• Steinbach LS, Daffner RH, Dalinka MK, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Shoulder trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 6 p. [37 references]

This is the current release of the guideline.

This guideline updates a previous version: Newberg A, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen TG, Keats TE, Manaster BJ, Pavlov H, Haralson RH, McCabe JB, Sartoris D. Shoulder trauma. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):299-302.

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

Shoulder trauma

Diagnosis
Evaluation

Emergency Medicine
Family Practice
Internal Medicine
Nuclear Medicine
Orthopedic Surgery
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of initial radiologic examinations for patients with shoulder trauma

Patients with shoulder trauma

1. X-rays
   • Anteroposterior (AP) (Grashey recommended) views with internal and external humeral rotation
   • Axillary
   • Impingement view
   • Scapular Y
2. Computed tomography (CT)
3. Magnetic resonance imaging (MRI)
   • Routine MRI
   • Magnetic resonance (MR) arthrogram
4. Arthrogram with or without computed tomography (CT)
5. Ultrasound (US)
6. Nuclear medicine, bone scan

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals, and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1 to 9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty (80) percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by this Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

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

Internal Peer Review

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

ACR Appropriateness Criteria®

Clinical Condition: Acute Shoulder Trauma (e.g., MVA, Sports)

Variant 1: Rule out fracture or dislocation.

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

Variant 2: Acute or recent trauma, normal recent radiographs, significant clinical symptoms.

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

Variant 3: Subacute shoulder pain - questionable bursitis or tendonitis, approximately 3 months duration. First study recommended.

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

Variant 4: Subacute shoulder pain, suspect rotator cuff tear/impingement; over age 35. Normal plain radiographs or radiographs that demonstrate coracoacromial arch osteophytes/syndesmophytes.

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

Variant 5: Subacute shoulder pain, under age 35.

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

Variant 6: Subacute shoulder pain, suspect instability/labral tear.

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

Summary

The shoulder is the joint that is the most unstable, has the most mobility, and is difficult to assess clinically.

All radiographic shoulder studies should include frontal examinations with both internal and external humeral rotation. The frontal views can be done straight AP. AP to the scapula by turning the patient into a 30 degree posterior oblique (Grashey) projection, or in both projections, but the committee recommends obtaining at least one of the frontal projections in the Grashey position to profile the glenohumeral joint. Some patients should have an axillary lateral view, a scapular Y view, or both; one or the other is advisable if there is a question of instability or dislocation. The transthoracic view has little to offer but still seems to turn up when outside films become available for review. There have been several reports assessing special views for the evaluation of shoulder impingement and the anterior acromion. An upright 30-degree caudad-angled radiograph or a suprascapular outlet view will suffice in most cases.

Arthrography was the mainstay of evaluation for rotator cuff tear until the advent of shoulder MRI. Arthrography is currently used only as a potential study in patients with suspected rotator cuff disease who have a contraindication to MRI, in regions where shoulder US expertise is not available. CT is useful for characterizing fractures if more information is needed pre-operatively. It can demonstrate fracture complexity, displacement and angulation, especially with the use of reformations. CT arthrography is a second-line procedure for shoulders with suspected instability or labral disorders, when magnetic resonance (MR) arthrography and MRI are unavailable or contraindicated. US can be used to evaluate the tendons of the rotator cuff and the biceps. It is operator-dependent and limited in evaluation of the other important deep shoulder structures and marrow. It can be used to determine if a partial-thickness or full-thickness rotator cuff tear is present. Shoulder MRI is currently the procedure of choice for evaluation of occult fractures and the shoulder soft tissues, including the tendons, ligaments, muscles, and labrocapsular structures.

MRI can aid in detecting osseous and soft tissue abnormalities that may predispose to or be the result of shoulder impingement. The soft tissue abnormalities in the supraspinatus tendon, subacromial bursa, and biceps tendon are well seen. The osseous lesions include morphologic abnormalities of the acromion, acromioclavicular joint, and coracoacromial ligament. When a tendon has a signal intensity abnormality without focal disruption or associated findings to suggest a partial-thickness tear, the terms "tendinosis" or "tendinopathy" have been used to signify an underlying tendon degeneration or inflammation. These terms suggest that there is a chronic, often pre-existing degenerative process. The presence of tendinous enlargement and a heterogeneous signal pattern that demonstrates diffuse increased signal intensity on T1- weighting often with a slight increase in signal intensity on T2-weighting, is seen in patients with tendinosis. Partial-thickness tears of the rotator cuff can be seen inferiorly at the articular surface, superiorly at the bursal surface, or within the tendon substance. Tears at the articular surface are the most common type of partial-thickness tears. These are the only types of partial-thickness tears demonstrated by conventional shoulder arthrography. Full-thickness tears of the rotator cuff tendons can be accurately identified using conventional non-arthrographic MRI with high sensitivity and specificity. Increased signal intensity extending from the inferior to the superior surface of the tendon on all imaging sequences is an accurate sign of a full-thickness rotator cuff tear. Ten percent of rotator cuff tears will only present with morphologic changes. Tendon retraction, muscle atrophy, and fatty infiltration are important prognosticators. This type of information can be useful for decisions regarding conservative versus operative repair, type of operative repair (open, mini open, or arthroscopic cuff repair; substitute or muscle transfer) and to provide a postoperative prognosis. If there is any question concerning the distinction between a full-thickness and partial-thickness tear, MR arthrography is recommended. It is particularly helpful if the abnormal signal intensity extends from the undersurface of the tendon.

The shoulder joint is the most unstable joint in the body. Instability can be difficult to diagnose, and the pain produced by the unstable shoulder could be mistaken for that of shoulder impingement, cervical disc disease, acromioclavicular joint disease, and other processes. During the last decade, MRI has allowed for direct visualization of many of the lesions related to instability, aiding in diagnosis as well as therapeutic planning and follow-up. Although high resolution non-enhanced MRI has been shown to have high accuracy rates for demonstrating labral tears, direct MR arthrography with intra-articular injection of a dilute gadolinium solution has gained popularity during the last decade because of its ability to distend the joint and outline labral and capsular structures as well as the undersurface of the rotator cuff.

Abbreviations

• AP, anteroposterior
• CT, computed tomography
• MRI, magnetic resonance imaging
• MVA, motor vehicle accident
• 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.

Selection of appropriate radiologic imaging procedures for evaluation of patients with shoulder trauma

Not stated

An 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 exams 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.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Steinbach LS, Daffner RH, Dalinka MK, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Shoulder trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 6 p. [37 references]

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

1995 (revised 2005)

American College of Radiology - Medical Specialty Society

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: Lynne S. Steinbach, MD; Murray K. Dalinka, MD; Richard H. Daffner, MD; Arthur A. DeSmet, 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; 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: Newberg A, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen TG, Keats TE, Manaster BJ, Pavlov H, Haralson RH, McCabe JB, Sartoris D. Shoulder trauma. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):299-302.

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 January 31, 2006. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents.