Chronic Hand and Wrist Pain

Variant: 1 Adult. Chronic hand or wrist pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography area of interest	Usually Appropriate	Varies
US area of interest	May Be Appropriate	O
Radiographic arthrography area of interest	Usually Not Appropriate	Varies
MR arthrography area of interest	Usually Not Appropriate	O
MRI area of interest without and with IV contrast	Usually Not Appropriate	O
MRI area of interest without IV contrast	Usually Not Appropriate	O
Bone scan area of interest	Usually Not Appropriate	☢☢☢
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CT arthrography area of interest	Usually Not Appropriate	Varies

Variant: 2 Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography wrist	Usually Appropriate	O
MRI wrist without IV contrast	Usually Appropriate	O
US wrist	May Be Appropriate	O
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	O
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	Relative Radiation Level
MRI hand without IV contrast	Usually Appropriate	O
US hand	May Be Appropriate	O
MRI hand without and with IV contrast	May Be Appropriate	O
Radiographic arthrography hand	Usually Not Appropriate	☢
MR arthrography hand	Usually Not Appropriate	O
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	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
US wrist	Usually Not Appropriate	O
Radiographic arthrography wrist	Usually Not Appropriate	☢
MR arthrography wrist	Usually Not Appropriate	O
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	Relative Radiation Level
US area of interest	May Be Appropriate	O
MRI area of interest without IV contrast	May Be Appropriate	O
Radiography wrist additional views	Usually Not Appropriate	☢
Radiographic arthrography area of interest	Usually Not Appropriate	Varies
MR arthrography area of interest	Usually Not Appropriate	O
MRI area of interest without and with IV contrast	Usually Not Appropriate	O
Bone scan area of interest	Usually Not Appropriate	☢☢☢
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CT arthrography area of interest	Usually Not Appropriate	Varies

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	Relative Radiation Level
US area of interest	Usually Appropriate	O
MRI area of interest without IV contrast	Usually Appropriate	O
MRI area of interest without and with IV contrast	May Be Appropriate	O
Radiographic arthrography area of interest	Usually Not Appropriate	Varies
MR arthrography area of interest	Usually Not Appropriate	O
Bone scan area of interest	Usually Not Appropriate	☢☢☢
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CT arthrography area of interest	Usually Not Appropriate	Varies

Panel Members

J. Derek Stensby, MD^a; Michael G. Fox, MD, MBA^b; Nicholas C. Nacey, MD^c; Donna G. Blankenbaker, MD^d; Matthew A. Frick, MD^e; Shari T. Jawetz, MD^f; Noah M. Raizman, MD^g; Nicholas Said, MD, MBA^h; Luke A. Stephens, MD, MSPHⁱ; Naveen Subhas, MD, MPH^j; Eric A. Walker, MD, MHA^k; Chadwick L. Wright, MD, PhD^l; Eric Y. Chang, MD^m.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

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)

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).

Discussion of Procedures by Variant

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
A. Bone scan area of interest

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
B. CT area of interest with IV contrast

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
C. CT area of interest without and with IV contrast

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
D. CT area of interest without IV contrast

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
E. CT arthrography area of interest

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
F. MR arthrography area of interest

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
G. MRI area of interest without and with IV contrast

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
H. MRI area of interest without IV contrast

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
I. Radiographic arthrography area of interest

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
J. Radiography area of interest

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
K. US area of interest

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
A. Bone scan wrist

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
B. CT arthrography wrist

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
C. CT wrist with IV contrast

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
D. CT wrist without and with IV contrast

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
E. CT wrist without IV contrast

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
F. MR arthrography wrist

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
G. MRI wrist without and with IV contrast

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
H. MRI wrist without IV contrast

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
I. Radiographic arthrography wrist

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
J. Radiography wrist additional views

Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
K. US wrist

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
A. Bone scan hand

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
B. CT arthrography hand

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
C. CT hand with IV contrast

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
D. CT hand without and with IV contrast

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
E. CT hand without IV contrast

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
F. MR arthrography hand

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
G. MRI hand without and with IV contrast

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
H. MRI hand without IV contrast

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
I. Radiographic arthrography hand

Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
J. US hand

Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study.

Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study.
A. Bone scan wrist

Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study.
J. US wrist

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
A. Bone scan area of interest

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
B. CT area of interest with IV contrast

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
C. CT area of interest without and with IV contrast

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
D. CT area of interest without IV contrast

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
E. CT arthrography area of interest

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
F. MR arthrography area of interest

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
G. MRI area of interest without and with IV contrast

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
H. MRI area of interest without IV contrast

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
I. Radiographic arthrography area of interest

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
J. Radiography wrist additional views

Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
K. US area of interest

Variant 6: Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study.

Variant 6: Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study.
A. Bone scan area of interest

Summary of Highlights

Supporting Documents

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 go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

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.

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, 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.”

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Disclaimer

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.