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Appropriateness Criteria

Variant 1: Child. Younger than 5 years of age. Concern for osteomyelitis or septic arthritis involving an extremity. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 1 3 10 1 0
References Study Quality
48 (8475290) 4
51 (11961445) 4
50 (25588046) 4
17 (29728840) 3
45 (28696851) 4
53 (23755165) 3
52 (19695738) 2
54 (7983130) 4
49 (3321461) 3
Radiography area of interest Usually appropriate Strong Varies Varies 9 9 0 0 0 0 1 0 2 3 11
References Study Quality
3 (21523583) 4
48 (8475290) 4
47 (6739205) 4
30 (20304319) 4
45 (28696851) 4
36 (26295653) 2
46 (23812139) 2
29 (7618566) 4
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 7 5 0
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
41 (22194497) 2
32 (30903335) 2
36 (26295653) 2
33 (26209118) 2
40 (25986395) 4
35 (23685708) 2
42 (20936273) 2
34 (21381610) 4
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI extremity area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 10 2 0
References Study Quality
43 (23883225) 2
MRI area of interest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 1 8 3 2 0
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
41 (22194497) 2
32 (30903335) 2
36 (26295653) 2
33 (26209118) 2
40 (25986395) 4
35 (23685708) 2
42 (20936273) 2
34 (21381610) 4
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI extremity area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 6 4 4 1 0
References Study Quality
43 (23883225) 2
MRI whole body without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 2 5 0 4 2 1 0 0
References Study Quality
44 (30623210) 2
13 (28514223) 4
MRI whole body without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 6 0 1 6 1 1 0 0
References Study Quality
44 (30623210) 2
13 (28514223) 4
Bone scan whole body and 3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 1 0 0 1 1 0 0
3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 1 0 0 0 1 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 4 0 0 0 1 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 3 2 1 0 0 1 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 3 0 1 0 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 2 1 0 1 0 0 0
Variant 2: Child. Younger than 5 years of age. Concern for osteomyelitis or septic arthritis involving an extremity. Initial radiographs normal, or with findings suggestive of osteomyelitis. 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 area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 1 2 3 8 1 0
References Study Quality
48 (8475290) 4
51 (11961445) 4
50 (25588046) 4
17 (29728840) 3
45 (28696851) 4
53 (23755165) 3
52 (19695738) 2
54 (7983130) 4
49 (3321461) 3
Image-guided aspiration area of interest Usually appropriate Limited Varies Varies 7 7 0 0 0 0 1 1 10 3 1
References Study Quality
48 (8475290) 4
66 (27603195) 3
65 (26830217) 3
18 (25575360) 4
64 (23389564) 2
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 5 4 7
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
41 (22194497) 2
32 (30903335) 2
18 (25575360) 4
36 (26295653) 2
33 (26209118) 2
40 (25986395) 4
35 (23685708) 2
42 (20936273) 2
34 (21381610) 4
67 (21102217) 3
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI extremity area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 2 7 6
References Study Quality
43 (23883225) 2
MRI extremity area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 4 2 7 1 0
References Study Quality
43 (23883225) 2
Bone scan whole body and 3-phase bone scan area of interest May be appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 2 5 4 3 0 0 0
References Study Quality
61 (12368368) 4
8 (23478935) 4
57 (21383641) 4
63 (20308478) 3
58 (22582364) 4
55 (1178860) 4
62 (179356) 4
60 (1250652) 4
56 (1572114) 4
59 (8113299) 4
MRI area of interest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 5 2 3 4 0
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
41 (22194497) 2
32 (30903335) 2
18 (25575360) 4
36 (26295653) 2
33 (26209118) 2
40 (25986395) 4
35 (23685708) 2
42 (20936273) 2
34 (21381610) 4
67 (21102217) 3
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI whole body without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 2 8 3 1 0 0
References Study Quality
44 (30623210) 2
MRI whole body without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 1 11 1 1 0 0
References Study Quality
44 (30623210) 2
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 3 3 1 2 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 1 0 2 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 1 2 1 2 0 1 0 0
Variant 3: Child. 5 years of age or older. Concern for osteomyelitis or septic arthritis involving an extremity. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 1 3 1 10 0 0
References Study Quality
48 (8475290) 4
51 (11961445) 4
50 (25588046) 4
17 (29728840) 3
45 (28696851) 4
53 (23755165) 3
52 (19695738) 2
54 (7983130) 4
49 (3321461) 3
Radiography area of interest Usually appropriate Moderate Varies Varies 9 9 1 0 0 1 1 0 1 4 9
References Study Quality
3 (21523583) 4
48 (8475290) 4
47 (6739205) 4
30 (20304319) 4
45 (28696851) 4
36 (26295653) 2
29 (7618566) 4
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 1 0 2 1 2 8 2
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
32 (30903335) 2
19 (30969258) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
36 (26295653) 2
33 (26209118) 2
20 (25698366) 3
35 (23685708) 2
34 (21381610) 4
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 7 5 0
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
32 (30903335) 2
19 (30969258) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
36 (26295653) 2
33 (26209118) 2
20 (25698366) 3
35 (23685708) 2
34 (21381610) 4
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI extremity area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 7 6 0
References Study Quality
43 (23883225) 2
MRI extremity area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 6 3 4 3 0
References Study Quality
43 (23883225) 2
Bone scan whole body and 3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 1 0 0 0 0 0 0
MRI whole body without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 0 6 1 2 1 0 0 0
MRI whole body without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 2 6 0 1 2 0 0 0
3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 1 0 1 1 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 1 0 0 2 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 1 3 2 0 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 2 0 1 1 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 2 2 0 1 0 0 0
Variant 4: Child. 5 years of age or older. Concern for osteomyelitis or septic arthritis involving an extremity. Initial radiographs normal, or with findings suggestive of osteomyelitis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided aspiration area of interest Usually appropriate Limited Varies Varies 7 7 0 0 0 1 1 6 5 1 2
References Study Quality
48 (8475290) 4
66 (27603195) 3
65 (26830217) 3
64 (23389564) 2
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 4 10
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
32 (30903335) 2
19 (30969258) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
36 (26295653) 2
33 (26209118) 2
20 (25698366) 3
35 (23685708) 2
34 (21381610) 4
67 (21102217) 3
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 7 7 1
References Study Quality
38 (20180105) 3
37 (19380545) 3
39 (22268189) 3
30 (20304319) 4
32 (30903335) 2
19 (30969258) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
36 (26295653) 2
33 (26209118) 2
20 (25698366) 3
35 (23685708) 2
34 (21381610) 4
67 (21102217) 3
29 (7618566) 4
31 (17118291) 4
28 (2068324) 2
MRI extremity area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 2 8 5
References Study Quality
43 (23883225) 2
MRI extremity area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 9 4 0
References Study Quality
43 (23883225) 2
US area of interest May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 8 4 0 0
References Study Quality
48 (8475290) 4
51 (11961445) 4
50 (25588046) 4
17 (29728840) 3
45 (28696851) 4
53 (23755165) 3
52 (19695738) 2
54 (7983130) 4
49 (3321461) 3
Bone scan whole body and 3-phase bone scan area of interest May be appropriate Limited ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 0 8 3 2 1 1 0
References Study Quality
61 (12368368) 4
57 (21383641) 4
63 (20308478) 3
58 (22582364) 4
62 (179356) 4
3-phase bone scan area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 6 2 5 1 1 0 0
References Study Quality
8 (23478935) 4
57 (21383641) 4
63 (20308478) 3
55 (1178860) 4
56 (1572114) 4
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 7 2 5 1 0 0 0
References Study Quality
57 (21383641) 4
63 (20308478) 3
58 (22582364) 4
60 (1250652) 4
59 (8113299) 4
MRI whole body without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 4 1 2 1 0 0 0
MRI whole body without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 3 2 2 3 1 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 2 5 1 2 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 1 1 2 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 9 2 3 1 2 0 0 0 0
Variant 5: Child. With one or more clinical signs concerning for septic arthritis. Initial radiographs normal or demonstrating possible joint effusion. 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 area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 4 9
References Study Quality
48 (8475290) 4
51 (11961445) 4
50 (25588046) 4
45 (28696851) 4
52 (19695738) 2
49 (3321461) 3
Image-guided aspiration area of interest Usually appropriate Limited Varies Varies 8 8 0 1 0 0 2 0 1 5 8
References Study Quality
48 (8475290) 4
66 (27603195) 3
65 (26830217) 3
64 (23389564) 2
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 2 0 1 0 3 5 6
References Study Quality
39 (22268189) 3
19 (30969258) 3
69 (29389760) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
68 (23653039) 4
MRI area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 7 5 1 0
References Study Quality
39 (22268189) 3
19 (30969258) 3
69 (29389760) 3
17 (29728840) 3
16 (26691242) 3
18 (25575360) 4
7 (25575359) 3
68 (23653039) 4
MRI extremity area of interest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 5 4 3 0
MRI extremity area of interest without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 12 0 3 1 0
Bone scan whole body and 3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 1 1 0 1 0 0 0
MRI whole body without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 0 9 1 1 4 0 1 0 0
MRI whole body without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 3 1 1 0 1 0 0
3-phase bone scan area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 1 2 1 0 0 0 0
References Study Quality
55 (1178860) 4
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 1 0 0 0 0 0
References Study Quality
59 (8113299) 4
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 8 4 3 1 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 2 1 0 1 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 3 1 1 0 1 0 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.