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Appropriateness Criteria

Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions not evaluated by the Ottawa rules. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
13 (20943841) 3
14 (29876703) 4
Radiography foot Usually not appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
1 (12595378) 4
3 (15231460) 3
9 (12675622) 3
10 (15532344) 2
11 (14705761) 4
4 (21450433) 3
12 (11858921) 4
6 (8433468) 1
5 (9774943) 4
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Variant 2: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are positive. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 1 16
References Study Quality
1 (12595378) 4
9 (12675622) 3
10 (15532344) 2
8 (10350289) 3
15 (25887075) 2
Radiography foot with weightbearing Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 1 0 0 0 3 5 8
References Study Quality
16 (22451574) 2
20 (24617695) 4
19 (12435655) 1
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 0 1 0 0
References Study Quality
13 (20943841) 3
23 (25269589) 2
14 (29876703) 4
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 0 0 0 1 0 0 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 0 1 0 0 0 0 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
CT foot without IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 0 1 1 1 0 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot be evaluated due to exclusionary criteria. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 2 15
References Study Quality
24 (16096591) 2
25 (8669741) 1
5 (9774943) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 0 10 3 0 3 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
26 (26797374) 3
US foot Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 0 0 0
References Study Quality
24 (16096591) 2
28 (11856673) 4
27 (9423650) 2
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 1 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 1 0 1 0 0 1 0
CT foot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
26 (26797374) 3
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 0 0 2 0 0
References Study Quality
22 (15546842) 4
21 (15333345) 3
26 (26797374) 3
Variant 4: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area not addressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe, tendon, etc). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 2 1 14
References Study Quality
29 (23015979) 4
31 (25239377) 2
30 (23091286) 3
Radiography foot with weightbearing Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 3 4 10
References Study Quality
29 (23015979) 4
32 (22915389) 4
CT foot without IV contrast May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 2 1 0 1 7 3 2 1 0
References Study Quality
33 (10584818) 2
21 (15333345) 3
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 2 1 0 0 0 0 0 0
References Study Quality
36 (12496521) 1
39 (22453857) 4
40 (15895226) 3
Fluoroscopy foot Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 14 1 1 0 0 0 0 0 1
References Study Quality
29 (23015979) 4
MRI foot without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 1 0 3 0 0 0 0 0
References Study Quality
38 (19048208) 4
34 (22619270) 2
36 (12496521) 1
37 (18820039) 3
35 (21645348) 3
MRI foot without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 4 1 0 0 0
References Study Quality
38 (19048208) 4
34 (22619270) 2
36 (12496521) 1
37 (18820039) 3
35 (21645348) 3
CT foot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 1 0 1 0 0 0
References Study Quality
33 (10584818) 2
21 (15333345) 3
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 1 0 1 0 0 0
References Study Quality
33 (10584818) 2
21 (15333345) 3
Variant 5: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury, tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 3 0 4 10
References Study Quality
55 (10464721) 4
54 (18287423) 3
38 (19048208) 4
41 (21098178) 4
29 (23015979) 4
42 (19696279) 3
43 (9694121) 4
33 (10584818) 2
44 (19339574) 3
37 (18820039) 3
21 (15333345) 3
45 (22915209) 2
46 (18440481) 4
39 (22453857) 4
51 (26888876) 2
56 (27336454) 4
52 (29112474) 3
53 (29570372) 3
CT foot without IV contrast Usually appropriate Strong ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 1 0 2 4 10
References Study Quality
38 (19048208) 4
41 (21098178) 4
49 (17185672) 2
50 (17996620) 4
42 (19696279) 3
43 (9694121) 4
33 (10584818) 2
44 (19339574) 3
22 (15546842) 4
21 (15333345) 3
45 (22915209) 2
46 (18440481) 4
48 (28112555) 4
47 (27234977) 4
US foot May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 0 11 5 0 0 0
References Study Quality
58 (17996621) 4
57 (18094286) 3
63 (18095247) 4
64 (16819605) 3
32 (22915389) 4
59 (19244072) 4
39 (22453857) 4
65 (16085620) 3
62 (26802947) 3
60 (27497976) 3
20 (24617695) 4
61 (23522739) 2
MRI foot without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 2 0 0
References Study Quality
55 (10464721) 4
54 (18287423) 3
38 (19048208) 4
41 (21098178) 4
29 (23015979) 4
42 (19696279) 3
43 (9694121) 4
33 (10584818) 2
44 (19339574) 3
37 (18820039) 3
21 (15333345) 3
45 (22915209) 2
46 (18440481) 4
39 (22453857) 4
51 (26888876) 2
56 (27336454) 4
52 (29112474) 3
53 (29570372) 3
CT foot with IV contrast Usually not appropriate Strong ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 1 0 0 0 1 1 0 0
References Study Quality
38 (19048208) 4
41 (21098178) 4
49 (17185672) 2
50 (17996620) 4
42 (19696279) 3
43 (9694121) 4
33 (10584818) 2
44 (19339574) 3
22 (15546842) 4
21 (15333345) 3
45 (22915209) 2
46 (18440481) 4
48 (28112555) 4
47 (27234977) 4
CT foot without and with IV contrast Usually not appropriate Strong ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 1 0 1 0 0 1 0 0
References Study Quality
38 (19048208) 4
41 (21098178) 4
49 (17185672) 2
50 (17996620) 4
42 (19696279) 3
43 (9694121) 4
33 (10584818) 2
44 (19339574) 3
22 (15546842) 4
21 (15333345) 3
45 (22915209) 2
46 (18440481) 4
48 (28112555) 4
47 (27234977) 4
Variant 6: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating trauma with a foreign body. Radiographs of the foot are negative. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US foot Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
24 (16096591) 2
28 (11856673) 4
25 (8669741) 1
27 (9423650) 2
MRI foot without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
28 (11856673) 4
66 (22744349) 2
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
66 (22744349) 2
MRI foot without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
28 (11856673) 4
66 (22744349) 2
CT foot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
66 (22744349) 2
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
66 (22744349) 2
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.