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Appropriateness Criteria

Variant 1: Adult. Suspect stress fracture, excluding vertebrae. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 9 9 1 0 0 0 1 1 2 0 10
References Study Quality
43 (12143987) 4
31 (17317066) 4
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 1 3 3 4 0 2 0 0
References Study Quality
21 (11981604) 4
20 (22583605) 4
19 (22341018) 4
18 (18806135) 3
17 (21285675) 2
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
References Study Quality
46 (16769791) 4
45 (24643763) 4
44 (19567620) 2
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 0 1 0 0
MRI area of interest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 6 1 4 1 2 0 0 1 0
References Study Quality
29 (14576960) 3
28 (19651835) 4
27 (14736647) 4
26 (22815414) 4
25 (16235078) 4
23 (15858094) 3
22 (16247722) 4
15 (17099238) 4
42 (23825184) 3
39 (16466974) 3
38 (17015602) 3
37 (16324973) 4
36 (18492915) 4
35 (16294127) 4
34 (19700255) 4
33 (17387472) 2
32 (18382945) 4
31 (17317066) 4
30 (16798139) 4
41 (18084759) 4
40 (21531099) 4
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 0 0 1 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 0 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Limited Varies Varies 1 1 9 1 1 2 1 0 1 0 0
References Study Quality
24 (25805712) 4
23 (15858094) 3
22 (16247722) 4
Variant 2: Adult. Suspect stress fracture, excluding vertebrae. Radiographs negative or indeterminate. 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 area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 2 0 12
References Study Quality
29 (14576960) 3
23 (15858094) 3
22 (16247722) 4
15 (17099238) 4
42 (23825184) 3
39 (16466974) 3
38 (17015602) 3
37 (16324973) 4
36 (18492915) 4
35 (16294127) 4
34 (19700255) 4
33 (17387472) 2
32 (18382945) 4
31 (17317066) 4
30 (16798139) 4
41 (18084759) 4
Radiography area of interest repeat in 10-14 days May be appropriate Limited Varies Varies 6 6 0 0 1 1 1 7 4 0 1
References Study Quality
31 (17317066) 4
43 (12143987) 4
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 2 5 5 2 0
References Study Quality
31 (17317066) 4
28 (19651835) 4
27 (14736647) 4
26 (22815414) 4
25 (16235078) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 4 4 2 1 2 3 5 1 1 0 0
References Study Quality
23 (15858094) 3
22 (16247722) 4
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 5 5 0 0 0 0 0 0
References Study Quality
46 (16769791) 4
45 (24643763) 4
44 (19567620) 2
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 2 0 1 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 0 0 1 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 1 0 0 1 0 0 0
Variant 3: Adult. Suspect pelvis or hip or sacrum stress fracture. Pregnant patient. Radiographs negative or indeterminate. 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 area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 2 12
References Study Quality
57 (17560159) 4
28 (19651835) 4
27 (14736647) 4
26 (22815414) 4
25 (16235078) 4
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 7 0 3 1 2 1 0 1 0
References Study Quality
45 (24643763) 4
44 (19567620) 2
Radiography area of interest repeat in 10-14 days Usually not appropriate Limited Varies Varies 3 3 6 0 6 2 1 0 0 0 0
References Study Quality
43 (12143987) 4
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 1 0 0 0
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 0 1 0 1 0 0
References Study Quality
31 (17317066) 4
62 (-3195179) 4
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 0 0 0 0 0 1 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 0 0 0 0 1 0 0
CT area of interest without IV contrast Usually not appropriate Limited Varies Varies 1 1 12 1 1 1 0 0 0 0 0
References Study Quality
62 (-3195179) 4
Variant 4: Adult. Suspect stress fracture, excluding vertebrae. High risk for fracture completion (ie, a patient with osteoporosis on bisphosphonate therapy) or immediate “need-to-know.” Radiographs negative or indeterminate. 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 area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 1 13
References Study Quality
28 (19651835) 4
27 (14736647) 4
26 (22815414) 4
25 (16235078) 4
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 3 2 6 1 2 1 0
References Study Quality
31 (17317066) 4
67 (15722819) 4
66 (12777887) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 0 0 0 12 1 1 1 0
References Study Quality
24 (25805712) 4
23 (15858094) 3
22 (16247722) 4
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 7 0 3 3 1 0 1 0 0
References Study Quality
45 (24643763) 4
44 (19567620) 2
Radiography area of interest repeat in 10-14 days Usually not appropriate Limited Varies Varies 1 1 8 1 3 1 1 1 0 0 0
References Study Quality
43 (12143987) 4
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 1 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 1 0 0 0 0 1 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 0 1 1 0 0 0
Variant 5: Adult. Suspect subchondral stress fracture at an extremity joint. Radiographs negative or indeterminate. 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 area of interest without IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 0 13
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 1 2 5 3 1 1 0 0
References Study Quality
31 (17317066) 4
68 (22117809) 4
66 (12777887) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 4 4 2 0 4 2 6 0 1 0 0
References Study Quality
23 (15858094) 3
22 (16247722) 4
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 0 0 0 1 0
References Study Quality
43 (12143987) 4
Radiography area of interest repeat in 10-14 days Usually not appropriate Limited Varies Varies 1 1 11 1 1 1 0 1 0 0 0
References Study Quality
43 (12143987) 4
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 3 0 0 1 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 0 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 1 0 0 0 0
Variant 6: Adult. Positive stress fracture on radiographs, excluding vertebrae. Need for determining extent (ie, for surgical planning, return to activity) or associated complication (ie, osteonecrosis or delayed healing). 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 area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 3 0 11
References Study Quality
13 (14623664) 4
42 (23825184) 3
74 (22451555) 3
73 (9442205) 3
72 (22623695) 3
71 (7573660) 4
CT area of interest without IV contrast Usually appropriate Expert Consensus Varies Varies 7 7 0 0 0 0 3 3 8 1 0
Radiography area of interest repeat in 10-14 days May be appropriate Expert Consensus Varies Varies 4 4 1 1 0 6 5 1 1 0 0
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 0 1 0 0 0
References Study Quality
46 (16769791) 4
45 (24643763) 4
44 (19567620) 2
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 3 4 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 1 0 0 1 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 0 0 0 2 0 0
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.