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Suspected Physical Abuse-Child

Variant: 1   Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skeletal survey Usually Appropriate ☢☢☢
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography area of interest May Be Appropriate (Disagreement) Varies
CT chest without IV contrast May Be Appropriate ☢☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
US head Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 2   Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography area of interest Usually Appropriate Varies
Radiography skeletal survey May Be Appropriate (Disagreement) ☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
US head Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 3   Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs , symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skeletal survey Usually Appropriate ☢☢☢
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography area of interest May Be Appropriate (Disagreement) Varies
MRI complete spine without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
MRV head without IV contrast May Be Appropriate O
US head Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
MRI cervical spine without IV contrast Usually Not Appropriate O
MRI complete spine without and with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography area of interest Usually Appropriate Varies
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography skeletal survey May Be Appropriate ☢☢☢
MRI complete spine without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
MRV head without IV contrast May Be Appropriate O
US head Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
MRI cervical spine without IV contrast Usually Not Appropriate O
MRI complete spine without and with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 5   Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skeletal survey Usually Appropriate ☢☢☢
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢☢
Radiography area of interest May Be Appropriate (Disagreement) Varies
CT chest with IV contrast May Be Appropriate ☢☢☢☢
CT chest without IV contrast May Be Appropriate ☢☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 6   Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography area of interest Usually Appropriate Varies
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢☢
Radiography skeletal survey May Be Appropriate (Disagreement) ☢☢☢
CT chest with IV contrast May Be Appropriate ☢☢☢☢
CT chest without IV contrast May Be Appropriate ☢☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 7   Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skeletal survey Usually Appropriate ☢☢☢
MRI head without IV contrast May Be Appropriate (Disagreement) O
Bone scan whole body May Be Appropriate ☢☢☢☢
CT chest without IV contrast May Be Appropriate ☢☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
US head Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
MRI cervical spine without IV contrast Usually Not Appropriate O
MRI complete spine without and with IV contrast Usually Not Appropriate O
MRI complete spine without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 8   Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skeletal survey Usually Appropriate ☢☢☢
MRI head without IV contrast May Be Appropriate (Disagreement) O
CT head without IV contrast May Be Appropriate (Disagreement) ☢☢☢
US abdomen Usually Not Appropriate O
US abdomen with IV contrast Usually Not Appropriate O
US head Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Panel Members
David M. Mirsky, MDa; Dianna M. E. Bardo, MDb; Ramesh S. Iyer, MD, MBAc; Sherwin S. Chan, MD, PhDd; V. Michelle Silvera, MDe; Andrea G. Asnes, MD, MSWf; Isabel A. Barata, MD, MS, MBAg; Richard A. Falcone Jr., MD, MPHh; Abhaya V. Kulkarni, MD, PhDi; Terry L. Levin, MDj; Nirav K. Pandya, MDk; Judy H. Squires, MDl; Andrew T. Trout, MDm; Matthew T. Whitehead, MDn; Sumit Pruthi, MD, MBBSo.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
A. Bone scan whole body
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
B. CT abdomen and pelvis with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
C. CT abdomen and pelvis without and with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
D. CT abdomen and pelvis without IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
E. CT chest with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
F. CT chest without and with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
G. CT chest without IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
H. CT head with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
I. CT head without and with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
J. CT head without IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
K. MRI head without and with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
L. MRI head without IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
M. MRV head without IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
N. Radiography area of interest
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
O. Radiography skeletal survey
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
P. US abdomen
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Q. US abdomen with IV contrast
Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
R. US head
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
A. Bone scan whole body
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
B. CT abdomen and pelvis with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
C. CT abdomen and pelvis without and with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
D. CT abdomen and pelvis without IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
E. CT chest with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
F. CT chest without and with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
G. CT chest without IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
H. CT head with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
I. CT head without and with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
J. CT head without IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
K. MRI head without and with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
L. MRI head without IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
M. MRV head without IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
N. Radiography area of interest
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
O. Radiography skeletal survey
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
P. US abdomen
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Q. US abdomen with IV contrast
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
R. US head
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
A. Bone scan whole body
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
B. CT cervical spine with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
D. CT cervical spine without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
E. CT head with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
F. CT head without and with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
G. CT head without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
H. MRI cervical spine without and with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
I. MRI cervical spine without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
J. MRI complete spine without and with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
K. MRI complete spine without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
L. MRI head without and with IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
M. MRI head without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
N. MRV head without IV contrast
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
O. Radiography area of interest
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
P. Radiography skeletal survey
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs, symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Q. US head
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
A. Bone scan whole body
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
B. CT cervical spine with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
D. CT cervical spine without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
E. CT head with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
F. CT head without and with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
G. CT head without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
H. MRI cervical spine without and with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
I. MRI cervical spine without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
J. MRI complete spine without and with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
K. MRI complete spine without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
L. MRI head without and with IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
M. MRI head without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
N. MRV head without IV contrast
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
O. Radiography area of interest
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
P. Radiography skeletal survey
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Q. US head
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
A. Bone scan whole body
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
B. CT abdomen and pelvis with IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
C. CT abdomen and pelvis without and with IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
D. CT abdomen and pelvis without IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
E. CT chest with IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
F. CT chest without and with IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
G. CT chest without IV contrast
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
H. Radiography area of interest
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
I. Radiography skeletal survey
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
J. US abdomen
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
K. US abdomen with IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
A. Bone scan whole body
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
B. CT abdomen and pelvis with IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
C. CT abdomen and pelvis without and with IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
D. CT abdomen and pelvis without IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
E. CT chest with IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
F. CT chest without and with IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
G. CT chest without IV contrast
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
H. Radiography area of interest
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
I. Radiography skeletal survey
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
J. US abdomen
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
K. US abdomen with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
A. Bone scan whole body
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
B. CT abdomen and pelvis with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
C. CT abdomen and pelvis without and with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
D. CT abdomen and pelvis without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
E. CT chest with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
F. CT chest without and with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
G. CT chest without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
H. MRI cervical spine without and with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
I. MRI cervical spine without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
J. MRI complete spine without and with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
K. MRI complete spine without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
L. MRI head without and with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
M. MRI head without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
N. MRV head without IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
O. Radiography skeletal survey
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
P. US abdomen
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
Q. US abdomen with IV contrast
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
R. US head
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
A. Bone scan whole body
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
B. CT abdomen and pelvis with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
C. CT abdomen and pelvis without and with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
D. CT abdomen and pelvis without IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
E. CT chest with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
F. CT chest without and with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
G. CT chest without IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
H. CT head with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
I. CT head without and with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
J. CT head without IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
K. MRI head without and with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
L. MRI head without IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
M. MRV head without IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
N. Radiography skeletal survey
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
O. US abdomen
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
P. US abdomen with IV contrast
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
Q. US head
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.