ACR Appropriateness Criteria® chronic wrist pain.

General

Guideline Title

ACR Appropriateness Criteria® chronic wrist pain.

Bibliographic Source(s)

• Rubin DA, Roberts CC, Bencardino JT, Bell AM, Cassidy RC, Chang EY, Gyftopoulos S, Metter DF, Morrison WB, Subhas N, Tambar S, Towers JD, Yu JS, Kransdorf MJ, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic wrist pain. Reston (VA): American College of Radiology (ACR); 2017. 21 p. [71 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Rubin DA, Weissman BN, Appel M, Arnold E, Bencardino JT, Fries IB, Hayes CW, Hochman MG, Jacobson JA, Luchs JS, Math KR, Murphey MD, Newman JS, Scharf SC, Small KM, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic wrist pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 13 p. [92 references]

This guideline meets NGC’s 2013 (revised) inclusion criteria.

NEATS Assessment

Disclosure of Guideline Funding Source

• Yes

Disclosure and Management of Financial Conflict of Interests

• 3

Guideline Development Group Composition: Multidisciplinary Group

• Yes

Guideline Development Group Composition: Methodologist Involvement

• Yes

Guideline Development Group Composition: Patient and Public Perspectives

• 1

Use of a Systematic Review of Evidence: Search Strategy

• 5

Use of a Systematic Review of Evidence: Study Selection

• 3

Use of a Systematic Review of Evidence: Synthesis of Evidence

• 4

Evidence Foundations for and Rating Strength of Recommendations: Grading the Quality or Strength of Evidence

• 2

Evidence Foundations for and Rating Strength of Recommendations: Benefits and Harms of Recommendations

• 5

Evidence Foundations for and Rating Strength of Recommendations: Evidence Summary Supporting Recommendations

• 4

Evidence Foundations for and Rating Strength of Recommendations: Rating the Strength of Recommendations

• 4

Specific and Unambiguous Articulation of Recommendations

• 5

External Review

• 1

Updating

• 3

Recommendations

Major Recommendations

ACR Appropriateness Criteria®

Chronic Wrist Pain

Variant 1: Chronic wrist pain. With or without prior injury. Best initial study.

Procedure	Appropriateness Category	Relative Radiation Level
X-ray wrist	Usually Appropriate
MRI wrist without IV contrast	Usually Not Appropriate	O
MRI wrist without and with IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 2: Chronic wrist pain. Routine radiographs normal or nonspecific. Persistent symptoms. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
MR arthrography wrist	May Be Appropriate	O
MRI wrist without and with IV contrast	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 3: Chronic wrist pain. Routine radiographs normal or nonspecific. Suspect inflammatory arthritis. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without and with IV contrast	Usually Appropriate	O
MRI wrist without IV contrast	Usually Appropriate	O
US wrist	May Be Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 4: Chronic wrist pain. Radiographs normal or show nonspecific arthritis. Exclude infection. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
Aspiration wrist	Usually Appropriate	Varies
MRI wrist without and with IV contrast	May Be Appropriate (Disagreement)	O
US wrist	May Be Appropriate (Disagreement)	O
MRI wrist without IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 5: Ulnar-sided chronic wrist pain. Radiographs normal or nonspecific. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
MR arthrography wrist	Usually Appropriate	O
CT arthrography wrist	May Be Appropriate
MRI wrist without and with IV contrast	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
X-ray arthrography wrist	Usually Not Appropriate
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 6: Radial-sided chronic wrist pain. Radiographs normal or nonspecific. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
MR arthrography wrist	May Be Appropriate	O
US wrist	May Be Appropriate	O
CT arthrography wrist	May Be Appropriate
MRI wrist without and with IV contrast	Usually Not Appropriate	O
X-ray arthrography wrist	Usually Not Appropriate
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 7: Chronic wrist pain. Radiographs normal or nonspecific. Suspect Kienböck’s disease. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
CT wrist without IV contrast	May Be Appropriate
MRI wrist without and with IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 8: Chronic wrist pain. Kienböck’s disease on radiographs. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
CT wrist without IV contrast	May Be Appropriate
MRI wrist without IV contrast	May Be Appropriate	O
MRI wrist without and with IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 9: Chronic wrist pain. Palpable mass or suspected occult ganglion cyst. Radiographs normal or nonspecific. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
MRI wrist without and with IV contrast	Usually Appropriate	O
US wrist	Usually Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 10: Chronic wrist pain. Suspect occult fracture or stress fracture. Radiographs nondiagnostic. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
CT wrist without IV contrast	Usually Appropriate
X-ray wrist additional views	May Be Appropriate
Tc-99m bone scan with SPECT/CT wrist	May Be Appropriate
MRI wrist without and with IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 11: Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI wrist without IV contrast	Usually Appropriate	O
CT wrist without IV contrast	Usually Appropriate
MRI wrist without and with IV contrast	May Be Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
US wrist	Usually Not Appropriate	O
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 12: Chronic wrist pain. Radiographs normal or nonspecific. Suspect carpal tunnel syndrome.

Procedure	Appropriateness Category	Relative Radiation Level
US wrist	May Be Appropriate	O
MRI wrist without IV contrast	May Be Appropriate	O
MRI wrist without and with IV contrast	Usually Not Appropriate	O
MR arthrography wrist	Usually Not Appropriate	O
CT wrist without IV contrast	Usually Not Appropriate
CT wrist with IV contrast	Usually Not Appropriate
CT wrist without and with IV contrast	Usually Not Appropriate
CT arthrography wrist	Usually Not Appropriate
X-ray arthrography wrist	Usually Not Appropriate
Tc-99m bone scan wrist	Usually Not Appropriate

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Summary of Literature Review

Introduction/Background

In patients with chronic wrist pain, imaging studies are an important adjunct to history, physical examination, laboratory testing, and electrophysiology studies. The choice of imaging modality depends on the patient’s presentation and the clinical questions being asked. There are scenarios where no imaging beyond baseline radiographs is necessary, but in other situations advanced imaging has added value for diagnostic evaluation and treatment planning.

Overview of Imaging Modalities

Radiographs

Imaging evaluation of the painful wrist should begin with radiographs. This simple, relatively inexpensive study may establish a specific diagnosis in patients with arthritis, complications of injury, infection, some bone or soft-tissue tumors and impaction syndromes, or static wrist instability. The standard radiographic examination consists of posterior-anterior (PA) and lateral views, often supplemented by one or more oblique view. The lateral view is important for demonstrating malalignment and soft-tissue swelling. A variety of stress positions and maneuvers can be performed to elicit dynamic instability that is not visible on standard radiographs. Other nonstandard projections may be indicated for specific suspected problems. Additionally, radiographs are necessary for accurate measurement of ulnar variance.

In the past, fluoroscopic observation was used to establish the diagnosis of dynamic wrist instability. However, in most practices fluoroscopy is used either for guidance during wrist injections or as an adjunct to arthrography. Percutaneous aspiration of the wrist – which is indicated in cases of suspected septic arthritis or to assess for intra-articular crystals – can be carried out with either fluoroscopic or ultrasound (US) guidance if imaging is needed.

Scintigraphy

Bone scintigraphy has been used for diagnosing occult wrist fractures and also as a screening procedure in patients with wrist pain and negative radiographs. However, while it is sensitive to bone abnormalities, scintigraphy suffers from a lack of specificity. Furthermore, bone scans cannot detect soft-tissue abnormalities — such as lesions of the ligaments, tendons, and cartilage — which are often responsible for chronic wrist pain.

Arthrography

Conventional (x-ray) arthrography can be performed with contrast injection into the radiocarpal joint alone or into the radiocarpal, midcarpal, and distal radioulnar joints (3-phase technique) for the diagnosis of triangular fibrocartilage complex (TFCC) tear and intrinsic ligament perforations. A recent meta-analysis found only moderate pooled sensitivity (76%) for the detection of full-thickness TFCC tears (82% for 3-phase technique and 72% for single-injection arthrograms). However, arthrography is unable to reliably show the size, shape, and stability of TFCC defects and is insensitive to partial-thickness tears. Similarly, while conventional arthrography can be used to diagnose full-thickness defects in the intrinsic intercarpal ligaments, it is unable to identify which components of those ligaments are affected, to distinguish degenerative from traumatic lesions, to find partial-thickness ligament tears, to demonstrate abnormalities of the extrinsic ligaments, or to show extra-articular abnormalities responsible for pain when there is no ligament or TFCC abnormality. Because of these limitations, arthrography has now largely been supplanted by cross-sectional imaging. Fluoroscopic-guided intra-articular injections are chiefly used as a first step when performing arthrographic computed tomography (CT) and magnetic resonance imaging (MRI) studies.

MRI

Wrist MRI accurately depicts abnormalities of the bones and bone marrow, articular cartilage, intrinsic and extrinsic ligaments, TFCC, synovium, tendons, and neurovascular structures, making it a powerful study for chronic pain caused by diverse etiologies.

A dedicated receiver coil or transmit-receive coil is necessary to provide the signal-to-noise ratio (SNR) needed for high-resolution, high-contrast MRI of the wrist. MR arthrography — either with direct contrast injection into one or more wrist compartments or performed indirectly after intravenous (IV) contrast administration — can enhance the yield of the study for diagnosing internal wrist derangements, especially abnormalities of the ligaments, articular cartilage, and TFCC of the wrist. MRI performed with a 3.0-T magnet and a dedicated coil provides better SNR and better contrast compared with wrist MRI performed with 1.5-T or lower field strength systems.

CT

CT of the wrist is used primarily when high-detail imaging of bone cortex or trabeculae is needed. In patients with chronic wrist pain and prior fractures, CT is typically the study of choice to evaluate fracture healing and joint congruence. When a radiographically occult fracture is suspected as the cause of a patient’s chronic pain, either CT or MRI can be used. Advantages of CT over MRI for the wrist include its ability to obtain high-resolution images of both wrists simultaneously, and the much shorter acquisition times for CT. These factors make CT the preferred examination for suspected distal radioulnar joint subluxation, where images of both wrists can be obtained in both supination and pronation. A disadvantage of CT include is its lower sensitivity to soft-tissue abnormalities compared with MRI.

High-resolution (typically multidetector) CT of the wrist following contrast injection into one or more wrist compartments (CT arthrography) is a powerful tool for diagnosing intra-articular abnormalities. The intraobserver agreement on CT arthrogram images is extremely high and better than that reported for MRI.

US

US of the wrist is useful for examining extra-articular soft tissues, such as suspected ganglion cysts, where its accuracy is similar to that of MRI, but its cost is lower. US can also be used to diagnose abnormalities of the flexor and extensor tendons and tendon sheaths. For de Quervain disease (stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendon compartment), preoperative identification of a septum or subcompartmentalization within the first dorsal compartment with US may affect surgical management.

In patients with suspected or established rheumatoid arthritis (RA), US examination of the wrist and selected finger joints can identify erosions and active synovitis (with the use of power Doppler), findings that influence early diagnosis and treatment decisions. Using US to measure the size of the median nerve is a validated technique in patients with clinical symptoms of carpal tunnel syndrome.

In addition, wrist US is a useful technique to guide therapeutic intra-articular and other soft-tissue injections.

Discussion of Procedures by Variant

Variant 1: Chronic Wrist Pain. With or Without Prior Injury. Best Initial Study

Radiographs

While there is no recent literature that directly addresses the role of first-line examinations for chronic wrist pain, radiographs are usually appropriate as an initial study. Radiographs are widely available, and for many bone, joint, and alignment abnormalities, radiographs alone are diagnostic. In other patients, nonspecific radiologic findings (including those in the soft tissues) combined with the history and physical examination may be sufficient for clinical diagnosis, or may suggest preferred secondary imaging studies.

MRI

MRI is not routinely used in the initial evaluation of chronic wrist pain.

MR Arthrography

MR arthrography is not routinely used in the initial evaluation of chronic wrist pain.

CT

CT is not routinely used in the initial evaluation of chronic wrist pain.

CT Arthrography

CT arthrography is not routinely used in the initial evaluation of chronic wrist pain.

US

US is not routinely used in the initial evaluation of chronic wrist pain.

Bone Scan

Bone scan is not routinely used in the initial evaluation of chronic wrist pain.

Arthrography

X-ray arthrography is not routinely used in the initial evaluation of chronic wrist pain.

Variant 2: Chronic Wrist Pain. Routine Radiographs Normal or Nonspecific. Persistent Symptoms. Next Study

MRI

In most cases, further imaging would not be required in patients with chronic wrist pain in whom initial radiographs did not show a specific diagnosis. Rather, the treating physician would be able to manage the patient based on history, physical examination findings, laboratory analysis, and electrodiagnostic studies. When further imaging is needed and none of the specific scenarios described in Variants 3 through 7, 10, or 12 apply, MRI is the preferred examination and MR arthrography may be appropriate in some circumstances.

MR Arthrography

MR arthrography may have an advantage over other studies when there is a strong suspicion of an internal wrist derangement such as a peripheral TFCC tear or intrinsic ligament abnormality.

CT

CT is not routinely used to further evaluate chronic wrist pain in cases without a specific, clinically suspected condition.

CT Arthrography

CT arthrography is not routinely used to further evaluate chronic wrist pain in cases without a specific, clinically suspected condition.

US

US is not routinely used to further evaluate chronic wrist pain in cases without a specific, clinically suspected condition.

Bone Scan

Bone scan is not routinely used to further evaluate chronic wrist pain in cases without a specific, clinically suspected condition.

Arthrography

X-ray arthrography is not routinely used to further evaluate chronic wrist pain in cases without a specific, clinically suspected condition.

Variant 3: Chronic Wrist Pain. Routine Radiographs Normal or Nonspecific. Suspect Inflammatory Arthritis. Next study

MRI

The diagnosis of a specific inflammatory arthritis is typically established based on clinical and laboratory analysis. Advanced imaging is usually performed to determine disease activity, guide management decisions, and prognosticate outcomes. In patients with early RA and other inflammatory arthritides, active synovitis may be better quantified following MRI with IV contrast administration, possibly if performed dynamically, allowing confident early diagnosis, prognostication, and treatment guidance in these patients. Additionally, inflammatory tenosynovitis may be more conspicuous after IV contrast administration. As is the case for any tomographic study, MRI is much more sensitive than radiographs for identifying erosions in RA. More importantly, though, the finding of enhancing bone marrow “edema” (osteitis) on MRI studies in patients with early RA is proving to be the best single predictor of future disease progression and functional deterioration, even compared to serologies and clinical measures.

US

The diagnosis of a specific inflammatory arthritis is typically established based on clinical and laboratory analysis. Advanced imaging is usually performed to determine disease activity, guide management decisions, and prognosticate outcomes. In patients with RA, US of the wrist and metacarpophalangeal joints can show inflammation as active synovitis. Identifying active synovitis with power Doppler assessment is a useful adjunct in making an early diagnosis of RA when a patient with early arthritis does not meet the 2010 criteria established by the American College of Rheumatology and the European League Against Rheumatism. The presence of synovitis predicts progression of erosions and erosions themselves. US can also depict small bone erosions with high spatial resolution; however, US is less sensitive to erosions that occur on the radial or ulnar sides of the inner carpal bones because direct scanning of these regions is blocked, unlike the dorsal and volar bone surfaces. Furthermore, unlike MRI, US cannot show changes within the bone marrow, which are the strongest prognosticators for disease progression in RA. In patients with established inflammatory arthritis who are undergoing therapy, judging progression or reduction of synovitis may be more difficult with sequential US compared to sequential MRI.

MR Arthrography

MR arthrography does not contribute to the diagnosis or management of patients with suspected inflammatory arthritides.

CT

While CT is more sensitive than radiographs for erosions, CT is not routinely used for the diagnosis and management of patients with suspected inflammatory arthritides.

CT Arthrography

CT arthrography does not contribute to the diagnosis or management of patients with suspected inflammatory arthritides.

Bone Scan

Bone scan does not contribute to the diagnosis or management of patients with suspected inflammatory arthritides.

Arthrography

X-ray arthrography does not contribute to the diagnosis or management of patients with suspected inflammatory arthritides.

Variant 4: Chronic Wrist Pain. Radiographs Normal or Show Nonspecific Arthritis. Exclude Infection. Next Study

Aspiration

No literature directly addresses the appropriateness of imaging studies beyond radiographs in patients with suspected infection in the wrist. However, generalizing from experience with septic arthritis in other joints, joint aspiration should not be delayed in order to obtain advanced imaging studies. In cases of suspected septic arthritis, percutaneous aspiration of the wrist is indicated, even when radiographs appear normal. Aspirates should be analyzed by cell count, gram stain, and appropriate cultures. Microscopic crystal analysis should also be obtained if there is a possibility of gout, acute pseudogout, or hydroxyapatite deposition disease. Aspiration can be performed without imaging guidance if the joint is distended, but either fluoroscopy or US may be useful if a specific compartment is to be targeted.

MRI

There may be a role for MRI with IV contrast enhancement in the staging of infections (for example, to delineate the location and extent of soft-tissue abscesses) after aspiration has been performed. Especially in chronic cases, MRI with IV contrast may be useful to identify a fluid collection or joint effusion to target for aspiration. However, MRI is usually not appropriate as the next study after radiographs for suspected wrist infections.

MR Arthrography

MR arthrography is not routinely used to evaluate suspected wrist infection.

CT

While CT with IV contrast enhancement can depict abscesses, it is usually not appropriate for evaluation of suspected wrist infections.

CT Arthrography

CT arthrography is not routinely used to evaluate suspected wrist infection.

US

There may be a role for US in the staging of infections (for example, to delineate the location and extent of soft-tissue abscesses) after aspiration has been performed. Alternatively, US may be used in conjunction with aspiration as a method to first identify collections and then as the imaging method to guide aspiration.

Bone Scan

Bone scan is not routinely used to evaluate suspected chronic wrist infection.

Arthrography

X-ray arthrography is not routinely used to evaluate suspected wrist infection.

Variant 5: Ulnar-sided Chronic Wrist Pain. Radiographs Normal or Nonspecific. Next Study

MRI

Both traumatic and degenerative lesions of the TFCC can produce chronic, ulnar-sided wrist pain. MRI is highly accurate for lesions involving the radial (central) zone of the disc, especially with the use of high-resolution fast spin-echo or 3-D gradient-recalled pulse sequences. There is some evidence suggesting that MRI performed with a 3.0 T system is even more accurate than MRI performed with a 1.5 T system for TFCC lesions, but there are no studies comparing the accuracy of the two field strengths in the same patients. The sensitivity for tears of the ulnar attachment of the disc and the peripheral attachments (the ulnocarpal ligaments) are only fair with noncontrast-enhanced wrist MRI. IV contrast seldom provides added benefit in patients with ulnar-sided wrist pain but may increase sensitivity for TFCC lesions if MR arthrography is desired but direct joint injection is not feasible.

MR Arthrography

Direct MR arthrography (performed with contrast injection of the radiocarpal or distal radioulnar compartments, alone or in combination) does result in better diagnostic accuracy for the TFCC compared with conventional MRI, especially for ulnar-sided lesions, even when compared to conventional MRI performed with a 3.0 T magnet. The same is true for intrinsic ligament injuries, such as those of the lunotriquetral ligament, which can produce ulnar-sided pain. Performing either MR arthrography or noncontrast-enhanced MRI is usually appropriate in this scenario.

CT Arthrography

The accuracy of CT arthrography is superior to MRI and similar to that of MR arthrography for TFCC and intrinsic ligament lesions. In addition, CT arthrography appears to be more accurate than either MRI or MR arthrography for identifying articular cartilage defects in the wrist. In contrast to MRI and MR arthrography, CT arthrography is less sensitive to lesions occurring outside of the joint (like abnormalities of the extensor carpi ulnaris tendon) that can result in ulnar-sided pain. For these reasons, CT arthrography may be appropriate in this setting, especially if there is a contraindication to MRI or if artifact from metallic implants produce too much artifact on MRI.

Arthrography

Conventional (x-ray) arthrography—performed with contrast injection into one or more wrist compartments—has moderate accuracy for the diagnosis of TFCC perforations. However, x-ray arthrography alone is usually not appropriate and has largely been supplanted by CT arthrography, MRI, and MR arthrography, which provide more anatomic detail that is needed for treatment planning and often demonstrate extra-articular abnormalities responsible for pain when there is no ligament or TFCC abnormality.

US

While some investigators have tried high-resolution US with or without arthrography for diagnosing intrinsic ligament or TFCC abnormalities, its sensitivity in comparison to MRI, MR arthrography, and CT arthrography is unknown. Additionally, imaging with US is largely limited to the dorsal fibers of the ligaments and TFCC. US is usually not appropriate in patients with ulnar-sided wrist pain.

CT

CT, with or without IV contrast, is not routinely used to further evaluate ulnar-sided chronic wrist pain when radiographs are normal or nonspecific.

Bone Scan

Bone scan is not routinely used to further evaluate ulnar-sided chronic wrist pain when radiographs are normal or nonspecific.

Variant 6: Radial-sided Chronic Wrist Pain. Radiographs Normal or Nonspecific. Next Study

MRI

MRI is accurate for diagnosing scapholunate ligament tears, and noncontrast-enhanced MRI is usually appropriate in this scenario. IV contrast seldom provides added benefit in patients with radial-sided wrist pain but may increase sensitivity for ligament lesions if MR arthrography is desired but direct joint injection is not feasible.

MR Arthrography

Direct MR arthrography (with contrast injection either into the radiocarpal joint or into all three compartments of the wrist) may be appropriate in this scenario; the examination has higher sensitivity than noncontrast-enhanced MRI—even when performed at 3.0 T—for diagnosis of complete and incomplete scapholunate and lunotriquetral ligament tears. For the scapholunate ligament, direct MR arthrography also allows more accurate determination of which specific segments of the ligament are torn compared to conventional MRI, which has important biomechanical implications for wrist stability. Direct MR arthrography also has an advantage over noncontrast-enhanced MRI for diagnosing extrinsic ligament abnormalities.

CT Arthrography

The accuracy of CT arthrography and MR arthrography are similar for lesions of the scapholunate ligament. Compared to conventional MRI, CT arthrography may be more sensitive for tears of the biomechanically important dorsal ligament fibers. In contrast to MRI and MR arthrography, CT arthrography is less sensitive for diagnosis of extra-articular findings (like ganglion cysts and tendon disorders) that can cause radial-sided pain. CT arthrography may be appropriate in this scenario.

CT

CT, with or without IV contrast, is not routinely used to further evaluate chronic radial-sided wrist pain when radiographs are normal or nonspecific.

US

While some investigators have tried high-resolution US with or without arthrography for diagnosing intrinsic ligament, its sensitivity in comparison to MRI, MR arthrography, and CT arthrography is unknown. Additionally, imaging with US is largely limited to the dorsal fibers of the ligaments. US may be appropriate in cases of suspected de Quervain disease (stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendon compartment), where preoperative identification of a septum or subcompartmentalization within the first dorsal compartment with US may affect surgical management. US may be appropriate in patients with radial-sided pain in cases where extra-articular pathology is the primary consideration.

Arthrography

Conventional (x-ray) arthrography has largely been supplanted by CT arthrography and MR arthrography because these cross-sectional studies are better able to predict which fibers of the scapholunate ligament are torn and whether any repairable fibers remain, both of which are important features that affect operative management. Additionally, while fibrocartilage and ligament perforations are moderately associated with ulnar-sided wrist pain, there is a poor correlation between ligament lesions and radial-sided pain. Furthermore, conventional arthrography is unable to show extra-articular findings (like ganglion cysts and tendon disorders) that can cause radial-sided pain, further limiting its usefulness in this patient population.

Bone Scan

Bone scan is not routinely used to further evaluate radial-sided chronic wrist pain when radiographs are normal or nonspecific.

Variant 7: Chronic Wrist Pain. Radiographs Normal or Nonspecific. Suspect Kienböck’s Disease. Next Study

MRI

While no recent literature addresses the role of MRI in suspected Kienböck’s disease, generalizing from experience with osteonecrosis elsewhere in the body, noncontrast-enhanced MRI is usually an appropriate examination for diagnosis. IV contrast seldom provides added benefit in patients with suspected lunate osteonecrosis.

CT

While no recent literature addresses the role of CT in suspected Kienböck’s disease, generalizing from experience with osteonecrosis elsewhere in the body, CT may be appropriate in some patients. IV contrast seldom provides added benefit in patients with suspected lunate osteonecrosis.

MR Arthrography

MR arthrography is not routinely used in the diagnosis of Kienböck’s disease.

CT Arthrography

CT arthrography is not routinely used in the diagnosis of Kienböck’s disease.

US

US is not routinely used in the diagnosis of Kienböck’s disease.

Bone Scan

Bone scan is not routinely used in the diagnosis of Kienböck’s disease.

Arthrography

X-ray arthrography is not routinely used in the diagnosis of Kienböck’s disease.

Variant 8: Chronic Wrist Pain. Kienböck’s Disease on Radiographs. Next Study

CT

No recent literature addresses the role of CT in suspected staging of Kienböck’s disease. In most cases, the radiographic findings are diagnostic and provide the necessary information (degree of carpal collapse, ulnar variance, and associated osteoarthritis) to adequately plan management. In cases in which the amount of collapse or the presence and size of bone fragments is uncertain from the radiographs and is deemed clinically important, noncontrast-enhanced CT may be appropriate. CT with IV contrast is usually not appropriate.

MRI

No recent literature addresses the role of MRI in suspected staging of Kienböck’s disease. In many cases, the radiographic findings are diagnostic and provide the necessary information (degree of carpal collapse, ulnar variance, and associated osteoarthritis) to adequately plan management. In cases in which the amount of collapse or the presence and size of bone fragments is uncertain from the radiographs and is deemed clinically important, noncontrast-enhanced MRI may be appropriate. MRI with IV contrast is usually not appropriate.

MR Arthrography

MR arthrography is not routinely used in the diagnosis of Kienböck’s disease.

CT Arthrography

CT arthrography is not routinely used in the diagnosis of Kienböck’s disease.

US

US is not routinely used in the diagnosis of Kienböck’s disease.

Bone Scan

Bone scan is not routinely used in the diagnosis of Kienböck’s disease.

Arthrography

X-ray arthrography is not routinely used in the diagnosis of Kienböck’s disease.

Variant 9: Chronic Wrist Pain. Palpable Mass or Suspected Occult Ganglion Cyst. Radiographs Normal or Nonspecific. Next Study

MRI

Soft-tissue masses

US

Wrist US or MRI (without or without and with IV contrast) are alternative initial examinations that are usually appropriate in this setting. US is useful for examining extra-articular soft tissues, such as suspected ganglion cysts, with an accuracy similar to that of MRI.

CT

There is no support in the literature for CT in the initial diagnosis of a palpable mass or suspected ganglion cyst with normal or nonspecific radiologic findings. CT may have a role in cases in which calcification or ossification is demonstrated radiologically, or in the staging of a lesion that is first evaluated by MRI or US, but CT with or without IV contrast are usually not appropriate initial examinations for a suspected soft-tissue mass.

MR Arthrography

MR arthrography is not routinely used to evaluate a palpable mass or ganglion cyst.

CT Arthrography

CT arthrography is not routinely used to evaluate a palpable mass or ganglion cyst.

Bone Scan

Bone scan is not routinely used to evaluate a palpable mass or ganglion cyst.

Arthrography

X-ray arthrography is not routinely used to evaluate a palpable mass or ganglion cyst.

Variant 10: Chronic Wrist Pain. Suspect Occult Fracture or Stress Fracture. Radiographs Nondiagnostic. Next Study

MRI

Either MRI without IV contrast or CT without IV contrast is usually appropriate in this scenario. MRI is highly sensitive to changes in bone marrow composition, and thus is frequently used to identify radiographically occult acute fractures throughout the skeleton, including in the wrist (see the NGC summary of the ACR Appropriateness Criteria® Acute hand and wrist trauma ). In patients with persistent symptoms thought to be due to an occult wrist fracture, MRI can be used as an alternative to presumptive casting and repeat radiographs. MRI is also sensitive to stress fractures and stress injuries of the physes, for example, in gymnasts. IV contrast does not add to the examination and is usually not appropriate.

CT

Either CT without IV contrast or MRI without IV contrast is usually appropriate in this scenario. CT can provide high-detail imaging of bone cortex and trabeculae and thus can be used to identify radiographically occult fractures and stress fractures. Acquisition times are shorter for CT compared to MRI, and CT may be easier to perform in patients who are casted. However, MRI’s sensitivity for bone bruises and soft-tissue injuries is greater than CT. In specific circumstances—like suspected fractures of the hook of the hamate—CT may be preferable to MRI. IV contrast does not add to the examination and is usually not appropriate.

Radiography

If not obtained as part of the initial radiographic series, additional views such as a carpal tunnel or semipronated oblique projection (a “scaphoid view”) may show an otherwise radiographically occult fracture, and may be appropriate.

Bone Scan

Bone scans are frequently positive for occult fractures by the time of clinical presentation, typically 1 to 2 weeks before radiographs. A normal bone scan can reliably exclude an occult scaphoid fracture because, like CT and MRI, bone scans have a high sensitivity; however, the specificity for bone scan is lower than CT and MRI because entities such as bone contusions, osteoarthritis, and other osteoblastic processes will show increased uptake. Scintigraphy may be a reasonable alternative to MRI in claustrophobic patients with suspected occult scaphoid fractures. Single-photon emission computed tomography (SPECT)/CT appears to be more sensitive than CT for occult fractures, with the CT component increasing examination specificity by co-registering scintigraphic activity with anatomic detail; a negative SPECT/CT has a high negative predictive value for occult and stress fractures, and may be appropriate in this scenario.

US

While there are circumstances in which an US may identify a specific occult fracture or healing stress fracture, there is no literature systematically analyzing US. It is usually not appropriate as the next study in this setting.

CT Arthrography

CT arthrography is not routinely used to evaluate a suspected occult or stress fracture.

MR Arthrography

MR arthrography is not routinely used to evaluate a suspected occult or stress fracture.

Arthrography

X-ray arthrography is not routinely used to evaluate a suspected occult or stress fracture.

Variant 11: Chronic Wrist Pain. Radiographs Show Old Scaphoid Fracture. Evaluate for Nonunion, Malunion, Osteonecrosis, or Post-traumatic Osteoarthritis. Next Study

MRI

Either MRI without IV contrast or CT without IV contrast is usually appropriate in this scenario. MRI shows only moderate sensitivity and specificity for predicting osteonecrosis of the proximal pole of scaphoid fractures, and even some scaphoid fractures with MRI evidence of osteonecrosis may still heal with treatment. While the addition of IV contrast, especially given dynamically, can improve the accuracy for osteonecrosis and predicting graft healing, the routine use of IV contrast for this indication is controversial: while nonenhancement of the proximal scaphoid pole is a reliable sign of osteonecrosis, enhancement can be seen in both viable and nonviable fracture fragments. MRI with IV contrast may be appropriate for these patients. Additionally, unlike the case for the knee and other larger joints, MRI shows only fair sensitivity for depicting articular cartilage defects in the distal radius and carpal bones, even with the use of indirect MR arthrography or 3.0 T scanners. The presence of focal bone marrow edema may be a clue to underlying chondral defects. Despite these limitations, noncontrast MRI and noncontrast CT are both usually appropriate examinations to evaluate potential sequelae of chronic scaphoid fractures, but only one of the tests needs to be performed for a given patient. The use of IV contrast for MRI may be appropriate in some cases.

MR Arthrography

A single study found that direct MR arthrography was more sensitive for articular cartilage defects compared to conventional MRI, but the same study showed that CT arthrography was even more sensitive. MR arthrography is not routinely used in this setting.

CT

Either CT without IV contrast or MRI without IV contrast is usually appropriate in this scenario. CT historically has been the most commonly used examination to detect scaphoid nonunion, malunion, osteonecrosis and wrist osteoarthritis in patients with chronic scaphoid fractures, despite a lack of evidence-based literature. IV contrast does not have added benefit in these patients and is usually not appropriate. Either CT or MRI is usually appropriate in this setting, but only one of the tests is necessary.

CT Arthrography

While CT arthrography may increase the sensitivity for articular cartilage defects, it is not routinely used in this setting.

US

Once a scaphoid fracture is identified, US does not contribute to the evaluation for complications of the fracture.

Bone Scan

Once a scaphoid fracture is identified, bone scan does not contribute to the evaluation for complications of the fracture.

Arthrography

Once a scaphoid fracture is identified, x-ray arthrography does not contribute to the evaluation for complications of the fracture.

Variant 12: Chronic Wrist Pain. Radiographs Normal or Nonspecific. Suspect Carpal Tunnel Syndrome. Next Study

US

Several meta-analyses have confirmed that the cross-sectional area of the median nerve (typically measured at the carpal tunnel inlet) is highly accurate for identifying carpal tunnel syndrome diagnosed clinically or with the combination of clinical and electrophysiologic studies. The expected sensitivity and specificity of US varies depending on what cut-off values are chosen for the size of the nerve and where in the carpal tunnel the measurements are made. There is strong evidence that US can be a replacement or complementary examination to nerve conduction studies and electromyography in patients with clinically suspected carpal tunnel syndrome. There is also some evidence that the presence of vessels or hypervascularity within the carpal tunnel, demonstrated with power Doppler US, is another feature of carpal tunnel syndrome. Nevertheless, clinical examination combined with electrophysiologic testing remains the gold standard for the diagnosis of carpal tunnel syndrome. US may be appropriate in cases where this initial evaluation is equivocal.

MRI

Historically, carpal tunnel syndrome has been diagnosed based on clinical signs and symptoms and confirmed by the results of electrodiagnostic studies. MRI without IV contrast may be appropriate in cases in which this initial evaluation is equivocal. The MRI findings that have been reported in wrists with carpal tunnel syndrome—including nerve enlargement, nerve flattening, and retinacular bowing—may be associated with clinical severity but have limited usefulness in patients with clinically recognized carpal tunnel syndrome and low predictive value in patients with nonspecific wrist pain. In rare cases of secondary carpal tunnel syndrome, MRI may identify a mass lesion compressing the median nerve. There is some evidence that the length of T2 hyperintensity in the median nerve can help prognosticate the success of surgery and that the shape and signal of the nerve predict clinical response to a steroid injection in patients with idiopathic carpal tunnel syndrome. MR neurography may be an option in patients with suspected carpal tunnel syndrome. The use of IV contrast does not contribute to diagnosis and is usually not appropriate.

MR Arthrography

MR arthrography is not routinely used to diagnose carpal tunnel syndrome.

CT

CT, with or without IV contrast, is not routinely used to diagnose carpal tunnel syndrome.

CT Arthrography

CT arthrography is not routinely used to diagnose carpal tunnel syndrome.

Bone Scan

Bone scan is not routinely used to diagnose carpal tunnel syndrome.

Arthrography

X-ray arthrography is not routinely used to diagnose carpal tunnel syndrome.

Summary of Recommendations

• Wrist radiographs are indicated as the best initial imaging examination in patients with chronic wrist pain.
• When radiographs are normal or equivocal and a patient has persistent symptoms with an unclear diagnosis, MRI without IV contrast is usually appropriate.
• In patients with suspected inflammatory arthritis, MRI either with or without IV contrast is usually appropriate if guidance for management or prognostication is needed.
• Patients with suspected wrist infection should undergo aspiration.
• When radiographs are normal or equivocal in a patient with ulnar-sided pain, either MRI without IV contrast or an MR arthrogram of the wrist is usually appropriate.
• When radiographs are normal or equivocal in a patient with radial-sided pain, MRI without IV contrast is usually appropriate.
• For patients with suspected Kienböck’s disease without radiographic confirmation, MRI without IV contrast is usually appropriate.
• For patients with radiographic evidence of Kienböck’s disease, further imaging is usually not necessary. In selected circumstances, either CT or MR without IV contrast may be appropriate for staging of the disease.
• In patients with a palpable mass or suspected ganglion cyst, one of the examinations, MRI without IV contrast, MRI with IV contrast, or wrist US, is usually appropriate.
• Either MRI or CT without contrast is usually appropriate in patients with suspected radiographically occult fractures or stress fractures.
• Patients with prior scaphoid fractures and chronic pain should undergo either CT or MR without IV contrast to evaluate for fracture complications.
• Suspected carpal tunnel syndrome is diagnosed by clinical evaluation combined with electrophysiologic studies. Further imaging is usually not needed, but in selected circumstances, either wrist US or MRI without contrast may be appropriate.

Abbreviations

• CT, computed tomography
• IV, intravenous
• MR, magnetic resonance
• MRI, magnetic resonance imaging
• Tc-99m, technetium 99 metastable
• US, ultrasound

Relative Radiation Level Designations

Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
	<0.1 mSv	<0.03 mSv
	0.1-1 mSv	0.03-0.3 mSv
	1-10 mSv	0.3-3 mSv
	10-30 mSv	3-10 mSv
	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as "Varies."

Clinical Algorithm(s)

Algorithms were not developed from criteria guidelines.

Scope

Disease/Condition(s)

Chronic wrist pain

Guideline Category

• Diagnosis
• Evaluation

Clinical Specialty

• Family Practice
• Internal Medicine
• Nuclear Medicine
• Orthopedic Surgery
• Radiology
• Rheumatology

Intended Users

• Advanced Practice Nurses
• Health Care Providers
• Hospitals
• Managed Care Organizations
• Physician Assistants
• Physicians
• Students
• Utilization Management

Guideline Objective(s)

To evaluate the appropriateness of imaging procedures for patients with chronic wrist pain

Target Population

Patients with chronic wrist pain

Interventions and Practices Considered

1. X-ray, wrist
2. Magnetic resonance imaging (MRI), wrist * Without intravenous (IV) contrast * Without and with IV contrast
3. X-ray arthrography, wrist
4. Ultrasound (US), wrist
5. Computed tomography (CT), wrist * Without IV contrast * With IV contrast * Without and with IV contrast
6. CT arthrography wrist
7. MR arthrography, wrist
8. Technetium (Tc)-99m bone scan, wrist
9. Aspiration, wrist

Major Outcomes Considered

• Utility of imaging procedures in differential diagnosis of chronic wrist pain
• Sensitivity, specificity, and accuracy of imaging procedures in the differential diagnosis of chronic wrist pain

Methodology

Methods Used to Collect/Select the Evidence

• Hand-searches of Published Literature (Primary Sources)
• Hand-searches of Published Literature (Secondary Sources)
• Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Literature Search Summary

Of the 91 citations in the original bibliography, 53 were retained in the final document.

A literature search was conducted in April 2015 and June 2017 to identify additional evidence published since the ACR Appropriateness Criteria ® Chronic Wrist Pain topic was finalized. Using the search strategies described in the literature search companion (see the “Availability of Companion Documents” field), 410 articles were found. Ten articles were added to the bibliography. Two articles were not used as they were duplicates already cited in the original bibliography or captured in more than one literature search. The remaining articles were not used due to either poor study design, the articles were not relevant or generalizable to the topic, or the results were unclear or biased.

The author added 5 citations from bibliographies, Web sites, or books that were not found in the literature searches.

Three citations are supporting documents that were added by staff.

See also the American College of Radiology (ACR) Appropriateness Criteria® literature search process document (see the “Availability of Companion Documents” field) for further information.

Number of Source Documents

Of the 91 citations in the original bibliography, 53 were retained in the final document. The literature search conducted in April 2015 and June 2017 found 10 articles that were added to the bibliography. The author added 5 citations from bibliographies, Web sites, or books that were not found in the literature searches. Three citations are supporting documents that were added by staff.

Methods Used to Assess the Quality and Strength of the Evidence

• Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Definitions of Study Quality Categories

Category 1 - The study is well-designed and accounts for common biases.

Category 2 - The study is moderately well-designed and accounts for most common biases.

Category 3 - The study has important study design limitations.

Category 4 - The study or source is not useful as primary evidence. The article may not be a clinical study, the study design is invalid, or conclusions are based on expert consensus.

The study does not meet the criteria for or is not a hypothesis-based clinical study (e.g., a book chapter or case report or case series description);

Or

The study may synthesize and draw conclusions about several studies such as a literature review article or book chapter but is not primary evidence;

Or

The study is an expert opinion or consensus document.

Category M - Meta-analysis studies are not rated for study quality using the study element method because the method is designed to evaluate individual studies only. An "M" for the study quality will indicate that the study quality has not been evaluated for the meta-analysis study.

Methods Used to Analyze the Evidence

• Review of Published Meta-Analyses
• Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The topic author assesses the literature then drafts or revises the narrative summarizing the evidence found in the literature. American College of Radiology (ACR) staff drafts an evidence table based on the analysis of the selected literature. These tables rate the study quality for each article included in the narrative.

The expert panel reviews the narrative, evidence table and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the variant table(s). Each individual panel member assigns a rating based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the “Availability of Companion Documents” field).

Methods Used to Formulate the Recommendations

• Expert Consensus (Delphi)

Description of Methods Used to Formulate the Recommendations

Overview

The purpose of the rating rounds is to systematically and transparently determine the panels’ recommendations while mitigating any undue influence of one or more panel members on another individual panel members’ interpretation of the evidence. The panel member’s rating is determined by reviewing the evidence presented in the Summary of Literature Review and assessing the risks or harms of performing the procedure or treatment balanced with the benefits of performing the procedure or treatment. The individual panel member ratings are used to calculate the median rating, which determines the panel’s rating. The assessment of the amount of deviation of individual ratings from the panel rating determines whether there is disagreement among the panel about the rating.

The process used in the rating rounds is a modified Delphi method based on the methodology described in the RAND/UCLA Appropriateness Method User Manual.

The appropriateness is rated on an ordinal scale that uses integers from 1 to 9 grouped into three categories (see the “Rating Scheme for the Strength of the Recommendations” field).

Determining the Panel’s Recommendation

• Ratings represent an individual’s assessment of the risks and benefits of performing a specific procedure for a specific clinical scenario on an ordinal scale. The recommendation is the appropriateness category (i.e., “Usually appropriate,” “May be appropriate,” or “Usually not appropriate”).
• The appropriateness category for a procedure and clinical scenario is determined by the panel’s median rating without disagreement (see below for definition of disagreement). The panel’s median rating is calculated after each rating round. If there is disagreement after the second rating round, the rating category is “May be appropriate (Disagreement)” with a rating of “5” so users understand the group disagreed on the final recommendation. The actual panel median rating is documented to provide additional context.
• Disagreement is defined as excessive dispersion of the individual ratings from the group (in this case, an Appropriateness Criteria [AC] panel) median as determined by comparison of the interpercentile range (IPR) and the interpercentile range adjusted for symmetry (IPRAS). In those instances when the IPR is greater than the IPRAS, there is disagreement. For a complete discussion, please refer to chapter 8 of the RAND/UCLA Appropriateness Method User Manual.
• Once the final recommendations have been determined, the panel reviews the document. If two thirds of the panel feel a final recommendation is wrong (e.g., does not accurately reflect the evidence, may negatively impact patient health, has unintended consequences that may harm health care, etc.) and the process must be started again from the beginning.

For additional information on the ratings process see the Rating Round Information document (see the “Availability of Companion Documents” field).

Additional methodology documents, including a more detailed explanation of the complete topic development process and all ACR AC topics can be found on the ACR Web site (see also the “Availability of Companion Documents” field).

Rating Scheme for the Strength of the Recommendations

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel's recommendation. "May be appropriate" is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

• Internal Peer Review

Description of Method of Guideline Validation

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are based on analysis of the current medical evidence literature and the application of the RAND/UCLA appropriateness method and expert panel consensus.

Summary of Evidence

Of the 71 references cited in the ACR Appropriateness Criteria ® Chronic Wrist Pain document, all of them are categorized as diagnostic references including 3 well-designed studies, 16 good-quality studies, and 23 quality studies that may have design limitations. There are 23 references that may not be useful as primary evidence. There are 6 references that are meta-analysis studies.

Although there are references that report on studies with design limitations, 19 well-designed or good-quality studies provide good evidence.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

In patients with chronic wrist pain, imaging studies are an important adjunct to history, physical examination, laboratory testing, and electrophysiology studies. The choice of imaging modality depends on the patient’s presentation and the clinical questions being asked. There are scenarios in which no imaging beyond baseline radiographs is necessary, but in other situations advanced imaging has added value for diagnostic evaluation and treatment planning.

Potential Harms

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 imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see the “Availability of Companion Documents” field).

Qualifying Statements

Qualifying Statements

• The American College of Radiology (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 U.S. Food and Drug Administration (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.
• ACR 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 society endorsement of the final document.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

• Living with Illness

IOM Domain

• Effectiveness

Identifying Information and Availability

Bibliographic Source(s)

• Rubin DA, Roberts CC, Bencardino JT, Bell AM, Cassidy RC, Chang EY, Gyftopoulos S, Metter DF, Morrison WB, Subhas N, Tambar S, Towers JD, Yu JS, Kransdorf MJ, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic wrist pain. Reston (VA): American College of Radiology (ACR); 2017. 21 p. [71 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2017

Guideline Developer(s)

• American College of Radiology - Medical Specialty Society

Source(s) of Funding

The funding for the process is assumed entirely by the American College of Radiology (ACR). ACR staff support the expert panels through the conduct of literature searches, acquisition of scientific articles, drafting of evidence tables, dissemination of materials for the Delphi process, collation of results, conference calls, document processing, and general assistance to the panelists.

Guideline Committee

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal Imaging

Composition of Group That Authored the Guideline

Panel Members : David A. Rubin, MD ( Principal Author ); Catherine C. Roberts, MD ( Panel Chair ); Jenny T. Bencardino, MD ( Panel Vice-chair ); Angela M. Bell, MD; R. Carter Cassidy, MD; Eric Y. Chang, MD; Soterios Gyftopoulos, MD; Darlene F. Metter, MD; William B. Morrison, MD; Naveen Subhas, MD; Siddharth Tambar, MD; Jeffrey D. Towers, MD; Joseph S. Yu, MD; Mark J. Kransdorf, MD ( Specialty Chair )

Financial Disclosures/Conflicts of Interest

Disclosing Potential Conflicts of Interest and Management of Conflicts of Interest

An important aspect of committee operations is the disclosure and management of potential conflicts of interest. In 2016, the American College of Radiology (ACR) began an organization-wide review of its conflict of interest (COI) policies. The current ACR COI policy is available on its Web site. The Appropriateness Criteria (AC) program’s COI process varies from the organization’s current policy to accommodate the requirements for qualified provider-led entities as designated by the Centers for Medicare and Medicaid Services’ Appropriate Use Criteria (AUC) program.

When physicians become participants in the AC program, welcome letters are sent to inform them of their panel roles and responsibilities, including a link to complete the COI form. The COI form requires disclosure of all potential conflicts of interest. ACR staff oversees the COI evaluation process, coordinating with review panels consisting of ACR staff and members, who determine when there is a conflict of interest and what action, if any, is appropriate. In addition to making the information publicly available, management may include exclusion from some topic processes, exclusion from a topic, or exclusion from the panel.

Besides potential COI disclosure, AC staff begins every committee call with the conflict of interest disclosure statement listed below reminding members to update their COI forms. If any updates to their COI information have not been submitted, they are instructed not to participate in discussion where an undisclosed conflict may exist.

Finally, all ACR AC are published as part of the Journal of the American College of Radiology (JACR) electronic supplement. Those who participated on the document and are listed as authors must complete the JACR process that includes completing the International Committee of Medical Journal Editors (ICMJE) COI form which is reviewed by the journal’s staff/publisher.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Rubin DA, Weissman BN, Appel M, Arnold E, Bencardino JT, Fries IB, Hayes CW, Hochman MG, Jacobson JA, Luchs JS, Math KR, Murphey MD, Newman JS, Scharf SC, Small KM, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic wrist pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 13 p. [92 references]

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Guideline Availability

Available from the American College of Radiology (ACR) Web site.

Availability of Companion Documents

The following are available:

• ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2017. Available from the American College of Radiology (ACR) Web site.
• ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 2015 Feb. 1 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 2015 Nov. 5 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Topic development process. Reston (VA): American College of Radiology; 2015 Nov. 2 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Rating round information. Reston (VA): American College of Radiology; 2017 Sep. 5 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2018. 4 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Manual on contrast media. Reston (VA): American College of Radiology; 2017. 125 p. Available from the ACR Web site.
• ACR Appropriateness Criteria®. Procedure information. Reston (VA): American College of Radiology; 2017 Mar. 4 p. Available from the ACR Web site.
• ACR Appropriateness Criteria® chronic wrist pain. Evidence table. Reston (VA): American College of Radiology; 2017. 25 p. Available from the ACR Web site.
• ACR Appropriateness Criteria® chronic wrist pain. Literature search summary. Reston (VA): American College of Radiology; 2017. 2 p. Available from the ACR Web site.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on May 6, 2001. The information was verified by the guideline developer as of June 29, 2001. This NGC summary was updated by ECRI on November 11, 2004. The information was verified by the guideline developer on December 21, 2004. This NGC summary was updated by ECRI on January 5, 2006. The updated information was verified by the guideline developer on January 19, 2006. This NGC summary was updated by ECRI Institute on May 19, 2010. The guideline developer agreed to not review the content. This summary was updated by ECRI Institute on January 13, 2011 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This summary was updated by ECRI Institute on April 17, 2013. The guideline developer agreed to not review the content. This summary was updated on May 10, 2018. The guideline developer agreed to not review the content.

This NEATS assessment was completed by ECRI Institute on May 10, 2018. The information was verified by the guideline developer on June 1, 2018.

Copyright Statement

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site.

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