Choosing Wisely:

Don’t order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.

Rationale and Comments: History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the workup of injury or pain (spine, knees, and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies are costly, frequently require sedation in the young child (five years old or less), and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient. Inappropriately obtained MRIs may need to be repeated in those circumstances. Additionally, a significant dose of radiation is delivered to the patient during a CT scan, so their utility in a specific case would be best confirmed prior to ordering. Therefore, in those conditions where advanced imaging is indicated, it has greater value when it is used to answer a specific question that arises from a thorough clinical and appropriate radiographic evaluation. Additionally, if you believe findings warrant additional advanced imaging, discuss with the consulting orthopedic surgeon to make sure the optimal studies are ordered.
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America
  • Sources:
  • American College of Radiology guidelines
  • Disciplines:
  • Pediatric
  • Orthopedic
  • References: • Piccolo CL, Galluzzo M, Ianniello S, Trinci M, Russo A, Rossi E, Zecconlini M, Laporta A, Guglielmi G, Muiele V. Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging. Mesculoskelet Surg. 2017;101(suppl 1):85-102.
    • LaBella CR, Hennrikus W, Hewett TE. Anterior cruciate ligament Injuries: diagnosis, treatment, and prevention. Pediatrics. 2014;133(5):e1437-e1450.
    • Tuite MJ, Kransdort MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Dempsey ME, Fries IB, Greenspan BS, Khurana B, Mosher TJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria® Acute Trauma to the Knee. Available at https:acsearch.acr.org/docs/69419/Narrative/ American College of Radiology. Revised 2014.
    • Deyle GD. The role of MRI in musculoskeletal practice: a clinical perspective. J Man Manip Ther. 2011;19(3):152-161.
    • Bateni C, Bindra J, Haus B. MRI of sports injuries in children and adolescents: what’s different from adults. Current Radiology Reports. 2014;2:45.

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