BackgroundDiffusion‐weighted imaging (DWI) is common for evaluating pediatric musculoskeletal lesions, but suffers from geometric distortion and intense acoustic noise.PurposeTo investigate the performance of a near‐silent and distortion‐free DWI sequence (DW‐SD) relative to standard echo‐planar DWI (DW‐EPI) in pediatric extremity MRI.Study TypeProspective validation study.SubjectsThirty‐nine children referred for extremity MRI.Field Strength/SequenceDW‐EPI and DW‐SD, based on a rotating ultrafast sequence modified with sinusoidal diffusion preparation gradients, at 3T.AssessmentDW‐SD image quality (Sanat) was assessed from 0 (nondiagnostic) to 5 (outstanding) and comparative image quality (Scomp) (from –2 = DW‐EPI more delineated to +2 = DW‐SD more delineated, 0 = same). ADC measured by DW‐SD and DW‐EPI were compared in bone marrow, muscle, and lesions.Statistical TestsWilcoxon rank‐sum test and confidence interval of proportions (CIOP) were calculated for Scomp, Student's t‐test, coefficient of variation (COV), and Bland–Altman analysis for ADC values, and intraclass correlation coefficient (ICC) for interreader agreement.ResultsDW‐SD and DW‐EPI ADC values for bone marrow, muscle, and lesions were not significantly different (P = 0.3, P = 0.2, and P = 0.27, respectively) and had an overall ADC COV of 14.8% (95% confidence interval: 12.3%, 16.9%) and no significant proportional bias on Bland–Altman analysis. Sanat CIOP was rated diagnostic or better (score of 3, 4, or 5) in 72–98% of cases for bone marrow, muscle, and soft tissues. DW‐SD was equivalent to or preferred over DW‐EPI in muscles and soft tissues, with CIOP 86–93% and 93%, respectively. Lesions were equally visualized on DW‐SD and DW‐EPI in 40–51%, with DW‐SD preferred in 44–56% of cases. DW‐SD was rated significantly better than DW‐EPI across all comparative variables that included bone marrow, muscle, soft tissue, cartilage, and lesions (P < 0.05). Readers had moderate to near‐perfect (ICC range = 0.45–0.85).Data ConclusionDW‐SD of the extremities provided similar ADC values and improved image quality compared with conventional DW‐EPI.Level of Evidence 2Technical Efficacy Stage 2J. MAGN. RESON. IMAGING 2021;53:504–513.