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Appropriateness Criteria

Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography tibia and fibula Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 1 2 5 8
References Study Quality
9 (16493917) 4
12 (9084078) 4
13 (18316353) 3
10 (1732293) 2
11 (1740701) 4
Radiography femur May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 1 3 1 5 5 0 0 0
References Study Quality
9 (16493917) 4
12 (9084078) 4
13 (18316353) 3
10 (1732293) 2
11 (1740701) 4
Radiography foot May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 1 4 1 2 5 3 0 0 0
References Study Quality
9 (16493917) 4
12 (9084078) 4
13 (18316353) 3
10 (1732293) 2
11 (1740701) 4
US hips Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 6 3 1 1 0 1 0 0
References Study Quality
15 (11281633) 4
14 (18492916) 4
US lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (11281633) 4
14 (18492916) 4
Radiography pelvis Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 3 2 4 1 5 1 0 0 0
References Study Quality
9 (16493917) 4
12 (9084078) 4
13 (18316353) 3
10 (1732293) 2
11 (1740701) 4
Radiography lumbar spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 2 2 5 3 4 0 0 0 0
References Study Quality
9 (16493917) 4
12 (9084078) 4
13 (18316353) 3
10 (1732293) 2
11 (1740701) 4
3-phase bone scan pelvis and lower extremity Usually not appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 1 0 0 1 0 0 0
References Study Quality
16 (17885058) 3
17 (19958848) 4
10 (1732293) 2
1 (3843430) 4
MRI lower extremity without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
19 (22528893) 4
MRI lower extremity without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
19 (22528893) 4
MRI whole body without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
22 (15243716) 3
20 (11418435) 2
23 (25896337) 4
21 (19567645) 2
24 (27822769) 4
25 (27891588) 4
MRI whole body without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
22 (15243716) 3
20 (11418435) 2
23 (25896337) 4
21 (19567645) 2
24 (27822769) 4
25 (27891588) 4
CT lower extremity with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (15046440) 3
CT lower extremity without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (15046440) 3
CT lower extremity without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (15046440) 3
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography lower extremity area of interest Usually appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 0 0 1 0 15
References Study Quality
12 (9084078) 4
31 (15228401) 4
27 (11242240) 4
28 (2898538) 4
29 (2331262) 4
30 (14212071) 4
32 (25539251) 3
26 (26554284) 4
US hips Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 5 3 1 2 0 0 0 0
References Study Quality
33 (20466368) 2
US lower extremity area of interest (not pelvis or hip) Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 4 4 1 1 0 0 0 0
References Study Quality
33 (20466368) 2
3-phase bone scan pelvis and lower extremity Usually not appropriate Expert Consensus ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 1 0 0 0 0 0 0
MRI lower extremity area of interest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 3 0 1 1 2 0 0 0
References Study Quality
6 (17566800) 4
34 (16741713) 4
35 (24609825) 4
37 (19995859) 2
36 (22764042) 4
38 (26122807) 4
MRI lower extremity area of interest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 7 1 4 1 2 1 0 0 0
References Study Quality
6 (17566800) 4
34 (16741713) 4
35 (24609825) 4
37 (19995859) 2
36 (22764042) 4
38 (26122807) 4
CT lower extremity area of interest with IV contrast Usually not appropriate Limited Varies Varies 1 1 12 3 1 0 0 0 0 0 0
References Study Quality
18 (15046440) 3
CT lower extremity area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
18 (15046440) 3
CT lower extremity area of interest without IV contrast Usually not appropriate Limited Varies Varies 1 1 11 3 0 2 0 0 0 0 0
References Study Quality
18 (15046440) 3
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI lower extremity without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
51 (20180105) 3
45 (19850805) 4
42 (16474970) 4
40 (17314640) 3
43 (-3091625) 4
50 (19380545) 3
39 (18560822) 2
41 (19858750) 4
46 (12357025) 4
47 (27408498) 4
48 (23230243) 4
49 (23478935) 4
52 (22194497) 2
44 (18209613) 4
MRI lower extremity without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
51 (20180105) 3
45 (19850805) 4
42 (16474970) 4
40 (17314640) 3
43 (-3091625) 4
50 (19380545) 3
39 (18560822) 2
41 (19858750) 4
46 (12357025) 4
47 (27408498) 4
48 (23230243) 4
49 (23478935) 4
52 (22194497) 2
44 (18209613) 4
US hips May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 6 1 4 1
References Study Quality
15 (11281633) 4
14 (18492916) 4
3-phase bone scan pelvis and lower extremity May be appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 3 8 4 0 0 0
References Study Quality
16 (17885058) 3
17 (19958848) 4
40 (17314640) 3
39 (18560822) 2
41 (19858750) 4
MRI whole body without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 0 2 9 2 0 1 0
References Study Quality
42 (16474970) 4
43 (-3091625) 4
22 (15243716) 3
53 (18799279) 4
54 (20304319) 4
55 (27043465) 4
MRI whole body without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 1 1 11 1 0 1 0
References Study Quality
42 (16474970) 4
43 (-3091625) 4
22 (15243716) 3
53 (18799279) 4
54 (20304319) 4
55 (27043465) 4
US lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (11281633) 4
14 (18492916) 4
Radiography femur Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 3 3 5 1 3 1 0 0 0
References Study Quality
40 (17314640) 3
39 (18560822) 2
Radiography foot Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 3 3 4 1 3 2 0 0 0
References Study Quality
40 (17314640) 3
39 (18560822) 2
Radiography tibia and fibula Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 3 3 4 1 3 2 0 0 0
References Study Quality
40 (17314640) 3
39 (18560822) 2
Radiography pelvis Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 2 6 6 2 0 0 0 0 0
References Study Quality
40 (17314640) 3
39 (18560822) 2
Radiography lumbar spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 3 3 5 2 2 1 0 0 0
References Study Quality
40 (17314640) 3
39 (18560822) 2
CT lower extremity with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US hips Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 2 10
References Study Quality
62 (11961445) 4
57 (16757758) 3
61 (15118038) 4
59 (25588046) 4
60 (25560622) 4
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 0 1 5 6 3
References Study Quality
51 (20180105) 3
71 (17019590) 4
69 (21129563) 4
40 (17314640) 3
50 (19380545) 3
68 (12368368) 4
41 (19858750) 4
67 (26001240) 4
70 (22268189) 3
56 (28170361) 4
MRI pelvis without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 2 5 4 2
References Study Quality
51 (20180105) 3
71 (17019590) 4
69 (21129563) 4
40 (17314640) 3
50 (19380545) 3
68 (12368368) 4
41 (19858750) 4
67 (26001240) 4
70 (22268189) 3
56 (28170361) 4
Radiography pelvis May be appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 2 2 1 5 5 1 0 0 0
References Study Quality
58 (6739205) 4
3-phase bone scan pelvis and lower extremity May be appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 4 4 3 0 4 3 4 2 0 0 0
References Study Quality
40 (17314640) 3
Radiography lumbar spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 4 0 2 3 0 0 0 0
References Study Quality
58 (6739205) 4
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 3 2 1 5 0 0 0 0
References Study Quality
63 (17127204) 4
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 2 0 0 0 0 0
References Study Quality
63 (17127204) 4
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 5 0 0 1 0 0 0 0
References Study Quality
63 (17127204) 4
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI lower extremity area of interest (not pelvis or hip) without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 1 1 5 3 4
References Study Quality
51 (20180105) 3
43 (-3091625) 4
50 (19380545) 3
41 (19858750) 4
76 (16275581) 4
MRI lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 0 2 2 6 5
References Study Quality
51 (20180105) 3
43 (-3091625) 4
50 (19380545) 3
41 (19858750) 4
76 (16275581) 4
US lower extremity area of interest (not pelvis or hip) May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 0 3 7 3 1 0 0
References Study Quality
54 (20304319) 4
73 (26998556) 4
74 (12695827) 3
55 (27043465) 4
Radiography lower extremity area of interest (not pelvis or hip) May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 1 4 1 4 5 0 0 0
References Study Quality
72 (14752569) 4
40 (17314640) 3
39 (18560822) 2
64 (20567730) 4
54 (20304319) 4
3-phase bone scan pelvis and lower extremity Usually not appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 5 4 0 0 0 0 0
References Study Quality
39 (18560822) 2
41 (19858750) 4
MRI whole body without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 4 8 1 0 0 0 0 0
References Study Quality
22 (15243716) 3
53 (18799279) 4
54 (20304319) 4
MRI whole body without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 5 7 1 0 0 0 0 0
References Study Quality
22 (15243716) 3
53 (18799279) 4
54 (20304319) 4
CT lower extremity area of interest (not pelvis or hip) without IV contrast Usually not appropriate Limited Varies Varies 1 1 10 3 1 1 1 0 0 0 0
References Study Quality
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
CT lower extremity area of interest (not pelvis or hip) with IV contrast Usually not appropriate Limited Varies Varies 3 3 5 2 4 3 2 0 0 0 0
References Study Quality
63 (17127204) 4
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
CT lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 11 3 1 0 1 0 0 0 0
References Study Quality
63 (17127204) 4
64 (20567730) 4
66 (18690452) 4
65 (16264122) Inadequate
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.