Chronic Hand and Wrist Pain

Variant: 1   Adult. Chronic hand or wrist pain. Initial imaging.
Procedure Appropriateness Category
Radiography area of interest Usually Appropriate
US area of interest May Be Appropriate
Radiographic arthrography area of interest Usually Not Appropriate
MR arthrography area of interest Usually Not Appropriate
MRI area of interest without and with IV contrast Usually Not Appropriate
MRI area of interest without IV contrast Usually Not Appropriate
Bone scan area of interest Usually Not Appropriate
CT area of interest with IV contrast Usually Not Appropriate
CT area of interest without and with IV contrast Usually Not Appropriate
CT area of interest without IV contrast Usually Not Appropriate
CT arthrography area of interest Usually Not Appropriate
Variant: 2   Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
Procedure Appropriateness Category
MR arthrography wrist Usually Appropriate
MRI wrist without IV contrast Usually Appropriate
US wrist May Be Appropriate
Radiography wrist additional views May Be Appropriate
CT arthrography wrist May Be Appropriate
CT wrist without IV contrast May Be Appropriate
Radiographic arthrography wrist Usually Not Appropriate
MRI wrist without and with IV contrast Usually Not Appropriate
CT wrist with IV contrast Usually Not Appropriate
CT wrist without and with IV contrast Usually Not Appropriate
Bone scan wrist Usually Not Appropriate
Variant: 3   Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
Procedure Appropriateness Category
MRI hand without IV contrast Usually Appropriate
US hand May Be Appropriate
MRI hand without and with IV contrast May Be Appropriate
Radiographic arthrography hand Usually Not Appropriate
MR arthrography hand Usually Not Appropriate
CT hand with IV contrast Usually Not Appropriate
CT hand without and with IV contrast Usually Not Appropriate
CT hand without IV contrast Usually Not Appropriate
CT arthrography hand Usually Not Appropriate
Bone scan hand Usually Not Appropriate
Variant: 4   Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study.
Procedure Appropriateness Category
MRI wrist without IV contrast Usually Appropriate
CT wrist without IV contrast Usually Appropriate
MRI wrist without and with IV contrast May Be Appropriate
US wrist Usually Not Appropriate
Radiographic arthrography wrist Usually Not Appropriate
MR arthrography wrist Usually Not Appropriate
CT arthrography wrist Usually Not Appropriate
CT wrist with IV contrast Usually Not Appropriate
CT wrist without and with IV contrast Usually Not Appropriate
Bone scan wrist Usually Not Appropriate
Variant: 5   Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
Procedure Appropriateness Category
US area of interest May Be Appropriate
MRI area of interest without IV contrast May Be Appropriate
Radiography wrist additional views Usually Not Appropriate
Radiographic arthrography area of interest Usually Not Appropriate
MR arthrography area of interest Usually Not Appropriate
MRI area of interest without and with IV contrast Usually Not Appropriate
Bone scan area of interest Usually Not Appropriate
CT area of interest with IV contrast Usually Not Appropriate
CT area of interest without and with IV contrast Usually Not Appropriate
CT area of interest without IV contrast Usually Not Appropriate
CT arthrography area of interest Usually Not Appropriate
Variant: 6   Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study.
Procedure Appropriateness Category
US area of interest Usually Appropriate
MRI area of interest without IV contrast Usually Appropriate
MRI area of interest without and with IV contrast May Be Appropriate
Radiographic arthrography area of interest Usually Not Appropriate
MR arthrography area of interest Usually Not Appropriate
Bone scan area of interest Usually Not Appropriate
CT area of interest with IV contrast Usually Not Appropriate
CT area of interest without and with IV contrast Usually Not Appropriate
CT area of interest without IV contrast Usually Not Appropriate
CT arthrography area of interest Usually Not Appropriate
J. Derek Stensby, MDa; Michael G. Fox, MD, MBAb; Nicholas C. Nacey, MDc; Donna G. Blankenbaker, MDd; Matthew A. Frick, MDe; Shari T. Jawetz, MDf; Noah M. Raizman, MDg; Nicholas Said, MD, MBAh; Luke A. Stephens, MD, MSPHi; Naveen Subhas, MD, MPHj; Eric A. Walker, MD, MHAk; Chadwick L. Wright, MD, PhDl; Eric Y. Chang, MDm.

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please visit https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

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.

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, because of both 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 with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

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.”

















































































The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination