head fractures on radiographs [10]. CT is the best examination for delineating fracture patterns and has been shown to be equivocal to MRI in identifying nondisplaced fractures, making it the preferred study for characterizing proximal humeral fractures. Contrast is generally not necessary unless there is concern for arterial injury (see Variant 9). 3-D volume-rendered CT images may be obtained to better characterize fracture patterns and humeral neck angulation, which can affect functional outcomes [42].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Arthrography Shoulder CT Arthrography Shoulder Arthrography is not routinely performed in conjunction with CT in the evaluation of proximal humeral fractures. In the acute setting, glenohumeral hemarthrosis can obscure soft-tissue structures typically evaluated on CT arthrography, and intra-articular iodinated contrast can obscure intra-articular humerus fracture planes. Because of the high association between humeral head fractures and rotator cuff tears, there may be a role for CT arthrogram in a patient with remote proximal humeral fracture having a suspected rotator cuff tear and contraindication to MRI.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MRI Shoulder MRI Shoulder MRI without contrast is inferior to CT in evaluating fracture planes in complex humerus fracture patterns and is, in general, inferior to CT in characterizing proximal humerus fractures. Although MRI can detect rotator cuff tears associated with proximal humeral fracture [43], any significant rotator cuff tear associated with the humeral head fracture is typically addressed during open reduction and internal fixation of the fracture. However, noncontrast MRI may be useful in assessing rotator cuff integrity in patients with proximal humeral fractures that do not undergo surgical fixation.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MR Arthrography Shoulder MR arthrography is not indicated in the acute setting of proximal humeral fractures. In the acute setting of proximal humeral fracture, a significant hemarthrosis is typically present, allowing for adequate distention of the glenohumeral joint for identification of intra-articular pathology on noncontrast MRI. MR arthrography is generally preferred over noncontrast MRI for evaluating soft-tissue injuries in patients with remote proximal humeral fracture and persistent pain [17,19].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET in combination with CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the proximal humerus.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize proximal humerus fractures suspected to be due to metastatic disease.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Variant 4: Traumatic shoulder pain. Radiographs show scapula fracture. Next imaging study. There is no consensus on indications for surgical fixation of scapula fractures. In general, isolated scapula body fractures heal well without surgical fixation, although associated rib fractures or higher injury severity score are associated with worse clinical outcomes and may benefit from more aggressive surgical fixation [45]. Scapula fractures involving the glenoid articular surface or glenoid neck may also require surgical fixation.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography is not routinely performed in the setting of scapula fractures. Intra-articular iodinated contrast can obscure intra-articular fracture lines involving the glenoid neck and articular surface. Acute intra-articular fractures are typically associated with significant hemarthrosis, which can limit evaluation of soft-tissue structures on CT arthrography.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MRI Shoulder MRI has limited usefulness in assessing scapular fractures. The thin cortex and sparse medullary cavity of the scapula body can make diagnosis of scapula body fractures difficult on MRI [49]. Typical shoulder-specific coils used for MRI are also unable to cover the entire scapula, requiring use of body coils with a larger field of view, which then results in suboptimal resolution for evaluation of scapular fracture displacement and angulation.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MR Arthrography Shoulder There is no role for an MR arthrogram in evaluation of scapula fractures.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. US Shoulder US Shoulder There is no role for US in evaluation of scapula fractures.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the scapula.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. Bone Scan Shoulder Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize scapula fractures suspected to be due to metastatic disease.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MRI Shoulder Similar to MR arthrography, noncontrast MRI is comparable to CT in evaluating glenoid and humeral head bone loss [12,18]. In general, noncontrast MRI performs well in diagnosing labroligamentous injuries [20,52]. However, noncontrast MRI is considered inferior to MR arthrography for assessing labroligamentous pathology frequently associated with Bankart and Hill-Sachs lesions [17,19]. Noncontrast MRI is a good alternative to MR arthrography in the setting of acute injury when significant glenohumeral joint effusion is present to assist in visualization of intra-articular soft-tissue pathology.


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. MR Arthrography Shoulder MR arthrography is the preferred study for evaluating subacute or chronic Bankart lesions because of its soft- tissue contrast. Multiple studies have shown MR arthrography to be reliable in diagnosing labroligamentous injuries [12,17,52] and superior to noncontrast MRI for this indication [17,19]. MR arthrography has been shown to be equivalent to CT in the assessment of glenoid and humeral head bone loss [12,18], while being superior to CT in assessment of labroligamentous injuries [12]. MR arthrography is also able to delineate humeral head and glenoid cartilage, which can be important because some Hill-Sachs lesions affect cartilage only [11].


Shoulder Pain Traumatic PCAs

Shoulder Pain Traumatic PCAs. CT Shoulder Noncontrast CT has historically been used to assess Hill-Sachs and bony Bankart lesions. However, MRI has been shown to be equivalent to CT for assessing both glenoid and humeral head bone loss [12,18,53], and CT is limited in the assessment of cartilaginous Hill-Sachs lesions [11]. In addition, CT cannot assess injury to soft-tissue structures like the labroligamentous complex, which further limits its usefulness in evaluating Bankart lesions. CT should be reserved for patients with a contraindication to MRI or patients in whom MRI assessment of bone loss is limited.