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X-Ray Ordering by Ortho and Rehab Staff - Adult/Pediatric - Ambulatory [98]

X-Ray Ordering by Ortho and Rehab Staff - Adult/Pediatric - Ambulatory [98] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 98

Delegation Protocol Title:
X‐Ray Ordering by Ortho and Rehab Staff – Adult/Pediatric – Ambulatory

Delegation Protocol Applies To:
UW Health Sports Medicine Clinic, Pediatric Orthopedic Clinic, Spine Clinic, Orthopedic Hand, Foot
and Ankle, and Joint Clinics

Target Patient Population:
Adult and pediatric patients with musculoskeletal symptoms

Delegation Protocol Champions:
Thomas Zdeblick, MD ‐ Department of Orthopedics and Rehabilitation
Blaise Nemeth, MD ‐ Department of Orthopedics and Rehabilitation

Delegation Protocol Reviewers:
Gina Greenwood ‐ UW Health Radiology
Phil Swain, PT, MBA ‐ UW Health Orthopedics
Kip Schick ‐ UW Health Clinics and Community Wellness

Responsible Department:
Department of Orthopedics and Rehabilitation

Purpose Statement:
This delegation protocol delegates authority from the treating provider to Licensed Athletic Trainers
(LATs) and Physical Therapists (PTs) functioning as physician extenders, Registered Nurses (RNs), and
Medical Assistants (MAs) to order X‐rays to evaluate for musculoskeletal conditions.

Who May Carry Out This Delegation Protocol:
Licensed Athletic Trainers (LATs) and Physical Therapists (PTs) functioning as physician extenders,
Medical Assistants (MAs) and Registered Nurses (RNs) trained in the use of this delegation protocol.

Guidelines for Implementation:
1. The protocol is initiated when a patient is referred to the clinic and arrives at or calls the clinic
with any of the conditions listed below:
1.1. Recent Trauma/Injury
1.2. Pain for longer than 6 months
1.3. Pain waking a patient from deep sleep
1.4. Swelling or mass in the area of pain
1.5. Prior history of surgery to the affected area
1.6. Prior history of fracture to the affected area
1.7. Loss of motion or mechanical symptoms
1.8. Necessity as indicated in prior office visit note
1.9. New patients scheduled for musculoskeletal problem

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2. The staff person will review the patient’s chart and PACs for previously obtained X‐rays. If the
patient does not have recent X‐rays or the views already obtained are not sufficient, they enter
an order for X‐rays.
3. The attached appendices will be used to determine the appropriate views. If staff members have
questions as to which views are necessary, the treating provider will be consulted.
4. The PT, LAT, or RN will screen the patient for contraindications using the x‐ray order screening
questions. The contraindications are as follows:
4.1. Pregnancy – if patient is or suspects they may be pregnant, X‐ray will not be ordered.

Order Mode: Cosign Required, Protocol/Policy

References: NA

Collateral Documents/Tools:
Department of Orthopedics and Rehabilitation X‐Ray View Summary Guides

Approved By
UW Health Ambulatory Protocol Committee: February 2014; *February 2017
UW Health Knowledge Management Council: February 2014; *February 2017
UWHC Medical Board: March 2014; *March 2017
UW Health Chief Medical Officer: March 2014; *March 2017

Effective Date: March 2017

Scheduled for Review: March 2020
*Expedited Review

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X‐Ray View Summary

Table 1. Department of Orthopedics and Rehabilitation Sports Medicine Clinic
UPPER EXTREMITY
Finger/Digit 3 views (PA, lateral and oblique)
Hand 3 views (PA, lateral and oblique)
Wrist 3 views (PA, lateral and oblique)
Forearm 2 views (AP and lateral)
Elbow 3 views (AP, lateral and radiocapitellar)

SHOULDER
Rotator Cuff Series 4 views (AP/AC, Neer, Arch and Axillary)
Instability Series 3 views (Neer, Axillary and West Point)
AC Joint 2 views (Straight AP and Axillary)
Clavicle 2 views (AP and Zanka)
Sternoclavicular Joint 2 views (AP and Serendipity)
Scapula 2 views (AP and Scapular Y)

POST‐OPERATIVE SHOULDER
Total Shoulder Arthroplasty 3 views (AP, Neer and Axillary with limited abduction)
‐To be taken 2 weeks post‐operatively
Reverse Total Shoulder Arthroplasty 3 views (AP, Neer and Axillary with limited abduction)
‐To be taken 2 weeks post‐operatively

LOWER EXTREMITY
Toe/Digit 3 views (PA, lateral and oblique)
Foot 3 views standing (AP, lateral and oblique)
Ankle 3 views (AP, lateral and standing Mortise)
Calcaneus 2 views (AP and lateral)
Tibia‐Fibula 3 views (AP, lateral and oblique) ‐OR‐2 views (AP and lateral)
Femur 3 views (AP, lateral and oblique) ‐OR‐2 views (AP and lateral)

KNEE
Knee 4 views (AP, lateral, Lauren and Tunnel)
Knee (R/O DJD or older than 40 yo) 4 views (AP, lateral, Lauren and Rosenberg)

POST‐OPERATIVE KNEE
Post‐op OATS 2 views (AP and lateral)
‐To be taken 1‐2 months post‐operatively
Post‐op Osteotomy 2 views (AP and lateral)
‐To be taken 4‐6 weeks post‐operatively
PELVIS/HIP
Hip 2 views (AP pelvis and frog lateral)
Hip (Evaluate for bony impingement) 2 views (AP pelvis and Cross‐Table Lateral)
Hip (Evaluate for bony
impingement)
3 views (AP pelvis, Dunn Lateral and False Profile)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


SPINE
Cervical Spine (Recent Trauma) 3 views (AP, lateral and Odontoid)
Cervical Spine (Chronic Problem/
Trauma)
2 views (AP and lateral)
Thoracic Spine 2 views (AP and lateral)
Lumbar Spine 2 views (AP and lateral)
Lumbar Spine (R/O Spondy) 4 views (AP, lateral and obliques)
Scoliosis 2 views standing (PA and lateral scoliosis views)


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X‐Ray View Summary

Table 2. Department of Orthopedics and Rehabilitation Pediatric Orthopedic Clinic
UPPER EXTREMITY
Finger/Digit 3 views (PA, lateral and oblique)
Hand 3 views (PA, lateral and oblique)
Hand/Bone Age 1 view (PA left hand)
Wrist 3 views (PA, lateral and oblique)
Wrist Fracture Follow‐Up 2 views (PA and lateral)
Wrist (Suspected Scaphoid Fx) 4 views (PA, lateral, oblique and scaphoid view)
Wrist (Suspected Perilunate Fx) 4 views (PA, lateral, oblique and grip)
Forearm 2 views (AP and lateral)
Elbow 3 views (AP, lateral and radiocapitellar)
Elbow (Supracondylar Fx) 2 views (AP and lateral, center on distal humerus)
Elbow (Lateral Condyle/Epicondyle
Fx)
3 view (AP, lateral and oblique in internal rotation, center on
distal humerus)
Elbow (Medial Condyle/Epicondyle
Fx)
3 view (AP, lateral and oblique in external rotation, center on
distal humerus)
Humerus 2 view (AP and lateral)
Proximal Humerus 3 view SHOULDER (AP, Neer and axillary)

SHOULDER
Rotator Cuff Series 4 views (AP/AC, Neer, Arch and Axillary)
Instability Series 3 views (Neer, Axillary and West Point)
AC Joint 2 views (Straight AP and Axillary)
Clavicle 2 views (AP and Zanka)
Sternoclavicular Joint 2 views (AP and Serendipity)
Scapula 2 views (AP and Scapular Y)
Proximal Humerus fx 3 views shoulder (AP, Neer and Axillary)

LOWER EXTREMITY
Toe/Digit 3 views (PA, lateral and oblique)
Foot 3 views standing (AP, lateral and oblique)
Ankle 3 views (AP, lateral and standing Mortise)
Calcaneus 2 views (Harris and lateral)
Tibia‐Fibula 2 views (AP and lateral) ‐OR‐4 views (AP, lateral, and bilateral
obliques if concern re: stress fracture)
Femur 2 views (AP and lateral) ‐OR‐ 3 views (AP, lateral and oblique)
Bilateral Legs
(Evaluate alignment and leg lengths)
1 view standing (TVO)
Use for all first visits for leg length discrepancy (LLD)
Follow‐up LLD: block under shorter leg, height per last note
Bilateral Legs
(Follow‐up leg lengths, supine)
Scanogram supine
Not to be used for first visit for leg length discrepancy


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

KNEE
Knee 4 views (AP, lateral, Lauren and Tunnel) Knee (R/O DJD or older
than 40 yo)
Knee (R/O DJD or older than 40 yo) ‐
OR‐(Evaluate for OCD, <18‐years old)
4 views (AP, lateral, Lauren and Rosenberg)
Knee (follow‐up dist femur/prox
tibia fracture)
2 views (AP and lateral)

PELVIS/HIP
Hip
(Legg‐Calve‐Perthes, Dysplasia (1
st

visit), other)
2 views (AP pelvis and frog lateral)
DDH follow‐up 1 view (Pelvis – AP only)
Hip (SCFE) 2 views (AP pelvis and frog lateral)

SPINE
Cervical Spine (Recent Trauma) 3 views (AP, lateral and Odontoid)
Cervical Spine (Chronic
Problem/Trauma)
2 views (AP and lateral)
Thoracic Spine 2 views (AP and lateral)
Lumbar Spine 2 views (AP and lateral)
Lumbar Spine (R/O Spondy) 4 views (AP, lateral and obliques)
Lumbar Spine (Following Spondy) 1 view (Spot Lateral Lumbar)
Scoliosis, Kyphosis 2 views standing (PA and lateral spine) –OR‐
1 view PA for follow‐up idiopathic scoliosis
‐If unable to stand, then sitting (AP and lateral)
‐If unable to sit, then supine (AP and lateral)

POST‐OPERATIVE SPINE
Pre‐op Spine Fusion 2 views supine, left and right bending, on 17x14 cassette
Post‐op Posterior Spine Fusion 2 views standing (PA and lateral scoliosis views)
‐If unable to stand, then sitting
‐If unable to sit, then supine


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X‐Ray View Summary

Table 3. Department of Orthopedics and Rehabilitation Spine Clinic
NECK
Neck Pain (New Patient) 2 views cervical spine (AP and lateral)
S/P ACDF 1 view spine (cervical lateral)
S/P ACDA 2 views cervical spine (AP and lateral ‐OR‐ flexion and
extension)
C1‐2 Fracture 2 views cervical spine (open mouth and lateral)
S/P Laminoplasty/Fracture 2 views cervical spine (AP and lateral)
Ligamentous Injury 2 views cervical spine (flexion and extension)

MID BACK
T1 fracture 2 views thoracic spine (AP and swimmers)
S/P Fracture/Fusion 2 views thoracic spine (AP and lateral)
S/P T10‐L1 Fracture/Fusion 2 views thoracolumbar spine, standing (AP and lateral)

LOW BACK
Low Back Pain (New patient) 2 views lumbar, standing (AP and lateral)
S/P Fusion/Fracture/XSTOP 2 views lumbar, standing (AP and lateral)
S/P Coccyxgectomy 1 view (lateral sacrum)

SCOLIOSIS
Scoliosis (New patient) 2 views scoliosis, standing (PA and lateral)
Scoliosis (Post‐op) 2 views scoliosis, standing (PA and lateral)
Scoliosis (Post‐op using tilt table) 2 views scoliosis, supine (PA and lateral)

HIP
Hip Pain 2 views (AP pelvis and frog lateral)


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X‐Ray View Summary

Table 4. Department of Orthopedics and Rehabilitation Clinic
(Joint, Hand/Upper Extremity, Foot/Ankle)
JOINT REPLACEMENT CLINIC
HIP
Hip (New patient) 2 views (AP pelvis and cross‐table lateral)
Hip (Post‐op THA) 2 views (AP pelvis and cross‐table lateral)
Hip (Post‐op SRA) 4 views (AP pelvis, AP hip, cross‐table lateral and frog leg)

KNEE
Knee (New patient) 4 views (AP, lateral, sunrise, and Rosenberg)
Knee (Post‐op TKA/UKA) 2 views (AP and lateral)

FOOT/ANKLE CLINIC
FOOT
Foot (New patient) 3 views standing (AP, lateral and oblique)
Calcaneus (New patient) 3 views standing or supine “Calcaneus Series” (lateral
foot, 45 degree internal oblique of ankle and Harris view
of calcaneus)

ANKLE
Ankle (New patient) 3 views standing (AP, lateral and mortise)

HAND/UPPER EXTREMITY CLINIC
HAND/WRIST/FOREARM
Finger
(Phalanx fx, tuft fx, jt dislocation, OA, mallet
finger, cyst, S/P pinning)
3 views (AP, lateral and oblique)
Hand
(Metacarpal fx, S/P thumb CMC
arthroplasty)
3 views (AP, lateral and oblique)
Wrist
(New patient, distal radius fx, carpal fx,
dislocation, OA, AVN, S/P distal radius ORIF,
S/P proximal row carpectomy, S/P 4 corner
fusion, S/P full fusion)
3 views (PA, lateral and oblique)
Wrist
(Scaphoid fx, S/P scaphoid ORIF)
4 views (PA, lateral, oblique and scaphoid)
Wrist
(Scapholunate injury)
4 views (PA, lateral, oblique, PA clenched fist/grip)
Forearm 2 view (AP and lateral)

ELBOW/HUMERUS/SHOULDER
Elbow
(Forearm fx, S/P forearm ORIF)
3 views (AP, lateral and radiocapitellar)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Humerus
(Mid humerus fx)
2 views (AP and lateral)
Shoulder
(GHJ OA, ACJ OA, RTC arthropathy)
4 views (AP, AP Neer, axillary and arch)
Shoulder
(1st visit S/P shoulder arthroplasty)
3 views (AP, AP Neer and axillary assisted)

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X‐Ray View Summary

Table 5. Department of Orthopedics and Rehabilitation Sports Medicine Clinic – Previsit Planning
NEW PATIENT SCHEDULED FOR
MUSCULOSKELETAL PROBLEM
Order X‐rays to be completed prior to physician visit if:
1. New patient with recent trauma/injury
2. New atient is over 40 years of age without recent trauma
and with no x‐rays in the past 3 years.
Hip Pain AP Pelvis and Lateral of Hip
Shoulder Pain AP, Neer AP, Scapular Y, Axillary
Neck Pain Cervical AP, Lateral
Low Back Pain Lumbar AP, Lateral
Elbow Pain AP, Lateral, Radiocapitellar
Wrist Pain PA, Oblique, Lateral, Scaphoid
Ankle Pain AP, Lateral, Mortise
Foot Pain AP, Lateral, Oblique
Knee Pain Bilateral standing AP, 45 degree PA (Rosenberg), Lateral,
Merchant/Sunrise
Hip Pain AP Pelvis and Lateral of Hip
Shoulder Pain AP, Neer AP, Scapular Y, Axillary


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org