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Imaging and Diagnostics Before Referral: What’s Essential and When?

Imaging and Diagnostics Before Referral: What’s Essential and When?

Best Practices

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Before referring a patient, ensure you have the right imaging and diagnostics. Learn which tests are essential for accurate veterinary referrals and when to use them

By 

Sustainable Vet Group

Updated on

March 4, 2025

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A pre-referral workup is the diagnostic process veterinarians carry out before sending an orthopedic case to a specialist. It ensures that referrals are timely, justified, and necessary, preventing unnecessary delays in treatment. Not every musculoskeletal case requires an immediate referral; thorough initial diagnostics help determine whether specialized orthopedic care is needed or if the condition can be managed in general practice.

One of the biggest challenges in orthopedic pre-referral workups is insufficient or incorrect diagnostics, leading to incomplete case presentations or misinterpretation of findings. Poor imaging quality, missing essential baseline tests, and unclear communication with specialists can cause delayed diagnoses and ineffective treatment plans.

This guide aims to help veterinarians overcome these challenges. Knowing when and how to use imaging and diagnostics will improve decision-making and enhance patient outcomes.

TL;DR

  • Perform a structured pre-referral workup – Begin with a thorough clinical assessment, including gait analysis, palpation tests, and initial imaging (X-rays, ultrasound) to decide if advanced diagnostics (CT/MRI) are necessary.
  • Know when to refer – Immediate referral is needed for severe fractures, complete CCL ruptures, spinal trauma (IVDD), and rapidly worsening lameness. Non-urgent cases (like mild joint instability or early osteoarthritis) should undergo a complete diagnostic workup before referral.
  • Use the right imaging – Use X-rays for fractures and joint problems, ultrasound for soft tissue injuries, CT for complex fractures, and MRI for spinal or neurological conditions. Avoid unnecessary repeat imaging before referral.
  • Optimize pre-referral efficiency – Complete all relevant initial imaging, perform baseline lab tests if surgery is planned, clearly document findings, and communicate with specialists to prevent redundant tests.
  • Avoid common pitfalls – Poorly positioned X-rays, misinterpreted ultrasound results, and premature or delayed referrals can lead to misdiagnosis. Proper imaging techniques and consulting with specialists improve accuracy and patient outcomes.

Decision-Making Algorithm for Pre-Referral Workups

A structured pre-referral workup ensures that the right diagnostic steps are taken before referring a patient to a specialist. The choice of imaging depends on clinical signs and initial findings.

Start with a Comprehensive Clinical Assessment

Before imaging, a thorough physical examination should guide decision-making. Key factors include:

  • Patient history: Onset, duration, and progression of symptoms, prior trauma, and response to treatment.
  • Gait analysis: Identification of lameness severity, weight-bearing issues, or neurologic deficits.
  • Palpation and orthopedic tests: Joint effusion, instability, crepitus, pain localization, and response to manipulation.
  • Neurologic evaluation: If spinal or nerve involvement is suspected, this will determine the need for advanced imaging.

A well-documented clinical assessment helps determine the most effective initial diagnostic approach.

Condition X-ray Sufficient? Ultrasound Needed? CT or MRI Required?
Simple fracture ✅ Yes ❌ No ❌ No
Comminuted/intra-articular fracture ❌ No ❌ No ✅ CT
Suspected osteosarcoma ✅ Yes ✅ Yes (if soft tissue extension) ✅ CT for extent
Joint effusion ❌ No ✅ Yes ❌ No
Cranial cruciate ligament rupture ❌ No ✅ Yes (partial tears) ✅ MRI for full assessment
Intervertebral disc disease (IVDD) ❌ No ❌ No ✅ MRI
Spinal trauma ❌ No ❌ No ✅ MRI or CT
Elbow dysplasia ❌ No ❌ No ✅ CT

By following this structured approach, unnecessary imaging can be reduced while ensuring the referral center has the information needed to provide specialized care.

Essential Pre-Referral Imaging & Diagnostics

Each technique has its own strengths and limitations, and using the correct one at the right time enhances diagnostic accuracy.

Radiography (X-rays)

X-rays are the first-line imaging choice for orthopedic evaluations. They are essential for detecting:

  • Fractures – Simple, displaced, or minimally comminuted fractures.
  • Joint abnormalities – Osteoarthritis, subluxations, luxations.
  • Bone tumors – Early identification of osteosarcoma or lytic lesions.

If lesions are unclear or deeper tissue involvement is suspected, advanced imaging (CT/MRI) should be considered before referral.

Ultrasound Imaging

Ultrasound is a non-invasive tool for soft tissue assessment in orthopedic cases. It is particularly useful for:

If ultrasound suggests significant soft tissue damage, CT or MRI may be required before referral.

Computed Tomography (CT) Scans

CT provides detailed cross-sectional imaging, enhancing the evaluation of:

  • Complex fractures (e.g., intra-articular or pelvic fractures requiring surgical planning).
  • Elbow dysplasia and subtle bone lesions.
  • Bone tumors (for surgical margins and metastasis evaluation).

CT should be used when X-rays do not provide a clear diagnosis, ensuring precise referral decisions.

Magnetic Resonance Imaging (MRI)

MRI is the gold standard for soft tissue and neurological cases, offering superior detail for:

MRI ensures accurate diagnosis and surgical planning for complex ligamentous and spinal cases.

When to Refer Based on Imaging Results

Referral is necessary when imaging findings indicate the need for specialized orthopedic expertise or advanced diagnostics. Below are the key situations warranting referral:

1. When X-Rays or Ultrasound Suggest Advanced Imaging (CT/MRI)

Consider a referral if initial imaging shows:

  • Bone tumors, complex fractures, or joint issues that need more evaluation.
  • Joint instability, subtle bone problems, or unclear lesions that require advanced imaging.
  • Abnormal ultrasound results indicating significant ligament or tendon injuries.

2. Neurological Cases Requiring MRI or Specialist Evaluation

Refer to an orthopedic specialist or neurologist when:

3. When Specialized Surgical Intervention is Required

Referral is needed for cases beyond general practice, such as:

  • Pelvic fractures needing plating or complex joint reconstructions.
  • Severe ligament injuries, like complete cranial cruciate ligament (CCL) ruptures, requiring surgical expertise.
  • Elbow dysplasia or other complex orthopedic conditions needing specialized procedures.

4. When Imaging Interpretation is Inconclusive

Refer to an orthopedic specialist or radiologist when:

  • X-rays or ultrasound results are unclear or hard to interpret.
  • Further expertise is needed to confirm a diagnosis and guide treatment.

Early referral ensures timely intervention, prevents misdiagnosis, and improves patient outcomes.

Pre-Referral Considerations to Avoid Redundant Tests

Before referring a patient, it's important to optimize diagnostic efficiency and avoid unnecessary tests that could delay treatment or increase costs. Proper pre-referral considerations ensure that only relevant diagnostics are performed, avoiding redundant procedures.

1. Ensure All Relevant First-Line Imaging is Completed

Before referral, conduct basic imaging like X-rays and ultrasound when needed. These provide essential diagnostic information to help decide if advanced imaging (CT/MRI) is necessary.

  • X-rays should be done for suspected fractures, osteoarthritis, or bone lesions.
  • Ultrasound is useful for checking joint effusion, soft tissue masses, or internal organ issues.
  • If findings are clear and sufficient, you may proceed with the referral without further imaging.

2. Perform Baseline Lab Tests to Rule Out Systemic Conditions

Routine complete blood count (CBC) and blood chemistry help assess infection, inflammation, anemia, or metabolic disorders that may influence treatment decisions. This is especially important when planning for surgery or anesthesia.

  • An elevated WBC count may indicate an active infection that needs medical management before surgery.
  • Liver and kidney function tests are crucial for assessing anesthetic risks.
  • Coagulation profiles help evaluate bleeding tendencies in surgical cases.

3. Clearly Document Clinical Findings for Referral Notes

A detailed referral note should summarize the patient’s history, clinical signs, diagnostic results, and the reason for referral. This ensures the receiving specialist understands the case clearly.

  • Include physical exam findings, pain assessments, and any gait abnormalities if applicable.
  • Attach radiographs, ultrasound reports, and lab results to avoid duplicate testing.
  • Provide tentative or differential diagnoses based on current findings.

4. Communicate with Referral Specialists in Advance

Consulting with the specialist before referral ensures that the necessary tests have been performed and avoids unnecessary procedures.

  • Some specialists prefer to perform imaging at their own facility for standardization and better diagnostic quality.
  • Confirm if additional diagnostics like CT, MRI, or biopsy should be done beforehand or left for the referral visit.
  • Discuss anesthesia protocols if sedation or contrast studies are expected.

5. Avoid Unnecessary Repeat Imaging

Repeated imaging can expose the patient to unnecessary radiation, stress, or additional costs. If previous X-rays or ultrasounds provide enough detail, there is no need for immediate re-imaging before referral.

  • Some referral centers require specific imaging protocols and may prefer to conduct CT/MRI scans in-house.
  • Sending high-quality DICOM files with referral notes prevents redundant imaging.

Common Pitfalls in Pre-Referral Workups & How to Avoid Them

Common pitfalls in orthopedic pre-referral workups can lead to misdiagnosis, repeated imaging, or poorly timed referrals. Below are the main issues and strategies to avoid them.

1. Inadequate X-Rays: Poor Positioning & Missing Views

Poorly positioned or incomplete X-rays can obscure fractures, joint abnormalities, or soft tissue damage, leading to misinterpretation.

How to Avoid:

  • Always take at least two orthogonal views (e.g., lateral and craniocaudal/mediolateral).
  • Use stress or oblique views for joint instability (e.g., CCL rupture, elbow dysplasia).
  • Ensure proper sedation for accurate positioning, especially for pelvic or spinal radiographs.

2. Misinterpretation of Ultrasound Findings

Ultrasound can be challenging when assessing soft tissue structures, joint effusions, or tendon injuries, leading to unnecessary referrals or missed diagnoses.

How to Avoid:

  • Consult a radiologist or orthopedic specialist for unclear cases.
  • Combine ultrasound findings with clinical signs, palpation tests, and lab results.
  • Be cautious with fluid-filled joint effusions, as some require MRI or arthroscopy for further assessment.

3. Sending Cases Too Early or Too Late

Referring a case too early may lead to unnecessary specialist visits, while delaying an urgent orthopedic referral can worsen the prognosis.

How to Avoid:

  • Immediate referral is necessary for unstable fractures, severe joint instability (complete CCL rupture), or spinal trauma requiring MRI.
  • Non-urgent cases (e.g., mild lameness, early osteoarthritis) should receive a full workup (X-rays, ultrasound, joint fluid analysis) before referral.
  • Communicate with specialists beforehand to confirm if additional diagnostics are needed before referral.

Avoiding these pitfalls ensures efficient diagnostics, timely referrals, and better patient outcomes.

Special Considerations for Emergency vs. Non-Urgent Cases

The urgency of a referral depends on how severe the orthopedic condition is and the immediate risk it poses to the patient's mobility and overall function.

Emergency Cases: Immediate Referral with Minimal Pre-Referral Imaging

Certain orthopedic conditions require urgent specialist intervention, where delaying referral for extensive diagnostics may worsen prognosis. In these cases, stabilization and rapid referral are the priorities:

  • Severe trauma (e.g., open fractures, joint luxations with neurovascular compromise, severe hemorrhage).
  • Complete cranial cruciate ligament (CCL) rupture with severe joint instability – If the dog is non-weight-bearing, in severe pain, or has suspected meniscal damage, urgent surgical intervention is needed.
  • Spinal trauma or suspected intervertebral disc disease (IVDD) with acute paralysis – MRI and surgical decompression may be necessary.
  • Severe limb deformities or rapidly progressing lameness – May require immediate orthopedic intervention.

For these cases, perform only essential imaging (e.g., rapid X-rays or ultrasound) before referral, focusing on stabilizing the patient and ensuring safe transport.

Non-Emergency Cases: Full Workup Before Referral

Non-urgent orthopedic cases allow time for comprehensive diagnostics before referral, helping specialists plan treatment effectively:

  • Chronic lameness – X-rays, joint ultrasound, and basic lab work should be completed before referral.
  • Partial CCL rupture or mild joint instability – In cases of chronic, progressive lameness with early degenerative joint disease, a full pre-referral workup (X-rays, joint effusion analysis, and possibly ultrasound) should be performed before considering surgical correction.
  • Elbow dysplasia or early-stage osteoarthritis – Require imaging confirmation and conservative treatment trials before referral.

For these cases, a complete workup ensures that the referral is necessary and helps guide specialist intervention.

Conclusion

In conclusion, a well-organized pre-referral workup is crucial for making sure veterinary patients get timely and proper care. By performing thorough clinical assessments and using the right imaging and diagnostic tools, veterinarians can decide when it's best to refer a patient to a specialist.

This method not only boosts diagnostic accuracy but also improves patient outcomes by avoiding unnecessary treatment delays.

By steering clear of common mistakes and optimizing pre-referral steps, veterinarians can ensure efficient diagnostics and effective communication with specialists, ultimately leading to better health outcomes for their patients.

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