Pediatric Radiology

, Volume 49, Issue 1, pp 114–121 | Cite as

Detection of pediatric musculoskeletal pathology using the fluid-sensitive sequence

  • Jie C. NguyenEmail author
  • Paul H. Yi
  • Kaitlin M. Woo
  • Humberto G. Rosas
Original Article



Musculoskeletal complaints are common among children, and magnetic resonance (MR) is increasingly used to supplement the clinical assessment. The validation of a short triage protocol could reduce the number of unnecessary contrast-enhanced MR studies that sometimes also require the need for sedation.


To compare the diagnostic accuracy between fluid-sensitive sequence and contrast-enhanced MR study in the detection of musculoskeletal pathology in the pelvis and the appendicular skeleton in children older than 2 years.

Materials and methods

We performed a retrospective review between Feb. 1, 2016, and Oct. 31, 2016, and identified 99 studies from 96 patients (48 boys and 48 girls; mean age ± standard deviation, 11.1±4.6 years) without syndromic deformity, recent trauma, a history of infectious or inflammatory arthropathy, prior instrumentation or incomplete records. Two radiologists reviewed each study twice, at least 1 month apart, first using only the fluid-sensitive sequences (triage study) and later using the contrast-enhanced study. Readers rated the presence or absence of pathology independently and generated final impressions in consensus. We used Cohen’s kappa (κ) and percentage agreement to compare agreement between readers and between studies, respectively.


Inter-reader agreement was overall higher for the contrast-enhanced studies (κ range = 0.91–1) than for the triage studies (κ range = 0.49–1). Percentage agreement between studies was high for the detection of pathology (97–100%) and for the impressions (93%). Clinical diagnoses were stress reaction or overuse in 31%, infection in 21%, space-occupying process in 17%, normal in 15%, inflammatory in 14%, and both inflammatory and overuse in 1%. The full study increased diagnostic confidence in five studies and accuracy in two but did not alter management.


The fluid-sensitive sequence had a near-perfect percentage of agreement with the contrast-enhanced study in the detection of musculoskeletal pathology and could possibly be used to screen children who need a contrast-enhanced MR study.


Children Contrast agent Magnetic resonance imaging Musculoskeletal Screening 



Findings were presented as an oral scientific paper at the Radiological Society of North America 2017 meeting in Chicago, IL.

Compliance with ethical standards

Conflicts of interest



  1. 1.
    Wingen M, Alzen G, Gunther RW (1998) MR imaging fails to detect bone marrow oedema in osteomyelitis: report of two cases. Pediatr Radiol 28:189–192CrossRefGoogle Scholar
  2. 2.
    Jaramillo D, Treves ST, Kasser JR et al (1995) Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 165:399–403CrossRefGoogle Scholar
  3. 3.
    Jaramillo D (2011) Infection: musculoskeletal. Pediatr Radiol 41:S127–S134CrossRefGoogle Scholar
  4. 4.
    Gafur OA, Copley LA, Hollmig ST et al (2008) The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines. J Pediatr Orthop 28:777–785CrossRefGoogle Scholar
  5. 5.
    Morrison WB, Schweitzer ME, Bock GW et al (1993) Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging. Radiology 189:251–257CrossRefGoogle Scholar
  6. 6.
    Schmid MR, Kossmann T, Duewell S (1998) Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 170:615–620CrossRefGoogle Scholar
  7. 7.
    Hopkins KL, Li KC, Bergman G (1995) Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skelet Radiol 24:325–330CrossRefGoogle Scholar
  8. 8.
    Edwards AD, Arthurs OJ (2011) Paediatric MR under sedation: is it necessary? What is the evidence for the alternatives? Pediatr Radiol 41:1353–1364CrossRefGoogle Scholar
  9. 9.
    Karian VE, Burrows PE, Zurakowski D et al (2002) The development of a pediatric radiology sedation program. Pediatr Radiol 32:348–353CrossRefGoogle Scholar
  10. 10.
    Bellolio MF, Puls HA, Anderson JL et al (2016) Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open 6:e011384Google Scholar
  11. 11.
    Bjur KA, Payne ET, Nemergut ME et al (2017) Anesthetic-related neurotoxicity and neuroimaging in children: a call for conversation. J Child Neurol 32:594–602CrossRefGoogle Scholar
  12. 12.
    Mohd Zaki F, Moineddin R, Grant R et al (2016) Accuracy of pre-contrast imaging in abdominal magnetic resonance imaging of pediatric oncology patients. Pediatr Radiol 46:1684–1693CrossRefGoogle Scholar
  13. 13.
    Jaimes C, Gee MS (2016) Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatr Radiol 46:916–927CrossRefGoogle Scholar
  14. 14.
    McDonald RJ, McDonald JS, Kallmes DF et al (2015) Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology 275:772–782CrossRefGoogle Scholar
  15. 15.
    Kanda T, Nakai Y, Oba H et al (2016) Gadolinium deposition in the brain. Magn Reson Imaging 34:1346–1350CrossRefGoogle Scholar
  16. 16.
    Sadowski EA, Bennett LK, Chan MR et al (2007) Nephrogenic systemic fibrosis: risk factors and incidence estimation. Radiology 243:148–157CrossRefGoogle Scholar
  17. 17.
    Weller A, Barber JL, Olsen OE (2014) Gadolinium and nephrogenic systemic fibrosis: an update. Pediatr Nephrol 29:1927–1937CrossRefGoogle Scholar
  18. 18.
    Nardone B, Saddleton E, Laumann AE et al (2014) Pediatric nephrogenic systemic fibrosis is rarely reported: a RADAR report. Pediatr Radiol 44:173–180CrossRefGoogle Scholar
  19. 19.
    Bierry G, Dietemann JL (2013) Imaging evaluation of inflammation in the musculoskeletal system: current concepts and perspectives. Skelet Radiol 42:1347–1359CrossRefGoogle Scholar
  20. 20.
    Eutsler EP, Khanna G (2016) Whole-body magnetic resonance imaging in children: technique and clinical applications. Pediatr Radiol 46:858–872CrossRefGoogle Scholar
  21. 21.
    Forbes-Amrhein MM, Marine MB, Wanner MR et al (2017) Journal club: can coronal STIR be used as screening for acute nontraumatic hip pain in children? AJR Am J Roentgenol 209:676–683CrossRefGoogle Scholar
  22. 22.
    Khoury NJ, Birjawi GA, Chaaya M et al (2003) Use of limited MR protocol (coronal STIR) in the evaluation of patients with hip pain. Skelet Radiol 32:567–574CrossRefGoogle Scholar
  23. 23.
    Browne LP, Guillerman RP, Orth RC et al (2012) Community-acquired staphylococcal musculoskeletal infection in infants and young children: necessity of contrast-enhanced MR for the diagnosis of growth cartilage involvement. AJR Am J Roentgenol 198:194–199CrossRefGoogle Scholar
  24. 24.
    Chan BY, Gill KG, Rebsamen SL et al (2016) MR imaging of pediatric bone marrow. Radiographics 36:1911–1930CrossRefGoogle Scholar
  25. 25.
    Averill LW, Hernandez A, Gonzalez L et al (2009) Diagnosis of osteomyelitis in children: utility of fat-suppressed contrast-enhanced MR. AJR Am J Roentgenol 192:1232–1238CrossRefGoogle Scholar
  26. 26.
    Kan JH, Young RS, Yu C et al (2010) Clinical impact of gadolinium in the MR diagnosis of musculoskeletal infection in children. Pediatr Radiol 40:1197–1205CrossRefGoogle Scholar
  27. 27.
    Petty RE, Southwood TR, Manners P et al (2004) International league of associations for rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton. 2001 J Rheumatol 31:390–392Google Scholar
  28. 28.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefGoogle Scholar
  29. 29.
    Patel SA, Hageman J, Quatman CE et al (2014) Prevalence and location of bone bruises associated with anterior cruciate ligament injury and implications for mechanism of injury: a systematic review. Sports Med 44:281–293CrossRefGoogle Scholar
  30. 30.
    O'Neill BR, Pruthi S, Bains H et al (2013) Rapid sequence magnetic resonance imaging in the assessment of children with hydrocephalus. World Neurosurg 80(27)Google Scholar
  31. 31.
    Ashley WW Jr, McKinstry RC, Leonard JR et al (2005) Use of rapid-sequence magnetic resonance imaging for evaluation of hydrocephalus in children. J Neurosurg 103:124–130CrossRefGoogle Scholar
  32. 32.
    Yasumoto M, Nonomura Y, Yoshimura R et al (2002) MR detection of iliac bone marrow involvement by malignant lymphoma with various MR sequences including diffusion-weighted echo-planar imaging. Skelet Radiol 31:263–269CrossRefGoogle Scholar
  33. 33.
    Ruzal-Shapiro C, Berdon WE, Cohen MD et al (1991) MR imaging of diffuse bone marrow replacement in pediatric patients with cancer. Radiology 181:587–589CrossRefGoogle Scholar
  34. 34.
    Ozgen A (2015) Comparison of fat-saturated T2-weighted and contrast-enhanced fat-saturated T1-weighted sequences in MR imaging of sacroiliac joints in diagnosing active sacroiliitis. Eur J Radiol 84:2593–2596CrossRefGoogle Scholar
  35. 35.
    Herregods N, Jaremko JL, Baraliakos X et al (2015) Limited role of gadolinium to detect active sacroiliitis on MR in juvenile spondyloarthritis. Skelet Radiol 44:1637–1646CrossRefGoogle Scholar
  36. 36.
    Weiss PF, Xiao R, Biko DM et al (2015) Detection of inflammatory sacroiliitis in children with magnetic resonance imaging: is gadolinium contrast enhancement necessary? Arthritis Rheumatol 67:2250–2256CrossRefGoogle Scholar
  37. 37.
    Madsen KB, Egund N, Jurik AG (2010) Grading of inflammatory disease activity in the sacroiliac joints with magnetic resonance imaging: comparison between short-tau inversion recovery and gadolinium contrast-enhanced sequences. J Rheumatol 37:393–400CrossRefGoogle Scholar
  38. 38.
    Ledermann HP, Schweitzer ME, Morrison WB (2002) Nonenhancing tissue on MR imaging of pedal infection: characterization of necrotic tissue and associated limitations for diagnosis of osteomyelitis and abscess. AJR Am J Roentgenol 178:215–222CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Radiology, 3NW39Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of RadiologyJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of Biostatistics and Medical InformaticsUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  4. 4.Department of RadiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

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