• Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic wrist pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [17 references]

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic wrist pain. Reston (VA): American College of Radiology (ACR); 2003. 8 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

ACR Appropriateness Criteria®

Clinical Condition: Chronic Wrist Pain

Variant 1: With or without prior injury. No specific area of pain specified. Best initial study.

Variant 2: Routine radiographs normal or nondiagnostic. Next study.

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

Variant 3: Suspect arthritis. Routine radiographs normal or nondiagnostic. Next study.

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

Variant 4: Arthritis on radiographs nondiagnostic on type, exclude infection. Next study.

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

Variant 5: On ulnar side, suspect triangular fibrocartilage or lunotriquetral (LT) ligament tear. Radiographs normal. Next study.

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

Variant 6: Radiographs normal. Suspect soft tissue tumor. Next study.

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

Variant 7: Radiographs show positive ulnar variance and irregularity in proximal lunate articular surface. Next study.

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

Variant 8: Radiographs normal or equivocal. Suspect Kienböck's disease. Next study.

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

Variant 9: Kienböck's disease on radiographs. Next study.

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

Variant 10: Pain for more than 3 weeks. Suspect occult fracture. Radiograph nondiagnostic. Next study.

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

Variant 11: Suspect Carpal tunnel syndrome

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

The role of imaging in chronic wrist pain has received much attention but remains controversial. There is considerable disagreement about which imaging study, if any, should be performed in a given situation. If one compares the radiologic literature to the orthopedic literature, the controversy becomes apparent.

Most physicians agree that the 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 occasionally in patients with wrist instability. The standard radiographic examination consists of posteroanterior (PA) and lateral views, and often an oblique view as well. Specific suspected problems may require additional views (e.g., posteroanterior in ulnar deviation to look for a scaphoid fracture). If the patient is suspected of having wrist instability, other views are often added to this routine. There is no universal or near-universal standard for this series, and it can consist of anything from posteroanterior views in radial and ulnar deviation to bilateral studies with multiple views of each wrist.

Fluoroscopy or video imaging is sometimes recommended to establish the diagnosis of dynamic wrist instability, and it has been suggested that it is a cost-effective method of making this diagnosis.

Bone scintigraphy has been used for the diagnosis of occult wrist fractures and also as a screening procedure in patients with wrist pain and negative radiographs. In these cases, a negative bone scan may obviate the need for further work-up.

Wrist arthrography, utilizing a radiocarpal injection, was commonly used in the diagnosis of tears of the triangular fibrocartilage (TFC) and interosseous ligaments. Many authors have replaced the standard radiocarpal wrist arthrogram with a three-injection technique, with injections into the radiocarpal, midcarpal, and distal radial-ulnar joints. Some authors have advocated bilateral tricompartmental arthrography because bilateral intercarpal communications are not uncommon.

Recently, magnetic resonance imaging (MRI) has been advocated for patients with chronic wrist pain because it provides a global examination of both the osseous and soft-tissue structures. It may be diagnostic in patients with triangular fibrocartilage and intraosseous ligament tears, occult fractures, avascular neurosis (AVN), and miscellaneous other abnormalities. It may aid in treatment planning for bone and soft-tissue tumors. Contrast-enhanced and dynamic MRI have been suggested in specific situations such as detecting erosions and their progression in rheumatoid arthritis. Some investigators have used MR arthrography, both direct and indirect, to detect ligamentous abnormalities of the wrist. One study found that indirect MR arthrography was more sensitive than conventional MRI in detecting scapholunate abnormalities but did not improve sensitivity in detecting triangular fibrocartilage or lunatotriquetral tears.

A recent paper showed that immediate MRI for patients with possible occult wrist fractures with a modified screening protocol was nearly equivalent in cost to follow-up with delayed imaging. This included the cost for orthopedic consultation and casting as well as additional follow-up with radiographs and in the orthopedic clinic. The loss of productivity resulting from casts and splints was excluded from the cost analysis.

Another study performed radiography, high-resolution ultrasound, and MRI on 15 consecutive patients with suspected scaphoid fractures. Of nine fractures, five were positive on radiograph, seven were positive on ultrasound (US), and all nine were present on MRI.

MRI is helpful in diagnosing ulnar-sided pain caused by impaction syndromes. It can differentiate between the impaction syndromes and also detect other causes of ulnar-sided pain including occult fractures and triangular fibrocartilage (TFC) tears.

Other authors used computed tomography (CT) post arthrography for the diagnosing ligament injuries of the wrist and claimed that it increased precision without affecting the sensitivity or specificity of the diagnosis. One study indicated that MR arthrography increased the diagnostic performance of the examination.

Tenography has a few advocates, but most authorities believe it has limited utility. CT can be used, particularly in the follow-up of complex fractures or distal radioulnar subluxations.

Many articles, particularly in the orthopedic literature, dispute the value of imaging in the diagnosis of ligamentous tears, because the authors believe that arthroscopy is more accurate and that treatment can be performed along with the diagnostic portions of the procedure. According to the American College of Radiology (ACR), no outcome or cost analysis studies have been performed regarding the results of the various treatment regimens.

Abbreviations

• CT, computed tomography
• MRI, magnetic resonance imaging
• NUC, nuclear medicine
• US, ultrasound

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

• Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic wrist pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [17 references]

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

1998 (revised 2005)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal Imaging

Panel Members: Murray K. Dalinka, MD (Principal Author and Panel Chair); Richard H. Daffner, MD; Arthur A. De Smet, MD; George Y. El-Khoury, MD; John B. Kneeland, MD; B.J. Manaster, MD, PhD; William B. Morrison, MD; Helene Pavlov, MD; David A. Rubin, MD; Robert Schneider, MD; Lynne S. Steinbach, MD; Barbara N. Weissman, MD; Robert H. Haralson III, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic wrist pain. Reston (VA): American College of Radiology (ACR); 2003. 8 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

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.