American College of Radiology
ACR Appropriateness Criteria®

Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot)

Variant 1: Suspected osteomyelitis, septic arthritis, or soft-tissue infection (excluding spine and diabetic foot). First study.
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 Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Soft-tissue or juxta-articular swelling. Suspected soft-tissue infection. Additional imaging following radiographs.
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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
US area of interest May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Soft-tissue or juxta-articular swelling with a history of puncture wound. Suspected foreign body. Negative radiographs.
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 O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually appropriate Varies Varies Varies 7 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Soft-tissue or juxta-articular swelling with cellulitis and a skin lesion, injury, wound, ulcer, or blister. Suspected osteomyelitis. Additional imaging following radiographs.
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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually appropriate Varies Varies Varies 7 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest May be appropriate ☢☢☢☢ 10-30 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) area of interest May be appropriate ☢☢☢☢ 10-30 mSv 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan area of interest May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Soft-tissue or juxta-articular swelling with a history of prior surgery. Suspected osteomyelitis or septic arthritis. Additional imaging following radiographs.
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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Aspiration area of interest Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan area of interest Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Pain and swelling or cellulitis associated with site of previous nonarthroplasty hardware. Suspected osteomyelitis or septic arthritis. Additional imaging following radiographs.
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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Aspiration area of interest Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually appropriate Varies Varies Varies 7 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest Usually appropriate ☢☢☢☢ 10-30 mSv 7 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan area of interest Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan area of interest Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Draining sinus (not associated with a joint prosthesis). Suspected osteomyelitis. Additional imaging following radiographs.
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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Clinical examination suggesting crepitus. Suspected soft-tissue gas. First study.
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 Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Initial radiographs showing soft-tissue gas in absence of puncture wound.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT area of interest without IV contrast May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 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.