Rapid MRI Protocol for Pediatric MSK Infections: Can We Safely Remove Contrast and Sedation?

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Rohan Shah, Alison Esteva-Sanders, Soroush Baghdadi, Jillian Krauss, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9140440/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Acute pediatric musculoskeletal (MSK) infection is a medical emergency in which rapid diagnosis is critical to prevent morbidity. Although contrast-enhanced MRI is the traditional diagnostic exam ordered, these protocols are lengthy and often require sedation. Rapid, non-contrast non-sedated MRI protocols have been shown to increase throughput without affecting clinical outcomes, but provider confidence and diagnostic accuracy remains unanswered. Objective: To evaluate radiologists and orthopaedic surgeons’ diagnostic accuracy and confidence when interpreting rapid MRI versus traditional contrast enhanced MRI for suspected acute pediatric musculoskeletal infection. Materials and Methods: This retrospective study included 70 cases presenting clinically with suspected pediatric musculoskeletal infection (35 rapid MRI, 35 traditional MRI) from 2017–2023. Final diagnoses were established by chart review using clinical outcomes and operative/procedural findings. Six readers (2 pediatric radiology attendings, 1 musculoskeletal radiology fellow, 2 pediatric orthopaedic attendings, 1 pediatric orthopaedic fellow) independently reviewed all cases, generating 210 rapid and 210 traditional reads. Readers were instructed to assess for infection, osteomyelitis, abscess, and pathologic joint effusion and rated their confidence level on a 3-point scale. Results: Among radiology and orthopaedic readers, sensitivity and specificity for diagnosing infection, osteomyelitis, abscess, and pathologic joint effusion did not differ significantly between rapid and traditional MRI (all p >0.05). Confidence ratings also did not differ for any diagnosis (all p >0.05), and were on average always at least moderately confident. Conclusion: Rapid, non-contrast MRI provides diagnostic accuracy and reader confidence comparable to traditional contrast-enhanced MRI for acute pediatric musculoskeletal infection. Therefore, rapid non-contrast, non-sedated MRI protocols can be safely implemented for acute MSK infection, without concern for reduction in diagnostic accuracy. Rapid MRI infection osteomyelitis non-contrast non-sedated MSK MRI Abscess Figures Figure 1 Figure 2 Figure 3 Introduction Acute musculoskeletal infection, including osteomyelitis, septic arthritis, and myositis, is a common medical emergency, estimated to have an incidence as high as 13 per 100,000 children annually [ 1 ]. Early diagnosis and treatment are crucial for preventing adverse sequelae, which include functional impairment, limb deformities, persistent infection, progression to sepsis, and mortality [ 2 , 3 ]. Consequently, there is great value in rapidly diagnosing acute musculoskeletal infection in children, allowing for decreased time to medical and surgical interventions. The diagnostic process typically involves a review of patients’ clinical presentation, laboratory findings, and imaging studies. In particular, magnetic resonance imaging (MRI) is largely considered the most valuable diagnostic modality due to its exceptional soft tissue contrast, which allows for early detection of edema, abscess, and complications such as osteomyelitis and septic arthritis [ 4 – 6 ]. Though MRI is the preferred diagnostic tool for acute musculoskeletal infection, there are several challenges in the pediatric population. Traditional MRI sequences with contrast are lengthy and require patients to sit still for prolonged periods of time, which can be difficult in children, especially when in pain [ 7 ]. Anesthesia, sedation, and contrast are frequently required to obtain these images, further slowing the process and creating the potential for rare, but significant complications [ 8 ]. We previously developed a rapid, non-contrast, limited sequence protocol that greatly decreased anesthesia rates, scan times, hospital lengths of stay, and charges without missing actionable diagnoses [ 9 ]. This rapid MRI protocol safely expedited MRI acquisition and allowed for earlier clinical decision making. However, the adoption of any new technique brings questions regarding provider accuracy and confidence with interpretation. The present study evaluates radiology and orthopaedic providers’ diagnostic accuracy and confidence with the rapid MRI protocol compared to traditional MRIs. Our hypothesis was that the diagnostic capability would match traditional MRI sequences and the reader’s perceived quality of the rapid MRI would suffice for interpretation of an assortment of musculoskeletal infection clinical scenarios. Methods The present study is a retrospective review and re-evaluation of suspected musculoskeletal infection cases that underwent either a traditional MRI protocol or rapid sequence MRI. Six total readers were asked to review cases for various diagnoses and provide confidence ratings to be compared between the two sequences. This study was approved by the local Institutional Review Board (IRB). The rapid MRI protocol has been previously described, and prioritizes fluid-sensitive sequences with avoidance of sedation and contrast administration [ 9 ]. This protocol was limited for use in the evaluation of possible acute musculoskeletal infections of the extremities and pelvis. This protocol begins with a large field-of-view (FOV) single-shot fast spin echo sequence to identify the anatomic area of interest. Then, small and focused FOV images of the area are acquired, including axial, sagittal, and coronal T2-weighted fat-suppressed (T2FS) images, a coronal T1-weighted sequence, and axial diffusion-weighted imaging (DWI) with an accompanying ADC (apparent diffusion coefficient) map. This protocol is now standard of care at our tertiary academic children’s hospital. Supplemental Table 1 outlines the sequences included in both our traditional and rapid protocols. Case libraries were generated by the senior author from a bank of rapid and traditional MRI scans from January 2017 to December 2023 to reflect a broad range of diagnoses, including osteomyelitis, subperiosteal abscess, soft tissue abscess, and intraosseous abscess. Cases were selected with particular attention to matching similar numbers of diagnoses between traditional and rapid cohorts. After selecting cases, comparison of abscess sizes between groups was performed to ensure similar size distribution. Osteomyelitis was defined by the presence of bone marrow edema (increased signal intensity on T2-weighted sequences with corresponding low signal on T1-weighted images) or bone destruction. Pathologic joint effusion was defined as fluid greater than expected physiologically but not specific to any diagnosis. To be as inclusive as possible on initial screening, possible abscesses were identified as any abnormal fluid collection, including those < 1 centimeter in size. After creating the case libraries, chart review was performed for each case to determine a final answer key, which was based entirely on actual clinical outcomes. Any disagreements between the senior author’s read of available imaging and “true” diagnoses were deferred to the clinical outcomes from chart review. Presence of osteomyelitis and septic arthritis was defined based on final diagnoses at discharge. Abscesses were defined by operative or procedural findings during hospital admission based on if purulence was identified. The final type of abscess was characterized as subperiosteal, soft tissue, or intraosseous based on operative report. Example images of subperiosteal, soft tissue, and intraosseous abscesses on the rapid MRI are demonstrated in Figs. 1 – 3 . As MRI studies are interpreted by a variety of providers, this study was designed to represent a realistic cross-section of physicians and at different levels of training. Six readers were recruited for this study: two attending pediatric radiologists (one musculoskeletal radiologist with > 20 years of experience and one night radiologist with 4 years of experience), one adult MSK radiology fellow, two fellowship-trained pediatric orthopaedic surgeons (one with > 15 years, another > 5 years of experience), and one pediatric orthopaedic surgery fellow. For each case, readers were asked whether the following were present: 1) any infection, 2) osteomyelitis, 3) subperiosteal abscess, 4) soft tissue abscess, 5) intraosseous abscess, and 6) pathologic joint effusion. Answers were collected and managed using REDCap electronic data capture tools hosted at our institution. If readers identified the presence of any abscess type, it was recorded as a yes to the presence of abscess. Additionally, readers were asked to rate their confidence for each diagnosis on a scale of 1 to 3. A score of 1 indicated “not confident,” 2 was “moderately confident,” and 3 reflected being “very confident.” Responses for the rapid and traditional cohort were compared using chi-squared (for sensitivity and specificity comparisons) and two-sample T tests (for confidence scores), with an a priori level of significance at P < 0.05. We compared overall sensitivity and specificity between rapid and traditional cohorts, as well as accuracy in identifying positive findings. Results The case library generated 70 cases of clinically suspected acute pediatric musculoskeletal infection for review, with 35 using the rapid protocol and 35 with traditional, pre- and post-contrast sequences. Table 1 outlines the diagnoses in rapid and traditional cohorts. Of note, there was no difference in the largest average dimension of abscess between the rapid and traditional cohorts (1.95 centimeters vs. 1.34 centimeters; p = 0.18). Table 1 Cases in Rapid and Traditional Cohorts Case Feature Rapid MRI n = 35 Traditional MRI n = 35 n (%) (%); ( µ, S.D. ) Presence of Any Infection Presence of Osteomyelitis Any Abscess¹ Subperiosteal Abscess Soft Tissue Abscess Intraosseous Abscess Pathologic Joint Effusion 31 (88.6%) 27 (77.1%) 15 (42.9%) 12 (34.3%) 5 (14.3%) 2 (5.7%) 11 (31.4%) 30 (85.7%) 25 (71.4%) 17 (48.6%) 11 (31.4%) 3 (12.0%) 4 (11.4%) 9 (25.7%) ¹Abscess types may not add up to 100% since some cases had multiple abscess types noted With three radiologists and three orthopedic surgeons serving as readers, we compiled a total of 210 rapid and 210 traditional reads. When comparing the rapid and traditional reads performed by radiologists (Table 2 ) and orthopedic surgeons (Table 3 ), there was no significant difference in sensitivity or specificity for identifying osteomyelitis, abscess, or pathologic joint effusion between rapid and traditional groups (all p > 0.05). Confidence ratings did not significantly differ for any outcome between rapid and traditional cohorts (all p > 0.05). Radiologists and orthopedic surgeons were on average always at least moderately confident in their choices. Each of the three radiology-trained readers identified 14 abscesses in the rapid cohort, correctly identifying the presence of abscess in 42 out of 42 (100.0%) total reads. In the traditional cohort, radiologists correctly identified abscesses in 46 out of 48 (95.8%) reads. The two undiagnosed abscesses included one intraosseous and one soft tissue case. The undiagnosed intraosseous case was a 0.6-centimeter abscess, while the soft tissue case was a 1.8-centimeter intramuscular abscess. Three orthopaedic surgery-trained readers independently evaluated 14 abscess cases in the rapid cohort, totaling 42 reads. They correctly identified abscesses in 41 of 42 reads (97.6%). The only undiagnosed case was a 0.1-centimeter subperiosteal abscess. In the traditional cohort, readers correctly identified abscesses in 48 out of 48 (100.0%) reads. Discussion The rapid MRI protocol preserves diagnostic accuracy and does not lead to decreased physician confidence in radiology attendings, pediatric orthopedic attendings, and MSK radiology fellows. Though there may be an initial period before readers become comfortable with their interpretations of more limited sequences, our study suggests that similar diagnostic confidence can be achieved. Since this protocol is already a standard at our institution, we are unable to perform a learning curve analysis retrospectively. Our study’s primary findings showed excellent diagnostic accuracy of the rapid MRI, comparable with traditional scans, which echoes findings from our recently published primary study on this novel protocol [ 9 ]. While the existing literature suggests that rapid protocols do not lead to higher false negative rates of infection, osteomyelitis, and pathologic joint effusion, it has remained a potential concern that excluding post-contrast images could make it more difficult to reliably identify abscesses, in particular, subperiosteal abscesses [ 10 ]. However, the use of diffusion weighted imaging in the rapid MRI protocol serves as an alternative to contrast and did not demonstrate impairment of reader accuracy or confidence in our study. Additionally, all six clinicians in our study reported high levels of confidence with reads in the rapid MRI cohort, comparable with the traditional scans. This finding suggests that the protocol can successfully be adopted without impeding provider comfort, which can be critical to both patient care and, oftentimes, provider satisfaction [ 11 , 12 ]. Appropriate confidence is critical for patient care, with under confidence in interpretations potentially leading to unnecessary interventions and excessive costs [ 13 , 14 ]. Future work studying the learning curve of adopting the rapid MRI would be valuable for informing future integration into hospital systems. The primary limitation of this study is that the rapid and traditional cohorts are not matched to include scans from the same patients, meaning that cases could be of varying complexity between the two cohorts. However, this risk has been minimized by the number of cases included and having similar numbers and characteristics of each diagnosis between the cohorts. It was unfortunately not possible to truly hide which cases were rapid or traditional studies the PACS system, as readers are able to observe the presence of post contrast sequences from traditional scans. This could lead to bias, although our results did not show a preference for the traditional cases. Readers were aware that they were participating in a quiz and not clinical care, potentially influencing their approaches to cases. Of note, all the readers in our study have had some experience with the rapid protocol pre-dating their participation in this study. These are also results from a single institution, limiting the generalizability of conclusions. Our study demonstrated that the rapid MRI protocol can successfully be adopted without sacrificing provider accuracy or confidence in their reads. As the protocol continues to be utilized, a follow-up study may be warranted to evaluate outcomes from a larger sample of cases and continue to evaluate for any potential negative impact on patient outcomes. Future investigations are needed to quantify the effects of the rapid protocol on healthcare costs within a larger system. Conclusion When compared to traditional contrast enhanced MRI, Rapid MRI for acute MSK infection offers similar accuracy for common infectious diagnoses. The subjective confidence amongst radiologists and orthopaedic surgeons was also similar when interpreting rapid versus traditional MRI scans. Rapid MRI protocols can therefore safely be implemented without sacrificing accuracy or confidence. Declarations Funding: None Data availability: The data that support the findings of this study are not openly available due to reasons of sensitivity. Data are located in controlled access data storage at our local institution. Statements and Declarations: I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Ethical Declarations: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. As the study was retrospective, we received a full waiver of HIPAA Authorization for the use and disclosure of protected health information for studies involving minimal risk to the privacy of individuals. The human ethics and consent to participate was therefore not applicable. The study was approved by the hospital’s official internal review board (IRB). References Riise ØR, Kirkhus E, Handeland KS et al (2008) Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr 8:45 Published 2008 Oct 20. 10.1186/1471-2431-8-45 Dartnell J, Ramachandran M, Katchburian M (2012) Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br 94(5):584–595. 10.1302/0301-620X.94B5.28523 Peltola H, Pääkkönen M (2014) Acute osteomyelitis in children. N Engl J Med 370(4):352–360. 10.1056/NEJMra1213956 Morrison WB, Schweitzer ME, Wapner KL, Hecht PJ, Gannon FH (1998) Osteomyelitis of the foot: relative importance of primary and secondary MR imaging signs. Radiology 207(3):625–632. 10.1148/radiology.207.3.9609898 Connolly SA, Connolly LP, Drubach LA, Jaramillo D, Treves ST (2002) Acute hematogenous osteomyelitis of children: assessment with MR imaging. Radiology 223(3):741–748. 10.1148/radiol.2233010907 Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA (2004) MRI findings of septic arthritis and associated osteomyelitis in adults and children. AJR Am J Roentgenol 182(1):119–122. 10.2214/ajr.182.1.1820119 Malviya S, Voepel-Lewis T, Tait AR (2000) Adverse events and risk factors associated with sedation and anesthesia for MRI in children. Anesth Analg 90(4):873–878. 10.1097/00000539-200004000-00020 Dillman JR, Hernandez RJ (2009) Role of sedation and anesthesia in pediatric imaging. Pediatr Radiol 39(5):438–446. 10.1007/s00247-008-1116-0 [9] Chan KS, McBride D, Wild J, Kwon S, Samet J, Gibly RF (2024) A Rapid MRI Protocol for the Evaluation of Acute Pediatric Musculoskeletal Infections: Eliminating Contrast and Decreasing Anesthesia, Scan Time, and Hospital Length of Stay and Charges. J Bone Joint Surg Am 106(8):700–707. 10.2106/JBJS.23.00564 Arnold JC, Bradley JS (2015) Osteoarticular infections in children. Infect Dis Clin North Am 29(3):557–574. 10.1016/j.idc.2015.05.012 Jaspan O, Wysocka A, Sanchez C, Schweitzer AD (2022) Improving the Relationship Between Confidence and Competence: Implications for Diagnostic Radiology Training From the Psychology and Medical Literature. Acad Radiol 29(3):428–438. 10.1016/j.acra.2020.12.006 Itri JN (2015) Patient-centered Radiology. Radiographics 35(6):1835–1846. 10.1148/rg.2015150110 Saposnik G, Redelmeier D, Ruff CC, Tobler PN (2016) Cognitive biases associated with medical decisions: a systematic review. BMC Med Inf Decis Mak 16(1):138 Published 2016 Nov 3. 10.1186/s12911-016-0377-1 Meyer AN, Payne VL, Meeks DW, Rao R, Singh H Physicians' diagnostic accuracy confidence (2013) resource requests: a vignette study. JAMA Intern Med 173(21):1952–1958. 10.1001/jamainternmed.2013.10081 Table 2 and 3 Table 2 and 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Table23.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9140440","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611760714,"identity":"dcf34d6a-dc50-4f01-8a24-eeda6ab98c32","order_by":0,"name":"Rohan Shah","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Rohan","middleName":"","lastName":"Shah","suffix":""},{"id":611760715,"identity":"4ff941c1-d8f0-4ef6-9796-b3b9afd900c7","order_by":1,"name":"Alison Esteva-Sanders","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Alison","middleName":"","lastName":"Esteva-Sanders","suffix":""},{"id":611760716,"identity":"a83bcd74-41ed-411c-9289-ce7e9817392a","order_by":2,"name":"Soroush Baghdadi","email":"","orcid":"","institution":"UCLA Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Soroush","middleName":"","lastName":"Baghdadi","suffix":""},{"id":611760717,"identity":"94ee93db-56b1-4d52-b185-e41c7ceb0f91","order_by":3,"name":"Jillian Krauss","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Jillian","middleName":"","lastName":"Krauss","suffix":""},{"id":611760718,"identity":"ea20bb6c-5055-4626-9a36-bb356f453d0b","order_by":4,"name":"Michelle Sagan","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Sagan","suffix":""},{"id":611760719,"identity":"3161dc64-e0cf-4ab5-9e24-804c80616911","order_by":5,"name":"Mary Wyers","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Wyers","suffix":""},{"id":611760720,"identity":"2417254b-1a35-4f6b-a60b-baa2434f5b11","order_by":6,"name":"Romie Gibly","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Romie","middleName":"","lastName":"Gibly","suffix":""},{"id":611760721,"identity":"3f9f7eb3-5e76-48b3-a3c1-f581ee3bd75f","order_by":7,"name":"Jonathan Samet","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBACxgYwZSMDZjI2SMgwHCBKS0IaD0wLD0EtEJBwmAdmAGEtzP2Hn274+OM8j8Htw40Pfu6w4OG7ffjYwx8MNvnyDjgcNiPN7OaMhNs8BucSmw17z0jwSJ5LSzfmYUiz3IjDOsYZDGa3eUBazjC2STO2SQAZPGbSDAyHDQwbcGjpP/7t9p+EcyAt7b8hWvi/Sf7Ap6Uhx+w2Q8IBsC3MUFvYgOF22EAeh/cZZ+SU3exJS+aRPMPYLNkL1CJ5hs1MmscgzcAAhxbD/uPbbvywsZPjO8P+8MPPtjogg/mZ5I8KGwN5HA7D5WCgFQYHsEvhcjBICodpo2AUjIJRMOIAALN+WlB6MlTGAAAAAElFTkSuQmCC","orcid":"","institution":"Northwestern University","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Samet","suffix":""}],"badges":[],"createdAt":"2026-03-16 16:53:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9140440/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9140440/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105499805,"identity":"4a9b3edf-9bc0-44fd-9d5b-d7b31e97a138","added_by":"auto","created_at":"2026-03-26 17:15:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":520126,"visible":true,"origin":"","legend":"\u003cp\u003e10 year old male patient with osteomyelitis of the distal tibia and subperiosteal abscess. Axial (a) and sagittal (b) T2 fat suppressed images from a rapid MRI protocol shows a small T2 hyperintense subperiosteal fluid collection along the anterolateral aspect of the tibia (arrows). This abscess was surgically confirmed during the hospital admission.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/e10455718e9082d7965b74a1.png"},{"id":105566691,"identity":"fec1a09a-e8e1-48af-85cf-f9250dcef75e","added_by":"auto","created_at":"2026-03-27 12:57:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":572792,"visible":true,"origin":"","legend":"\u003cp\u003e16 year old male with extensive osteomyelitis complicated by intraosseous and subperiosteal abscesses. Sagittal (a) and coronal (b) T2 fat suppressed images from a rapid MRI protocol shows an intraosseous abscess (short arrows) which is T2 hyperintense and has a T2 hypointense irregular rim. T2 hypointense periosteum is lifted by the T2 hyperintense subperiosteal abscess (long arrows). There was also concomitant septic arthritis with a pathologically enlarged knee joint effusion (arrowhead). The abscesses and septic joint were all surgically confirmed during the hospital admission.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/dd7b7d5933996efafe2c3c68.png"},{"id":105566420,"identity":"ae579008-0b1f-4bf2-9d0e-97be76cba18f","added_by":"auto","created_at":"2026-03-27 12:56:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":475867,"visible":true,"origin":"","legend":"\u003cp\u003e24 year old male patient with myositis and intramuscular abscess in the posterior calf musculature. (a) Axial T2 fat suppressed, (b) axial DWI, and (c) axial ADC images from a rapid MRI protocol showing an irregular shaped T2 hyperintense intramuscular collection (arrow). The fluid collection demonstrates high signal on the DWI, and low signal on the ADC, consistent with restricted diffusion of an abscess (arrows).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/8356c51f6c3f70c0c29014ff.png"},{"id":107870019,"identity":"06c54a52-dbaf-4329-b51f-480e4aae3f13","added_by":"auto","created_at":"2026-04-27 07:38:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1745690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/09a2426a-b140-42dc-987e-8a12f91cd4f4.pdf"},{"id":105567440,"identity":"e0783136-02ab-4e94-a82f-8b906dd72be6","added_by":"auto","created_at":"2026-03-27 12:59:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14696,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/9d78c7c2796f188bb1fa2086.docx"},{"id":105565859,"identity":"f19a4896-8059-4f96-8322-2c78d4ec90f0","added_by":"auto","created_at":"2026-03-27 12:54:37","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18017,"visible":true,"origin":"","legend":"","description":"","filename":"Table23.docx","url":"https://assets-eu.researchsquare.com/files/rs-9140440/v1/11a210c35df7d611de6574a1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRapid MRI Protocol for Pediatric MSK Infections: Can We Safely Remove Contrast and Sedation?\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute musculoskeletal infection, including osteomyelitis, septic arthritis, and myositis, is a common medical emergency, estimated to have an incidence as high as 13 per 100,000 children annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Early diagnosis and treatment are crucial for preventing adverse sequelae, which include functional impairment, limb deformities, persistent infection, progression to sepsis, and mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Consequently, there is great value in rapidly diagnosing acute musculoskeletal infection in children, allowing for decreased time to medical and surgical interventions. The diagnostic process typically involves a review of patients\u0026rsquo; clinical presentation, laboratory findings, and imaging studies. In particular, magnetic resonance imaging (MRI) is largely considered the most valuable diagnostic modality due to its exceptional soft tissue contrast, which allows for early detection of edema, abscess, and complications such as osteomyelitis and septic arthritis [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Though MRI is the preferred diagnostic tool for acute musculoskeletal infection, there are several challenges in the pediatric population. Traditional MRI sequences with contrast are lengthy and require patients to sit still for prolonged periods of time, which can be difficult in children, especially when in pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Anesthesia, sedation, and contrast are frequently required to obtain these images, further slowing the process and creating the potential for rare, but significant complications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe previously developed a rapid, non-contrast, limited sequence protocol that greatly decreased anesthesia rates, scan times, hospital lengths of stay, and charges without missing actionable diagnoses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This rapid MRI protocol safely expedited MRI acquisition and allowed for earlier clinical decision making. However, the adoption of any new technique brings questions regarding provider accuracy and confidence with interpretation. The present study evaluates radiology and orthopaedic providers\u0026rsquo; diagnostic accuracy and confidence with the rapid MRI protocol compared to traditional MRIs. Our hypothesis was that the diagnostic capability would match traditional MRI sequences and the reader\u0026rsquo;s perceived quality of the rapid MRI would suffice for interpretation of an assortment of musculoskeletal infection clinical scenarios.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe present study is a retrospective review and re-evaluation of suspected musculoskeletal infection cases that underwent either a traditional MRI protocol or rapid sequence MRI. Six total readers were asked to review cases for various diagnoses and provide confidence ratings to be compared between the two sequences. This study was approved by the local Institutional Review Board (IRB).\u003c/p\u003e \u003cp\u003eThe rapid MRI protocol has been previously described, and prioritizes fluid-sensitive sequences with avoidance of sedation and contrast administration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This protocol was limited for use in the evaluation of possible acute musculoskeletal infections of the extremities and pelvis. This protocol begins with a large field-of-view (FOV) single-shot fast spin echo sequence to identify the anatomic area of interest. Then, small and focused FOV images of the area are acquired, including axial, sagittal, and coronal T2-weighted fat-suppressed (T2FS) images, a coronal T1-weighted sequence, and axial diffusion-weighted imaging (DWI) with an accompanying ADC (apparent diffusion coefficient) map. This protocol is now standard of care at our tertiary academic children\u0026rsquo;s hospital. Supplemental Table\u0026nbsp;1 outlines the sequences included in both our traditional and rapid protocols.\u003c/p\u003e \u003cp\u003eCase libraries were generated by the senior author from a bank of rapid and traditional MRI scans from January 2017 to December 2023 to reflect a broad range of diagnoses, including osteomyelitis, subperiosteal abscess, soft tissue abscess, and intraosseous abscess. Cases were selected with particular attention to matching similar numbers of diagnoses between traditional and rapid cohorts. After selecting cases, comparison of abscess sizes between groups was performed to ensure similar size distribution. Osteomyelitis was defined by the presence of bone marrow edema (increased signal intensity on T2-weighted sequences with corresponding low signal on T1-weighted images) or bone destruction. Pathologic joint effusion was defined as fluid greater than expected physiologically but not specific to any diagnosis. To be as inclusive as possible on initial screening, possible abscesses were identified as any abnormal fluid collection, including those\u0026thinsp;\u0026lt;\u0026thinsp;1 centimeter in size.\u003c/p\u003e \u003cp\u003eAfter creating the case libraries, chart review was performed for each case to determine a final answer key, which was based entirely on actual clinical outcomes. Any disagreements between the senior author\u0026rsquo;s read of available imaging and \u0026ldquo;true\u0026rdquo; diagnoses were deferred to the clinical outcomes from chart review. Presence of osteomyelitis and septic arthritis was defined based on final diagnoses at discharge. Abscesses were defined by operative or procedural findings during hospital admission based on if purulence was identified. The final type of abscess was characterized as subperiosteal, soft tissue, or intraosseous based on operative report. Example images of subperiosteal, soft tissue, and intraosseous abscesses on the rapid MRI are demonstrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAs MRI studies are interpreted by a variety of providers, this study was designed to represent a realistic cross-section of physicians and at different levels of training. Six readers were recruited for this study: two attending pediatric radiologists (one musculoskeletal radiologist with \u0026gt;\u0026thinsp;20 years of experience and one night radiologist with 4 years of experience), one adult MSK radiology fellow, two fellowship-trained pediatric orthopaedic surgeons (one with \u0026gt;\u0026thinsp;15 years, another\u0026thinsp;\u0026gt;\u0026thinsp;5 years of experience), and one pediatric orthopaedic surgery fellow. For each case, readers were asked whether the following were present: 1) any infection, 2) osteomyelitis, 3) subperiosteal abscess, 4) soft tissue abscess, 5) intraosseous abscess, and 6) pathologic joint effusion. Answers were collected and managed using REDCap electronic data capture tools hosted at our institution. If readers identified the presence of any abscess type, it was recorded as a yes to the presence of abscess. Additionally, readers were asked to rate their confidence for each diagnosis on a scale of 1 to 3. A score of 1 indicated \u0026ldquo;not confident,\u0026rdquo; 2 was \u0026ldquo;moderately confident,\u0026rdquo; and 3 reflected being \u0026ldquo;very confident.\u0026rdquo; Responses for the rapid and traditional cohort were compared using chi-squared (for sensitivity and specificity comparisons) and two-sample T tests (for confidence scores), with an \u003cem\u003ea priori\u003c/em\u003e level of significance at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. We compared overall sensitivity and specificity between rapid and traditional cohorts, as well as accuracy in identifying positive findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe case library generated 70 cases of clinically suspected acute pediatric musculoskeletal infection for review, with 35 using the rapid protocol and 35 with traditional, pre- and post-contrast sequences. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the diagnoses in rapid and traditional cohorts. Of note, there was no difference in the largest average dimension of abscess between the rapid and traditional cohorts (1.95 centimeters vs. 1.34 centimeters; p\u0026thinsp;=\u0026thinsp;0.18).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCases in Rapid and Traditional Cohorts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCase Feature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRapid MRI\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraditional MRI\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(%);\u003c/b\u003e \u003cb\u003e(\u003c/b\u003e\u003cb\u003e\u0026micro;, S.D.\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of Any Infection\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePresence of Osteomyelitis\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eAny Abscess\u0026sup1;\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSubperiosteal Abscess\u003c/p\u003e \u003cp\u003eSoft Tissue Abscess\u003c/p\u003e \u003cp\u003eIntraosseous Abscess\u003c/p\u003e \u003cp\u003e\u003cb\u003ePathologic Joint Effusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (88.6%)\u003c/p\u003e \u003cp\u003e27 (77.1%)\u003c/p\u003e \u003cp\u003e15 (42.9%)\u003c/p\u003e \u003cp\u003e12 (34.3%)\u003c/p\u003e \u003cp\u003e5 (14.3%)\u003c/p\u003e \u003cp\u003e2 (5.7%)\u003c/p\u003e \u003cp\u003e11 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (85.7%)\u003c/p\u003e \u003cp\u003e25 (71.4%)\u003c/p\u003e \u003cp\u003e17 (48.6%)\u003c/p\u003e \u003cp\u003e11 (31.4%)\u003c/p\u003e \u003cp\u003e3 (12.0%)\u003c/p\u003e \u003cp\u003e4 (11.4%)\u003c/p\u003e \u003cp\u003e9 (25.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u0026sup1;Abscess types may not add up to 100% since some cases had multiple abscess types noted\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith three radiologists and three orthopedic surgeons serving as readers, we compiled a total of 210 rapid and 210 traditional reads. When comparing the rapid and traditional reads performed by radiologists (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and orthopedic surgeons (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), there was no significant difference in sensitivity or specificity for identifying osteomyelitis, abscess, or pathologic joint effusion between rapid and traditional groups (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Confidence ratings did not significantly differ for any outcome between rapid and traditional cohorts (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Radiologists and orthopedic surgeons were on average always at least moderately confident in their choices.\u003c/p\u003e \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003eEach of the three radiology-trained readers identified 14 abscesses in the rapid cohort, correctly identifying the presence of abscess in 42 out of 42 (100.0%) total reads. In the traditional cohort, radiologists correctly identified abscesses in 46 out of 48 (95.8%) reads. The two undiagnosed abscesses included one intraosseous and one soft tissue case. The undiagnosed intraosseous case was a 0.6-centimeter abscess, while the soft tissue case was a 1.8-centimeter intramuscular abscess. Three orthopaedic surgery-trained readers independently evaluated 14 abscess cases in the rapid cohort, totaling 42 reads. They correctly identified abscesses in 41 of 42 reads (97.6%). The only undiagnosed case was a 0.1-centimeter subperiosteal abscess. In the traditional cohort, readers correctly identified abscesses in 48 out of 48 (100.0%) reads.\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe rapid MRI protocol preserves diagnostic accuracy and does not lead to decreased physician confidence in radiology attendings, pediatric orthopedic attendings, and MSK radiology fellows. Though there may be an initial period before readers become comfortable with their interpretations of more limited sequences, our study suggests that similar diagnostic confidence can be achieved. Since this protocol is already a standard at our institution, we are unable to perform a learning curve analysis retrospectively.\u003c/p\u003e \u003cp\u003eOur study\u0026rsquo;s primary findings showed excellent diagnostic accuracy of the rapid MRI, comparable with traditional scans, which echoes findings from our recently published primary study on this novel protocol [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While the existing literature suggests that rapid protocols do not lead to higher false negative rates of infection, osteomyelitis, and pathologic joint effusion, it has remained a potential concern that excluding post-contrast images could make it more difficult to reliably identify abscesses, in particular, subperiosteal abscesses [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the use of diffusion weighted imaging in the rapid MRI protocol serves as an alternative to contrast and did not demonstrate impairment of reader accuracy or confidence in our study.\u003c/p\u003e \u003cp\u003eAdditionally, all six clinicians in our study reported high levels of confidence with reads in the rapid MRI cohort, comparable with the traditional scans. This finding suggests that the protocol can successfully be adopted without impeding provider comfort, which can be critical to both patient care and, oftentimes, provider satisfaction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Appropriate confidence is critical for patient care, with under confidence in interpretations potentially leading to unnecessary interventions and excessive costs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Future work studying the learning curve of adopting the rapid MRI would be valuable for informing future integration into hospital systems.\u003c/p\u003e \u003cp\u003eThe primary limitation of this study is that the rapid and traditional cohorts are not matched to include scans from the same patients, meaning that cases could be of varying complexity between the two cohorts. However, this risk has been minimized by the number of cases included and having similar numbers and characteristics of each diagnosis between the cohorts. It was unfortunately not possible to truly hide which cases were rapid or traditional studies the PACS system, as readers are able to observe the presence of post contrast sequences from traditional scans. This could lead to bias, although our results did not show a preference for the traditional cases. Readers were aware that they were participating in a quiz and not clinical care, potentially influencing their approaches to cases. Of note, all the readers in our study have had some experience with the rapid protocol pre-dating their participation in this study. These are also results from a single institution, limiting the generalizability of conclusions.\u003c/p\u003e \u003cp\u003eOur study demonstrated that the rapid MRI protocol can successfully be adopted without sacrificing provider accuracy or confidence in their reads. As the protocol continues to be utilized, a follow-up study may be warranted to evaluate outcomes from a larger sample of cases and continue to evaluate for any potential negative impact on patient outcomes. Future investigations are needed to quantify the effects of the rapid protocol on healthcare costs within a larger system.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhen compared to traditional contrast enhanced MRI, Rapid MRI for acute MSK infection offers similar accuracy for common infectious diagnoses. The subjective confidence amongst radiologists and orthopaedic surgeons was also similar when interpreting rapid versus traditional MRI scans. Rapid MRI protocols can therefore safely be implemented without sacrificing accuracy or confidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: None\u003c/p\u003e\n\n\u003cp\u003eData availability: The data that support the findings of this study are not openly available due to reasons of sensitivity. Data are located in controlled access data storage at our local institution.\u003c/p\u003e\n\n\u003cp\u003eStatements and Declarations: I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\n\u003cp\u003eEthical Declarations: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eAs the study was retrospective, we received a full waiver of HIPAA Authorization for the use and disclosure of protected health information for studies involving minimal risk to the privacy of individuals. The human ethics and consent to participate was therefore not applicable. 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JAMA Intern Med 173(21):1952\u0026ndash;1958. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamainternmed.2013.10081\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2013.10081\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"},{"header":"Table 2 and 3","content":"\u003cp\u003eTable 2 and 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rapid MRI, infection, osteomyelitis, non-contrast non-sedated MSK MRI, Abscess","lastPublishedDoi":"10.21203/rs.3.rs-9140440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9140440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Acute pediatric musculoskeletal (MSK) infection is a medical emergency in which rapid diagnosis is critical to prevent morbidity. Although contrast-enhanced MRI is the traditional diagnostic exam ordered, these protocols are lengthy and often require sedation. Rapid, non-contrast non-sedated MRI protocols have been shown to increase throughput without affecting clinical outcomes, but provider confidence and diagnostic accuracy remains unanswered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate radiologists and orthopaedic surgeons’ diagnostic accuracy and confidence when interpreting rapid MRI versus traditional contrast enhanced MRI for suspected acute pediatric musculoskeletal infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e This retrospective study included 70 cases presenting clinically with suspected pediatric musculoskeletal infection (35 rapid MRI, 35 traditional MRI) from 2017–2023. Final diagnoses were established by chart review using clinical outcomes and operative/procedural findings. Six readers (2 pediatric radiology attendings, 1 musculoskeletal radiology fellow, 2 pediatric orthopaedic attendings, 1 pediatric orthopaedic fellow) independently reviewed all cases, generating 210 rapid and 210 traditional reads. Readers were instructed to assess for infection, osteomyelitis, abscess, and pathologic joint effusion and rated their confidence level on a 3-point scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among radiology and orthopaedic readers, sensitivity and specificity for diagnosing infection, osteomyelitis, abscess, and pathologic joint effusion did not differ significantly between rapid and traditional MRI (all \u003cem\u003ep\u003c/em\u003e\u0026gt;0.05). Confidence ratings also did not differ for any diagnosis (all \u003cem\u003ep\u003c/em\u003e\u0026gt;0.05), and were on average always at least moderately confident.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Rapid, non-contrast MRI provides diagnostic accuracy and reader confidence comparable to traditional contrast-enhanced MRI for acute pediatric musculoskeletal infection. Therefore, rapid non-contrast, non-sedated MRI protocols can be safely implemented for acute MSK infection, without concern for reduction in diagnostic accuracy.\u003c/p\u003e","manuscriptTitle":"Rapid MRI Protocol for Pediatric MSK Infections: Can We Safely Remove Contrast and Sedation?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 17:15:51","doi":"10.21203/rs.3.rs-9140440/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e26dc510-5725-4a94-9d08-2bf6893cab48","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T22:38:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 17:15:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9140440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9140440","identity":"rs-9140440","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}