ProtocolPulse

MRI MSK

MRI
NICE NG382016NICE CG1242011, updated 2023NICE NG122015, updated 2026RCR iRefer2017, continuously updatedBOA BOAST2020v2.0 · March 2026
Varies
EDOutpatient
All imaging requests must be justified by an IR(ME)R practitioner (radiologist or radiographer)
Open in NICE

Scaphoid fracture (NG38 Rec 1.2.3)

— ANY of the following

  • Consider MRI for first-line imaging in suspected scaphoid fracturesNICE NG38 Rec 1.2.3
  • Sensitivity 94.2% vs CT 81.5%; detects soft tissue injuries
  • NICE cost-effectiveness: MRI most cost-effective

Occult hip fracture (CG124)

MRI PREFERRED. CT only if MRI unavailable within 24 hours or contraindicated. Nuclear bone scan NO LONGER recommended.

  • Offer MRI if hip fracture suspected despite negative adequate X-raysNICE CG124 Rec 1.1.1
  • CT only if MRI is unavailable within 24 hours or MRI is contraindicatedNICE CG124 Rec 1.1.1
  • Nuclear bone scan NO LONGER recommended

Knee internal derangement

— ANY of the following

  • Ottawa Knee Rules for initial X-ray
  • MRI for meniscal tears, ACL/PCL, osteochondral lesions
  • BOA BOAST: MRI for pre-op ACL confirmationBOA BOAST
  • Usually after ≥6 weeks conservative unless acute locked knee

Soft tissue sarcoma (NG12)

— ANY of the following

  • USS first for unexplained lump increasing in sizeNICE NG12
  • MRI modality of choice for local staging
  • Threshold: >5 cm, deep to fascia, painful, or recurrent
  • All sarcoma MRI at specialist centres BEFORE biopsy

Osteomyelitis

— ANY of the following

  • MRI with IV contrast — sensitivity >90%, specificity >80%
  • Negative MRI effectively excludes osteomyelitis

Avascular necrosis (AVN)

— ANY of the following

  • MRI gold standard — classic 'double-line sign' on T2
  • Detects before X-ray changes

Notes

Local preference

MRI preferred over CT for occult hip fracture (CG124)

NICE CG124
Information

Nuclear bone scan no longer recommended for occult hip

Information

All sarcoma MRI should be at specialist centres before biopsy

Information

MRI most cost-effective for scaphoid (NICE modelling)

NICE NG38
Modality Preference

MRI preferred. Superior soft tissue contrast for all listed indications. NICE-preferred for scaphoid and hip fracture.

Source: NICE NG38; CG124; NG12

Change Log

v1.02026-03-05CT Hip initial publication
v2.02026-03-08Expanded to comprehensive MRI MSK: scaphoid, hip, knee, sarcoma, osteomyelitis, AVN.

Not clinical advice. This protocol is a reference tool only. All imaging justifications remain the clinical and legal responsibility of the authorising practitioner under IR(ME)R 2017 (as amended 2024). Protocol content should be verified against current NICE, RCR, and specialty guidelines before use in practice.

AI-assisted content. Clinical criteria were developed with AI assistance and cross-referenced against cited source guidelines. Verify against original sources. Guidelines referenced are current at the stated version date and may have been updated since.