Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence-based approach. Part 2: upper extrem

The grades of recommendations (A-D and GPP) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Table 1. Adult Shoulder Disorders

Patient Presentation	Recommendations
Adult patients with full or limited movement and nontraumatic shoulder pain of less than 4-weeks (wk) duration Patients unlikely to require initial radiographic examination if: no precipitating fall, no sudden onset of pain or swelling, no palpable mass or deformity; no pain at rest, and normal range of motion (ROM) (adapted from Fraenkel et al., 2000) prospective validation needed).	Radiographs not initially indicated (B)
General indications for radiographs include: No response to care after 4 wk Significant activity restriction >4 wk Nonmechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment) Red flags indicators Most patients with chronic shoulder pain can be adequately evaluated with a history, physical examination, and plain radiographs.	If radiographs are indicated (C) Anteroposterior (AP) internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane) *Additional views: Posteroanterior (PA) chest view, cervical spine AP and lateral views, Grashey view Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)* Pain and significant disability lasting over 6 mo, despite attention to occupation and sporting factors In the absence of clinical improvement after 4 wk of therapy If function does not improve or deteriorates History of instability, or acute, severe post-traumatic acromioclavicular pain In presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph Special investigations (B) Magnetic resonance imaging (MRI), ultrasonography, computed tomography (CT)
Glenohumeral joint disorders Consult specific clinical diagnoses and related patient presentations for additional help in decision making.
Specific Clinical Diagnoses
1. Rotator cuff disorders (tendinopathy) MC cause of shoulder pain Classified according to its clinical progression: I. Acute inflammation (tendinitis/bursitis) II. Degeneration/chronic inflammation (tendinitis) III. Rupture and arthritis Impingement: Night pain, upper arm pain and tenderness, cuff weakness, atrophy, painful arc, painful crepitation High-sensitivity tests (0.8): Neer, Hawkins, horizontal adduction, Jobe, impingement sign and painful arc High-specificity tests (0.8): drop arm test, yergason, speed, passive external rotation Rotator cuff tear: Traumatic in young people and atraumatic in elderly; there is strong evidence that clinical tests are able to rule-out full tears but have questionable value for partial tears: 3 positive tests or 2 if >60 years of age (YOA) is predictive of a tear: supraspinatus weakness, external rotation weakness, Hawkins	Radiographs not initially indicated (D) Early radiograph if soft tissue calcification is expected If radiographs are indicated (D) AP internal rotation, AP external rotation, axillary view *Additional view: Neer's view (y-scapula) or Acromio-clavicular joint (A-C) joint views Special investigations (C)* MRI is gold standard. Impingement is a dynamic process which may be assessed by US Rotator cuff full and partial thickness tear: MRI, Ultrasound (US), Magnetic resonance arthrography (MRA) improves diagnostic accuracy Calcifying bursitis within cuff tendons: MRI
2. Adhesive capsulitis (frozen shoulder) Onset typically between the ages of 40-65 years (y) Progressive deep joint pain and stiffness of spontaneous onset and restricted activities >50% loss of passive abduction and external rotation, usually loss of all ROM, pain at end range, no local tenderness	Radiographs not routinely indicated (D) Special investigations (D) MRI with direct or indirect arthrogram Distended arthrogram
3. Osteoarthritis (DJD) Usually ≥60 YOA, progressive pain, crepitus, decreased end-ROM, tender joint	Radiographs indicated if (D) Unrelieved by 4 wk of conservative care Suspected underlying specific cause (pathology) AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane) *Additional views*: Supraspinatus outlet view
4. Glenohumeral joint inflammatory arthritis Involved in most forms of inflammatory arthritis (Rheumatoid arthritis [RA], gout, reactive arthritis [Reiter's], Juvenile rheumatoid arthritis [JRA], Ankylosing spondylitis [AS])	Radiographs indicated (D) AP internal rotation, AP external rotation, axillary view *Additional views: Grashey view Advanced imaging and specialist referral recommended (D/GGP)* In suspected septic arthritis, consider MRI promptly for complete assessment of glenohumeral joint, preferably with intraarticular gadolinium
5. Glenohumeral instability Usually between the ages of 20 and 35 y, history (Hx) of dislocation or subluxation, apprehension sign Generalized ligamentous laxity (in multidirectional and voluntary instability)	Radiographs indicated (D) AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane) Advanced imaging and specialist referral recommended (C) Acute setting: conventional MRI Chronic instability: MRA Postoperative shoulder, multislice CT arthrography
Adult patients with significant shoulder/glenohumeral joint trauma Radiographic examination is appropriate if there is trauma sufficient to produce fracture, or dislocation, with accompanying signs/symptoms compatible with fracture or dislocation. Loss of normal shape, palpable mass or deformity Severely restricted shoulder mobility Examination is unable to localize anatomical structure responsible for patient symptoms History of epileptic seizure or electrical shock Clinical decision rule in suspected shoulder dislocation may include: First-time dislocation Blunt trauma (fall >1 flight of stairs, assault, or motor vehicle crash) When the clinician is uncertain of the joint position Clinical decision rule in suspected fracture-dislocation may include: First-time dislocation Blunt trauma (fall >1 flight of stairs, a fight/assault episode, or motor vehicle crash) or a motor vehicle crash Age >40 y * Prospective validation needed	Radiographs indicated (B) AP neutral view (do not move the shoulder), Y-scapula view (lateral in scapular plane), axillary view (if possible) *Additional view: Transthoracic lateral Advanced imaging and specialist referral recommended (D)* Repeat films in 10 days if a fracture remains a possibility after normal initial evaluation or refer for Computed tomography (CT) scan. Callus formation or abnormal alignment may be present. MRI Ultrasound (US) and CT arthrography
A-C joint disorders Teenage to 50 YOA; usually secondary to trauma or osteoarthritis; pain localized to the AC joint and possible swelling	Radiographs not initially indicated in non traumatic origin (C) If radiographs indicated (D) AP view in a 15° cephalic angulation Stress radiographs (bilateral comparison): the value of stress views remains uncertain. Special investigations (D) CT/MRI useful for pathological/surgical cases, especially in separations of types IV-VI as vascular/ neurological complications can result. US if CT and MRI not available

Table 2. Adult Elbow Disorders

Patient Presentation	Recommendations
Adult patients with full or limited movement and nontraumatic elbow pain of less than 4 wk duration	Radiographs not initially indicated (C)
General indications for radiographs include: No response to care after 4 wk Significant activity restriction >4 wk Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment) Red flag indicators History of cancer, signs or symptoms (S&S) of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained elbow pain with no previous films (tumor?) Red skin, fever, systemically unwell (infection?) History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) Trauma, acute disabling pain and significant weakness Unexplained significant sensory or motor deficit (neurological lesion?)	Indicated before other imaging studies (B) AP in full extension, lateral at 90° and medial oblique views *Additional views: AP in pronation, tangential (axial) Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)* Pain and significant disability despite attention to occupation and sporting factors In the absence of clinical improvement after 4 wk of therapy If function does not improve or deteriorates History of instability, or acute, severe posttraumatic injury In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph High-field-strength MRI provides greater detail than mid-field or low-field MR systems CT and US may be more optimal than a low-field magnet in evaluation of the elbow
Chronic elbow pain in the adult patient	Radiographs indicated (C) AP in full extension, lateral at 90° and medial oblique views *Additional views: AP in pronation, tangential (axial) Medical referral recommended and advanced imaging recommended (C)* When the etiology is uncertain and the patient has failed appropriate conservative therapeutic trials (see recommendation above).
Specific Clinical Diagnoses
1. Lateral epicondylitis (tennis elbow) Epicondylar pain AND tenderness at the elbow laterally AND pain on resisted wrist extension—Cozen test: 2. Medial epicondylitis (Golfers' elbow) Epicondylar pain AND tenderness at the elbow medially AND pain on resisted wrist flexion.	Radiographs not initially indicated (C) Special investigations not indicated (C) Radiographs not initially indicated (D) Special investigations not indicated (C)
Adult patients with localized elbow pain following trauma *Elbow extension test: The inability to fully extend the elbow is a reliable indicator of osseous/joint injury Instability tests*: Lateral pivot-shift apprehension test (most sensitive), lateral pivot-shift test, posterolateral rotary drawer test, and stand up test	Radiographs indicated (C) AP in full extension, lateral at 90° and medial oblique views *Additional views (C): AP in pronation, tangential view (axial), lateral stress view Special investigations (GPP)* Increasing use of MRI for the determination of associated injuries of the lateral and medial collateral ligaments and cartilage
Diffuse non-specific pain in the forearm (or wrist)	Radiographs not initially indicated (D)
Forearm pain following trauma	Radiographs indicated (D) AP and lateral views

Table 3. Adult Wrist and Hand Disorders

Patient Presentation	Recommendations
Adult patients with nontraumatic localized wrist and hand pain symptoms	Radiographs not initially indicated (D)
General indications for radiographs include: No response to care after 4 wk Significant activity restriction >4 wk Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)—(e.g., Keinbock's disease) Red flag indicators Signs and Symptoms (S&S) of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained wrist pain with no previous films (tumor?) Red skin, fever, systemically unwell (infection?) History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) (Trauma section) Trauma, acute disabling pain and significant weakness Unexplained significant sensory or motor deficit (neurological lesion at the wrist?) Suspected associated inflammatory arthropathies of wrist and hand Specific indications for radiographs include: Noninvestigated chronic wrist and hand pain Multiple sites of Degenerative joint disease (DJD) as visualized on radiographs Possible Triangular fibrocartilage complex (TFCC) abnormality Possible wrist instability, including perilunate instability, dorsal and volar intercalated segmental instability, scapholunate advanced collapse, scapholunate dissociation, ulnar translocation of the wrist—Trauma section Possible operative candidate Consult clinical presentation with related specific clinical diagnoses for additional help in decision making	If radiographs are indicated (C) PA, lateral, and medial oblique views of the wrist *Additional views: Radial and ulnar deviation views or clenched fist views are reserved for more subtle problems Special investigations (D)* The combination of standard radiographs and US can diagnose a wide variety of disorders. MRI is the procedure of choice to exclude osteonecrosis, marrow, and joint disease including infection.
Specific Clinical Diagnoses
1. Tendinopathy of the wrist Pain and tenderness over a specific tendon or tendon group are the hallmarks of this condition. Other findings include localized swelling, impaired function, crepitus, pain with passive stretching of the tendon, and positive provocative testing. Tendinosis, however, can be asymptomatic.	Radiographs not initially indicated (D) If radiographs are indicated (D) PA, lateral, and medial oblique views of the wrist Consider conventional radiography, in persistent painful "soft tissue injuries," not only to exclude bony injury but also to aid diagnosis (Dx) of rare cases of acute spontaneous calcific peritendinitis of the hand and wrist
2. De Quervain's tenosynovitis (stenosing tenosynovitis or tenovaginitis) Pain over the radial styloid AND tender swelling of first extensor compartment AND EITHER pain reproduced by resisted thumb extension OR positive Finkelstein's test Associated symptoms include warmth and crepitus (Naredo et al, 2002)	Radiographs not initially indicated (D)
3. Carpal Tunnel Syndrome (CTS) Pain OR paraesthesia OR sensory loss in median nerve distribution in at least 2 of the first 4 fingers AND either one positive Tinel's or Phalen's, Thenar atrophy, female gender, obesity (body mass index ≥30), worsening of symptoms at night/awakening, or abnormal nerve conduction time Clinical prediction rule (level IV): Age >45 y Shaking hands for symptom relief Reduced median sensory field of thumb Wrist ratio index (carpal canal volume) >.67 Symptom Severity Scale (SSS) score (Brigham and Women Hospital) >1.9 Likelihood of CTS increase with number of positive tests (18.3 or 90% when all 5 tests positive)	Radiographs not initially indicated (C) Special investigations (D) Advanced imaging reserved for patients with equivocal presentation or with diabetes and diffuse peripheral neuropathy that confounds electrodiagnostic studies MRI may be used to image anatomical abnormality (e.g., space-occupying lesion such as a ganglion). US may be a useful alternative. High-resolution sonography may show median nerve enlargement and increased hypoechogenicity
4. Osteoarthritis History: age >50 y, morning joint stiffness <30 minutes (min) Physical examination: crepitation, bony tenderness, bony enlargement, no palpable warmth Other characteristics include: long standing pain, no extraarticular symptoms; nonresponsive to Nonsteroidal Antiinflammatory Drugs (NSAIDs), or corticosteroid medication; relieved with rest; deformity or fixed contracture, joint effusion; insidious onset	Radiographs not initially indicated (D) It is common to have incomplete concordance between pathologic changes, radiographic and clinical features in osteoarthritis (OA).
5. Inflammatory or crystal induced arthropathy (excluding Rheumatoid arthritis[RA]) Gout, Calcium pyrophosphate dihydrate crystal deposition disease (CPPD), etc Dx of inflammatory arthritis is primarily based on history and physical examination: Unrelenting morning stiffness >30 min Pain at rest Pain or stiffness better with light activity (during remission) Polyarticular involvement, especially the hands Palpable warmth Joint effusion Diffuse tenderness Decreased ROM Fever/chills or other systemic symptoms Responsive to NSAID or corticosteroid medication Flexion contracture in long-standing arthritis	Radiographs indicated (C) PA, lateral, and medial oblique of the wrist and hand Special investigations (C) If routine radiographs are normal or nondiagnostic, MRI is the study of choice; biopsy/aspiration to rule out (R/O) infection Gadolinium-enhanced MRI of the hand and wrist is a superior technique for detection of tenosynovitis in inflammatory arthritis
6. RA Symmetrical involvement of wrist, metacarpophalangeal and proximal interphalangeal finger joints RA diagnostic criteria (≥4/7 required): Morning joint stiffness >1 hour (h) Arthritis involving ≥3 joints for at least 6 wk Hand arthritis (wrist, metacarpophalangeal joint (MCP), proximal interphalangeal joint [PIP]) Symmetric arthritis Rheumatoid nodules Serum Rhesus (Rh) factor Radiographic changes	Radiographs indicated (C) PA, lateral, and medial oblique views of the wrists and hands (Norgaard's/ball catcher projection) Radiographs of the hands, feet, and chest are recommended at the initial evaluation Special investigations (C) MRI is the modality of choice in early Dx and management of RA. MRI helps differentiate erosive from nonerosive disease.
7. Osteonecrosis (avascular necrosis [AVN]) Nonmechanical pain Unrelenting pain at rest Constant or progressive symptoms and signs Pain not reproduced on assessment Swelling, tenderness	Radiographs indicated (C) PA, lateral, and medial oblique Special investigations (D) MRI modality of choice to evaluate bone marrow changes in early stages
8. Complex regional pain syndrome (CRPS) Synonyms: Reflex sympathetic dystrophy Sudek's atrophy At least 4 of the following must be present in order for a Dx of CRPS to be made: Examination findings: Temperature/color change Edema Trophic skin, hair, nail growth abnormalities Impaired motor function Hyperpathia/allodynia Sudomotor changes Associated conditions: Fractures or other trauma Central nervous system (CNS) and spinal disorders Peripheral nerve injury	Radiographs indicated (D) PA, lateral, and medial oblique Special investigations (D) MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities 3-phase Nuclear medicine (NM) scan recommended if radiograph is not diagnostic
9. Suspected Triangular fibrocartilage complex (TFCC) lesion (articular disk) Typically produces ulnar-sided wrist pain, which may become chronic and associated with clicking or popping sounds with certain movements	Radiographs indicated (D) PA, lateral, and medial oblique Special investigations (D) MRI and gadolinium-enhanced MRI
10. Trigger finger (TF) (stenosing tenosynovitis) Intermittent, troublesome locking of the digit in flexion. More common in women 40-60 YOA and in patients with diabetes, RA, gout, and other connective tissue disorders Patients typically present with an insidious onset of morning pain and snapping, clicking, locking, or stiffness in the affected digit. A painful nodule may be palpable at the distal palmar crease. The nodule may move during active movement	Radiographs not initially indicated (D)
Acute wrist trauma in the adult patient The following evaluation helps predict or rule out (R/O) fractures when no deformity is present: Pain on passive and active motion Localized tenderness and edema Pain with grip and resisted supination	Radiographs indicated (C) PA, lateral and pronation-oblique views (medial oblique) of the wrist Additional views (D) PA ulnar deviation (20°), lateral oblique, maximal wrist extension and ulnar deviation Additional views (D) stress tests (include PA with closed fist to stress scapholunate ligament)
A. Carpal navicular (scaphoid) fracture: Accounts for 70%-80% of all carpal fractures; Most common (MC) in young active males Anatomical snuffbox tenderness Longitudinal thumb compression Resisted supination B. Suspected lunate instability: Pain centered over the dorsal wrist immediately ulnar to the extensor carpi radialis tendons; pain and abnormal movement noted on Watson test; Specialized testing may be indicated earlier in such case.	Special investigations (C) Increasing use of MRI as only examination for: Scaphoid fractures Pisiform and hamate Scaphotrapezium-trapezoid joint Scapholunate instability
Acute hand and finger trauma in the adult patient Traumatic injuries to the hand can be evaluated routinely by conventional radiography.	Radiographs indicated (D) Hand: PA, lateral and pronation-oblique (medial oblique) Isolated finger: PA, lateral, pronation-oblique (AP for the thumb) Additional views (GPP) Stress view of the thumb to identify gamekeeper's thumb (possible avulsion fracture of the thumb proximal phalangeal base) Special investigations (D) Consider advanced imaging (MRI, US, or arthrography) in suspected Stener lesion (entrapment of the ulnar collateral ligament) with gamekeeper's fractures.

Definitions:

Levels of Evidence

Classification based on Stroke Prevention and Educational Awareness Diffusion (SPREAD) validated methodological criteria.

1++: High-quality meta-analyses without heterogeneity, systematic reviews of randomized controlled trials (RCTs) each with small confidence intervals CI), or RCTs with very small CI and/or very small alpha and beta

1+: Well-conducted meta-analyses without clinically relevant heterogeneity, systematic reviews of RCTs, or RCTs with small CI and/or small alpha and beta

1−: Meta-analyses with clinically relevant heterogeneity, systematic reviews of RCTs with large CI, or RCTs with large CI and/or alpha or beta

2++: High-quality systematic reviews of case-control or cohort studies. High-quality case-control or cohort studies with very small CI and/or very small alpha and beta

2+: Well-conducted case-control or cohort studies with small CI and/or small alpha and beta

2−: Case-control or cohort studies with large CI and/or large alpha or beta

3: Nonanalytic studies, (e.g., case reports, case series)

4: Expert opinion

− (minus): Meta-analyses with clinically relevant heterogeneity; systematic reviews of trials with large confidence intervals; trials with large CIs, and/or large alpha and/or beta

Grades of Recommendation

This tool has been developed to grade recommendations according to the strength of available scientific evidence (level A to D)

A: At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to the target population; or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+,directly applicable to the target population and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++**

D: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or evidences from trials classified as (minus) regardless of the level

Good practice point: Recommended best practice based on the clinical experience of the guideline development group, without research evidence.

This tool aims to evaluate the scientific evidence according to prespecified levels of certainty (1++ to 4). In this study, Good Practice Point also represents consensus of the Delphi panel. CI indicates confidence intervals.

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