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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.