Appropriate use criteria
ACR Appropriateness Criteria® Acutely Limping Child Up To Age 5

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Abstract

Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler’s fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Section snippets

Introduction/Background

Acute onset of limp or refusal to walk is a common complaint in children, accounting for approximately 4% of visits in one pediatric emergency department [1]. The acutely limping child can be a diagnostic dilemma for clinicians. Most commonly, the acute limp is caused by minor trauma or self-limiting benign conditions but can also be caused by limb-threatening or life-threatening etiologies 2, 3, 4, 5, 6. The cause of limp can usually be determined by a careful history and physical examination.

Variant 1: Child Up to Age 5. Acute Limp. Nonlocalized Symptoms. No Concern for Infection. Initial Imaging

The most common noninfectious etiology of acute limping in children is a minor traumatic injury [8]. Unfortunately, particularly in younger children, it is common that the pain cannot be accurately localized to one focal area. When there is no concern for infection and pain cannot be localized through history or physical examination, an imaging strategy designed to first localize the source of the pain and subsequently better characterize the cause is typically pursued.

Other Diagnoses

Since acute limping and hip pain in children can have many etiologies, the causes are covered in more than one of the appropriateness criteria documents. As such, symptoms localized to the back are covered in the ACR Appropriateness Criteria® topic on “Back Pain-Child” [77].

Summary of Recommendations

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    Variant 1: A radiograph of the tibia/fibula is usually appropriate for the initial imaging of children up to age 5 with acute limp, nonlocalized symptoms, and no concern for infection.

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    Variant 2: Radiographs of the lower extremity area of interest are usually appropriate for the initial imaging of children up to age 5 with acute limp, pain, localized symptoms, and no concern for infection.

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    Variant 3: MRI of the lower extremity without and with IV contrast or MRI lower extremity without IV

Summary of Evidence

Of the 78 references cited in the ACR Appropriateness Criteria® Acutely Limping Child Up To Age 5 document, 77 references are categorized as diagnostic references including 7 good-quality studies, and 11 quality studies that may have design limitations. There are 59 references that may not be useful as primary evidence. There is 1 reference that is a meta-analysis study.

The 78 references cited in the ACR Appropriateness Criteria® Acutely Limping Child Up To Age 5 document were published from

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

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

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    • Cited by (14)

    • Transient synovitis of the hip: Current practice and risk of misdiagnosis

      2022, American Journal of Emergency Medicine
      Citation Excerpt :

      The optimal imaging strategy for children presenting with hip pain or limp, prior to diagnosing TS is unclear. The necessity of hip radiographs is controversial [10,18-20], and while hip ultrasound is increasingly described in the literature, it is of questionable utility, as presence of an effusion does not distinguish between TS and septic arthritis [20-25]. Bacterial osteomyelitis and pyomyositis can present similarly to septic arthritis, and similar inflammatory markers have been used to diagnose these conditions [26-28].

    • ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton)

      2022, Journal of the American College of Radiology
      Citation Excerpt :

      Infants and toddlers with septic arthritis or osteomyelitis often present with a limp, though it is often difficult in this population to localize a site of involvement on physical examination. In these cases, imaging is often utilized to help identify the affected site [22]. Concurrent osteomyelitis and septic arthritis are common.

    • Pediatric Nuclear Medicine: Technical Aspects

      2022, Nuclear Medicine and Molecular Imaging: Volume 1-4

    • The Limping Child

      2020, Pediatric Clinics of North America
      Citation Excerpt :

      Bartoloni and colleagues5 have developed several helpful imaging algorithms to guide diagnostic imaging approach based on age group: toddlers (1–3 years of age), children (3–10 years), and adolescents (11–16 years) (Figs. 3–5). If unable to determine the site, initial full-length imaging may be necessary.6 The most common cause of limp is again minor trauma, and radiographs are a good start.

    • Bacterial osteomyelitis in pediatric patients: a comprehensive review

      2024, Skeletal Radiology

    • Evaluating the child with a limp

      2023, American Family Physician
    View all citing articles on Scopus

    The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

    Reprint requests to: [email protected].

    Dr. Chan reports grants from GE Healthcare, outside the submitted work. The other authors have no conflicts of interest related to the material discussed in this article.

    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.

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