AC Portal
Document Navigator

Acutely Limping Child Up To Age 5

Variant: 1   Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography tibia and fibula Usually Appropriate ☢
Radiography femur May Be Appropriate ☢☢
Radiography foot May Be Appropriate (Disagreement) ☢
US hips Usually Not Appropriate O
US lower extremity Usually Not Appropriate O
Radiography pelvis Usually Not Appropriate ☢☢
Radiography lumbar spine Usually Not Appropriate ☢☢
3-phase bone scan pelvis and lower extremity Usually Not Appropriate ☢☢☢☢
MRI lower extremity without and with IV contrast Usually Not Appropriate O
MRI lower extremity without IV contrast Usually Not Appropriate O
MRI whole body without and with IV contrast Usually Not Appropriate O
MRI whole body without IV contrast Usually Not Appropriate O
CT lower extremity with IV contrast Usually Not Appropriate ☢☢☢☢
CT lower extremity without and with IV contrast Usually Not Appropriate ☢☢☢☢☢
CT lower extremity without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography lower extremity area of interest Usually Appropriate ☢☢
US hips Usually Not Appropriate O
US lower extremity area of interest (not pelvis or hip) Usually Not Appropriate O
3-phase bone scan pelvis and lower extremity Usually Not Appropriate ☢☢☢☢
MRI lower extremity area of interest without and with IV contrast Usually Not Appropriate O
MRI lower extremity area of interest without IV contrast Usually Not Appropriate O
CT lower extremity area of interest with IV contrast Usually Not Appropriate Varies
CT lower extremity area of interest without and with IV contrast Usually Not Appropriate Varies
CT lower extremity area of interest without IV contrast Usually Not Appropriate Varies

Variant: 3   Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI lower extremity without and with IV contrast Usually Appropriate O
MRI lower extremity without IV contrast Usually Appropriate O
US hips May Be Appropriate O
3-phase bone scan pelvis and lower extremity May Be Appropriate ☢☢☢☢
MRI whole body without and with IV contrast May Be Appropriate O
MRI whole body without IV contrast May Be Appropriate O
US lower extremity Usually Not Appropriate O
Radiography femur Usually Not Appropriate ☢☢
Radiography foot Usually Not Appropriate ☢
Radiography tibia and fibula Usually Not Appropriate ☢
Radiography pelvis Usually Not Appropriate ☢☢
Radiography lumbar spine Usually Not Appropriate ☢☢
CT lower extremity with IV contrast Usually Not Appropriate ☢☢☢☢
CT lower extremity without and with IV contrast Usually Not Appropriate ☢☢☢☢☢
CT lower extremity without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US hips Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without IV contrast Usually Appropriate O
Radiography pelvis May Be Appropriate ☢☢
3-phase bone scan pelvis and lower extremity May Be Appropriate ☢☢☢☢
Radiography lumbar spine Usually Not Appropriate ☢☢
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

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 Peds Relative Radiation Level
MRI lower extremity area of interest (not pelvis or hip) without IV contrast Usually Appropriate O
MRI lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually Appropriate O
US lower extremity area of interest (not pelvis or hip) May Be Appropriate O
Radiography lower extremity area of interest (not pelvis or hip) May Be Appropriate ☢☢
3-phase bone scan pelvis and lower extremity Usually Not Appropriate ☢☢☢☢
MRI whole body without and with IV contrast Usually Not Appropriate O
MRI whole body without IV contrast Usually Not Appropriate O
CT lower extremity area of interest (not pelvis or hip) without IV contrast Usually Not Appropriate Varies
CT lower extremity area of interest (not pelvis or hip) with IV contrast Usually Not Appropriate Varies
CT lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually Not Appropriate Varies

Panel Members
Nabile M. Safdar, MD, MPHa; Cynthia K. Rigsby, MDb; Ramesh S. Iyer, MDc; Adina L. Alazraki, MDd; Sudha A. Anupindi, MDe; Dianna M. E. Bardo, MDf; Brandon P. Brown, MDg; Sherwin S. Chan, MD, PhDh; Tushar Chandra, MDi; Jonathan R. Dillman, MD, MScj; Scott R. Dorfman, MDk; Matthew D. Garber, MDl; H.F. Samuel Lam, MD, MPHm; Jie C. Nguyen, MD, MSn; Alan Siegel, MD, MSo; Roger F. Widmann, MDp; Boaz Karmazyn, MDq.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
A. Radiography Lower Extremities
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
B. US Hips or Lower Extremity
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
C. 3-Phase Bone Scan Pelvis and Lower Extremity
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
D. CT Lower Extremity
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
E. MRI Lower Extremity
Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging.
F. MRI Whole-Body
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
A. Radiography Lower Extremity
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
B. US Hips or Lower Extremity
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
C. 3-Phase Bone Scan Pelvis and Lower Extremity
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
D. CT Lower Extremity
Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging.
E. MRI Lower Extremity
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
A. Radiography Lower Extremities
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
B. US Hips or Lower Extremity
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
C. 3-Phase Bone Scan Pelvis and Lower Extremity
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
D. MRI Lower Extremity
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
E. MRI Whole-Body
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging.
F. CT Lower Extremity
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
A. Radiography Pelvis or Lumbar Spine
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
B. US Hips
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
C. 3-Phase Bone Scan Pelvis and Lower Extremity
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
D. CT Pelvis
Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging.
E. MRI Pelvis
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
A. Radiography Lower Extremity
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
B. US Lower Extremity
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
C. 3-Phase Bone Scan Pelvis and Lower Extremity
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
D. CT Lower Extremity
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
E. MRI Lower Extremity
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
F. MRI Whole-Body
Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging.
G. Other Diagnoses
Summary of Highlights
Summary of Evidence
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.

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.”
References
1. Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7-10.
2. Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. 2005; 52(4):1083-1106, ix.
3. Jain N, Sah M, Chakraverty J, Evans A, Kamath S. Radiological approach to a child with hip pain. Clin Radiol. 2013;68(11):1167-1178.
4. Offiah AC. Acute osteomyelitis, septic arthritis and discitis: differences between neonates and older children. Eur J Radiol. 2006;60(2):221-232.
5. Swischuk LE. Emergency pediatric imaging: changes over the years. Part II. Emerg Radiol. 2005; 11(5):253-261.
6. Swischuk LE. The limping infant: imaging and clinical evaluation of trauma. Emerg Radiol. 2007; 14(4):219-226.
7. Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. Am Fam Physician. 2009; 79(3):215-224.
8. Frick SL. Evaluation of the child who has hip pain. Orthop Clin North Am. 2006;37(2):133-140, v.
9. Katz DA. Slipped capital femoral epiphysis: the importance of early diagnosis. Pediatr Ann. 2006; 35(2):102-111.
10. Aronson J, Garvin K, Seibert J, Glasier C, Tursky EA. Efficiency of the bone scan for occult limping toddlers. Journal of Pediatric Orthopedics. 12(1):38-44, 1992 Jan.
11. Englaro EE, Gelfand MJ, Paltiel HJ. Bone scintigraphy in preschool children with lower extremity pain of unknown origin. J Nucl Med. 1992; 33(3):351-354.
12. John SD, Moorthy CS, Swischuk LE. Expanding the concept of the toddler's fracture. Radiographics. 1997; 17(2):367-376.
13. Baron CM, Seekins J, Hernanz-Schulman M, Yu C, Kan JH. Utility of total lower extremity radiography investigation of nonweight bearing in the young child. Pediatrics. 121(4):e817-20, 2008 Apr.
14. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. 2008;190(6):1621-1626.
15. Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. Journal of the American Academy of Orthopaedic Surgeons. 9(2):89-98, 2001 Mar-Apr.
16. Connolly SA, Connolly LP, Drubach LA, Zurakowski D, Jaramillo D. MRI for detection of abscess in acute osteomyelitis of the pelvis in children. AJR Am J Roentgenol. 2007; 189(4):867-872.
17. Nadel HR. Pediatric bone scintigraphy update. Semin Nucl Med. 2010; 40(1):31-40.
18. Cutler L, Molloy A, Dhukuram V, Bass A. Do CT scans aid assessment of distal tibial physeal fractures?. J Bone Joint Surg Br. 86(2):239-43, 2004 Mar.
19. Iyer RS, Chapman T, Chew FS. Pediatric bone imaging: diagnostic imaging of osteoid osteoma. [Review]. AJR Am J Roentgenol. 198(5):1039-52, 2012 May.
20. Daldrup-Link HE, Franzius C, Link TM, et al. Whole-body MR imaging for detection of bone metastases in children and young adults: comparison with skeletal scintigraphy and FDG PET. AJR Am J Roentgenol. 2001;177(1):229-236.
21. Fritz J, Tzaribatchev N, Claussen CD, Carrino JA, Horger MS. Chronic recurrent multifocal osteomyelitis: comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data. Radiology. 2009;252(3):842-851.
22. Mentzel HJ, Kentouche K, Sauner D, et al. Comparison of whole-body STIR-MRI and 99mTc-methylene-diphosphonate scintigraphy in children with suspected multifocal bone lesions. Eur Radiol. 14(12):2297-302, 2004 Dec.
23. Aquino MR, Tse SM, Gupta S, Rachlis AC, Stimec J. Whole-body MRI of juvenile spondyloarthritis: protocols and pictorial review of characteristic patterns. [Review]. Pediatric Radiology. 45(5):754-62, 2015 Apr.
24. Weiss PF, Chauvin NA, Roth J. Imaging in Juvenile Spondyloarthritis. [Review]. Curr Rheumatol Rep. 18(12):75, 2016 Dec.
25. Littooij AS, Kwee TC, Enriquez G, et al. Whole-body MRI reveals high incidence of osteonecrosis in children treated for Hodgkin lymphoma. British Journal of Haematology. 176(4):637-642, 2017 02.Br J Haematol. 176(4):637-642, 2017 02.
26. Naranje S, Kelly DM, Sawyer JR. A Systematic Approach to the Evaluation of a Limping Child. Am Fam Physician. 2015;92(10):908-916.
27. Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, Gruber MA, Meinhard BP. Toddler's fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152-156.
28. Oudjhane K, Newman B, Oh KS, Young LW, Girdany BR. Occult fractures in preschool children. J Trauma. 1988; 28(6):858-860.
29. Tenenbein M, Reed MH, Black GB. The toddler's fracture revisited. Am J Emerg Med. 1990;8(3):208-211.
30. Dunbar JS, Owen HF, Nogrady MB, McLeese R. Obscure Tibial Fracture of Infants--the Toddler's Fracture. J Can Assoc Radiol. 1964;15:136-144.
31. Pierce D, Mangona KL, Bisset G, Naik-Mathuria B. Computed Tomography in the Evaluation of Pediatric Trauma. Clinical Pediatric Emergency Medicine. 2015;16(4):220-229.
32. Quartuccio N, Fox J, Kuk D, et al. Pediatric bone sarcoma: diagnostic performance of 18F-FDG PET/CT versus conventional imaging for initial staging and follow-up. AJR Am J Roentgenol. 204(1):153-60, 2015 Jan.
33. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 41(8):862-8, 2010 Aug.
34. Johnson K. Imaging of juvenile idiopathic arthritis. Pediatr Radiol. 2006; 36(8):743-758.
35. Lanni S, Martini A, Malattia C. Heading toward a modern imaging approach in juvenile idiopathic arthritis. Curr Rheumatol Rep. 2014;16(5):416.
36. Malattia C, Consolaro A, Pederzoli S, et al. MRI versus conventional measures of disease activity and structural damage in evaluating treatment efficacy in juvenile idiopathic arthritis. Annals of the Rheumatic Diseases. 72(3):363-8, 2013 Mar.
37. Malattia C, Damasio MB, Basso C, et al. Dynamic contrast-enhanced magnetic resonance imaging in the assessment of disease activity in patients with juvenile idiopathic arthritis. Rheumatology (Oxford). 2010;49(1):178-185.
38. Ahlawat S, Fayad LM. De Novo Assessment of Pediatric Musculoskeletal Soft Tissue Tumors: Beyond Anatomic Imaging. Pediatrics. 2015;136(1):e194-202.
39. Browne LP, Mason EO, Kaplan SL, Cassady CI, Krishnamurthy R, Guillerman RP. Optimal imaging strategy for community-acquired Staphylococcus aureus musculoskeletal infections in children. Pediatr Radiol. 2008; 38(8):841-847.
40. Karmazyn B, Loder RT, Kleiman MB, et al. The role of pelvic magnetic resonance in evaluating nonhip sources of infection in children with acute nontraumatic hip pain. J Pediatr Orthop. 2007; 27(2):158-164.
41. Kumar J, Ramachandran M, Little D, Zenios M. Pelvic osteomyelitis in children. J Pediatr Orthop B. 19(1):38-41, 2010 Jan.
42. Karmazyn B, Kleiman MB, Buckwalter K, Loder RT, Siddiqui A, Applegate KE. Acute pyomyositis of the pelvis: the spectrum of clinical presentations and MR findings. Pediatr Radiol. 2006; 36(4):338-343.
43. Kim J, Jaramillo D. Imaging of acute hematogenouse osteomyelitis and septic arthritis in children and adults. In: Medina LS, Blackmore CC, eds. Evidence-Based Imaging: Optimizing Imaging in Patient Care. New York: Springer; 2006:591.
44. McPhee E, Eskander JP, Eskander MS, Mahan ST, Mortimer E. Imaging in pelvic osteomyelitis: support for early magnetic resonance imaging. J Pediatr Orthop. 2007;27(8):903-909.
45. Arthurs OJ, Gomez AC, Heinz P, Set PA. The toddler refusing to weight-bear: a revised imaging guide from a case series. Emerg Med J. 2009; 26(11):797-801.
46. Lim S, Sinnathamby W, Noordeen H. Refusal to walk in an afebrile well toddler. Postgrad Med J. 2002;78(923):568, 570.
47. Tyagi R. Spinal infections in children: A review. J Orthop. 2016;13(4):254-258.
48. van den Heuvel R, Hertel M, Gallagher J, Naidoo V. A toddler who refused to stand or walk: lumbar spondylodiscitis. BMJ Case Rep. 2012;2012.
49. Guillerman RP.. Osteomyelitis and beyond. Pediatr Radiol. 43 Suppl 1:S193-203, 2013 Mar.
50. Averill LW, Hernandez A, Gonzalez L, Pena AH, Jaramillo D. Diagnosis of osteomyelitis in children: utility of fat-suppressed contrast-enhanced MRI. AJR Am J Roentgenol. 2009; 192(5):1232-1238.
51. Kan JH, Young RS, Yu C, Hernanz-Schulman M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. Pediatr Radiol. 40(7):1197-205, 2010 Jul.
52. Browne LP, Guillerman RP, Orth RC, Patel J, Mason EO, Kaplan SL. Community-acquired staphylococcal musculoskeletal infection in infants and young children: necessity of contrast-enhanced MRI for the diagnosis of growth cartilage involvement. AJR Am J Roentgenol. 198(1):194-9, 2012 Jan.
53. Darge K, Jaramillo D, Siegel MJ. Whole-body MRI in children: current status and future applications. Eur J Radiol. 2008;68(2):289-298.
54. Karmazyn B.. Imaging approach to acute hematogenous osteomyelitis in children: an update. [Review] [28 refs]. Semin Ultrasound CT MR. 31(2):100-6, 2010 Apr.
55. Davis JT, Kwatra N, Schooler GR. Pediatric whole-body MRI: A review of current imaging techniques and clinical applications. J Magn Reson Imaging. 2016;44(4):783-793.
56. Nguyen A, Kan JH, Bisset G, Rosenfeld S. Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying Osteomyelitis?. J Pediatr Orthop. 37(2):e114-e119, 2017 Mar.
57. Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006; 88(6):1251-1257.
58. Volberg FM, Sumner TE, Abramson JS, Winchester PH. Unreliability of radiographic diagnosis of septic hip in children. Pediatrics 1984;74:118-20.
59. Laine JC, Denning JR, Riccio AI, Jo C, Joglar JM, Wimberly RL. The use of ultrasound in the management of septic arthritis of the hip. J Pediatr Orthop B. 24(2):95-8, 2015 Mar.
60. Plumb J, Mallin M, Bolte RG. The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip. [Review]. Pediatric Emergency Care. 31(1):54-8; quiz 59-61, 2015 Jan.
61. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am. 2004; 86-A(5):956-962.
62. Gordon JE, Huang M, Dobbs M, Luhmann SJ, Szymanski DA, Schoenecker PL. Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children. J Pediatr Orthop. 2002; 22(3):312-316.
63. Palestro CJ, Love C, Miller TT. Infection and musculoskeletal conditions: Imaging of musculoskeletal infections. [Review] [95 refs]. Baillieres Best Pract Res Clin Rheumatol. 20(6):1197-218, 2006 Dec.
64. Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Seminars in plastic surgery 2009;23:80-9.
65. Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005; 87(11):2464-2471.
66. West AT, Marshall TJ, Bearcroft PW. CT of the musculoskeletal system: what is left is the days of MRI? Eur Radiol. 2009;19(1):152-164.
67. Monsalve J, Kan JH, Schallert EK, Bisset GS, Zhang W, Rosenfeld SB. Septic arthritis in children: frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management. AJR Am J Roentgenol. 204(6):1289-95, 2015 Jun.
68. Connolly LP, Connolly SA, Drubach LA, Jaramillo D, Treves ST. Acute hematogenous osteomyelitis of children: assessment of skeletal scintigraphy-based diagnosis in the era of MRI. J Nucl Med. 2002; 43(10):1310-1316.
69. Wang E, Ma L, Edmonds EW, Zhao Q, Zhang L, Ji S. Psoas abscess with associated septic arthritis of the hip in infants. J Pediatr Surg. 2010; 45(12):2440-2443.
70. Kim EY, Kwack KS, Cho JH, Lee DH, Yoon SH. Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint. AJR Am J Roentgenol. 198(2):428-33, 2012 Feb.
71. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol. 2006; 36(11):1154-1158.
72. Blickman JG, van Die CE, de Rooy JW. Current imaging concepts in pediatric osteomyelitis. Eur Radiol. 2004; 14 Suppl 4:L55-64.
73. Hryhorczuk AL, Restrepo R, Lee EY. Pediatric Musculoskeletal Ultrasound: Practical Imaging Approach. AJR Am J Roentgenol. 2016;206(5):W62-72.
74. Trusen A, Beissert M, Schultz G, Chittka B, Darge K. Ultrasound and MRI features of pyomyositis in children. Eur Radiol. 2003;13(5):1050-1055.
75. Azam Q, Ahmad I, Abbas M, Syed A, Haque F. Ultrasound and colour Doppler sonography in acute osteomyelitis in children. Acta Orthop Belg. 2005;71(5):590-596.
76. Koulouris G, Morrison WB. MR imaging of hip infection and inflammation. [Review] [31 refs]. Magnetic Resonance Imaging Clinics of North America. 13(4):743-55, 2005 Nov.
77. Booth TN, Iyer RS, Falcone RA, Jr., et al. ACR Appropriateness Criteria® Back Pain-Child. J Am Coll Radiol 2017;14:S13-S24.
78. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
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.