dromlakhani Obtain plain radiographs for suspected Paget's disease
STEP 1 — Gather Information
Collect history of unexplained bone pain, deformity, or elevated serum alkaline phosphatase; perform physical exam focusing on bony tenderness, warmth, or deformity. If suspicion of Paget's disease is present, proceed; otherwise consider alternative diagnoses.
STEP 2 — Rule In / Rule Out
Assess whether clinical features warrant imaging: if unexplained bone pain, elevated ALP, or bony deformity exists, rule in for radiographic evaluation; if none are present, rule out Paget's disease and investigate other causes.
STEP 3 — Classify or Stratify
Determine skeletal regions to image based on symptoms or lab findings (e.g., painful spine, pelvis, long bones) to target plain radiographs of those suspicious areas.
STEP 4 — Decide
Order plain radiographs of the identified suspicious skeletal regions to evaluate for characteristic Paget's changes (osteolytic, mixed lytic-sclerotic, cortical thickening).
Clinical Guardrails / Mimics / Pitfalls
Do not rely solely on bone scintigraphy without radiographs; early osteolytic lesions may be missed if only late sclerotic phases are imaged. Avoid confusing Paget's changes with metastatic disease, fibrous dysplasia, or infection without correlating clinical and lab data.
Concrete Clinical Example
A 68‑year‑old man presents with 6‑month history of worsening left thigh pain and an elevated alkaline phosphatase of 210 U/L. Plain radiographs of the femur show an expansile mixed lytic‑sclerotic lesion with cortical thickening, confirming suspected Paget's disease.
Source: Paget’s Disease of Bone: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2014, 10.1210/jc.2014-2910