• Rubin DA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 9 p. [53 references]

This is the current release of the guideline.

This guideline updates a previous version: Rubin DA, Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 8 p. [47 references]

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

Acute hand and wrist trauma

Diagnosis

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 acute hand and wrist trauma

Patients with acute hand and wrist trauma

1. X-ray, wrist, hand, or finger
   • Valgus stress and contralateral comparison, thumb
   • Arthrography, thumb
2. Computed tomography (CT), wrist, hand, or finger, without contrast
3. Magnetic resonance imaging (MRI), wrist, hand, or finger, without contrast
4. Magnetic resonance arthrography (MRA), thumb
5. Nuclear medicine (NUC), technetium (Tc)-99m bone scan, wrist and hand
6. Ultrasound (US), wrist, hand, or finger
7. Cast and repeat x-ray wrist

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.

Not stated

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Review of Published Meta-Analyses
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 1-9, 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 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

Not only can magnetic resonance imaging (MRI) accurately show scaphoid fractures, but in cases where no scaphoid fracture is present, the MRI often demonstrate other, unsuspected fractures of the distal radius or carpus, or soft-tissue injuries. In this role, MRI may be cost-effective, especially if immediate MR examination is performed in lieu of presumptive casting, if MRI is done with a limited protocol and at a reduced charge, and if the total cost of presumptive care, including productivity lost from work, is included in the analysis.

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 Hand or Wrist Trauma

Variant 1: Wrist trauma, first exam.

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

Variant 2: Suspect acute distal radius fracture. Radiographs normal. Next procedure.

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

Variant 3: Comminuted, intra-articular distal radius fracture on radiographs. Surgical planning

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

Variant 4: Suspect acute scaphoid fracture, first exam.

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

Variant 5: Suspect acute scaphoid fracture. Radiographs normal. Next procedure.

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

Variant 6: Suspected occult scaphoid fracture. Initial radiographs and repeat radiographs after 10-14 days of casting normal. Continued clinical suspicion of scaphoid fracture. Next procedure.

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

Variant 7: Suspect distal radioulnar joint subluxation.

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

Variant 8: Suspect hook of the hamate fracture. Initial radiographs normal or equivocal.

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

Variant 9: Suspect metacarpal fracture or dislocation.

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

Variant 10: Suspect phalangeal fracture or dislocation.

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

Variant 11: Suspect thumb fracture or dislocation.

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

Variant 12: Suspect gamekeeper injury (thumb MCP ulnar collateral ligament injury).

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

Summary of Literature Review

For most patients with trauma of the hand, wrist, or both, radiographs provide adequate diagnostic information and guidance for the treating physician. However, in one large study, wrist fractures, especially those of the distal radius and scaphoid, accounted for more delayed diagnoses than any other traumatized region in patients with initially normal emergency room radiographs. Thus, when initial radiographs are equivocal, or in the presence of certain clinical or radiographic findings, further imaging is appropriate. This may be as simple as additional radiographic projections, or it may include sonography, bone scintigraphy, computed tomography (CT), or magnetic resonance imaging (MRI).

As is true for many extremities, a two-view radiographic examination is not adequate for detecting fracture in the wrist, hand, or fingers. In most patients with suspected distal radius fractures, a three-view radiographic examination (posteroanterior [PA], lateral, and 45-degree semipronated oblique) suffices, while a recent study suggests that the routine addition of a fourth projection--a semisupinated oblique projection--would increase the yield for distal radius fractures, which may be visible only on this fourth view. Nevertheless, when high-field or low-field MRI is performed in addition to radiographs, radiographically occult fractures of the distal radius as well as unsuspected fractures of the carpal bones are frequently demonstrated. In injured wrists with normal or suspicious radiographs that do not account for the clinical symptoms, performing MR imaging results in a change in diagnosis in 55% of cases, and a change in management in 66% of cases. However, a recent randomized controlled trial showed that routine performance of an immediate, abbreviated, low-field MRI study in acutely injured wrists did not predict the need for further treatment any better than the combination of physical examination and radiography. Furthermore, there was no statistically significant difference in outcomes measures--including quality of life, time lost from work, and total costs–with this strategy compared to performing radiographs alone. In addition to MRI, multidetector CT can both show radiographically occult carpal fractures and exclude or confirm suspected fractures, when initial radiographs are equivocal, but the panel rated MRI as a more appropriate modality to use before CT, if there are no contraindications to MRI. CT does have an important role in treatment planning when initial radiographs show a complex fracture-dislocation of the carpus.

Successful treatment of distal radius fractures is predicated on re-establishment of radial length, inclination, and tilt, as well as restoration of the articular surfaces. Specifically, the presence of a coronally oriented fracture line, die-punch depression, and more than three articular surface fragments may indicate the need for operative reduction. Less than 2 mm residual step-off of the distal radial articular surface is considered a congruent reduction necessary for good long-term outcome. Most patients with intra-articular fractures of the distal radius develop radiographic radiocarpal osteoarthritis that progresses over time, even when the original fracture was treated with open reduction and internal fixation; however, the development of radiographic osteoarthritis does not correlate with function, even 15 years after initial injury. CT examination reveals involvement of the radiocarpal and distal radioulnar articular surfaces, intra-articular displacements and depressions, and comminuting more accurately than radiographs.

Measurements of articular surface gap and step-off are more reproducible when performed using CT compared with radiographs, and for displacements >2 mm, there is poor correlation between radiographic and CT findings. Thus, in distal radius fractures where there is a high likelihood of intra-articular incongruence (e.g., fractures in young adults, which frequently result from high-energy impact loading), selective or even routine use of CT to supplement the standard radiographic examination is warranted. The distal radial articular surface is best evaluated by multidetector CT with multiplanar reformatted images; if multidetector CT is not available, direct sagittal images can be obtained, but the imaging process may be difficult if the patient has a cast or external fixator. The addition of 3D surface-rendered reconstructions to the standard 2D CT images may increase interobserver agreement and will change planned management of intra-articular distal radius fractures in up to 48% of cases. MRI also shows intra-articular extension of distal radius fractures more frequently than does radiography and demonstrates concomitant intra-articular soft-tissue injuries—predominantly tears of the scapholunate interosseous ligament—that may affect surgical treatment. However, current evidence suggests that MRI performed immediately at the time of injury has no added value for predicting whether additional treatment will be necessary for soft-tissue injuries, and the panel recommends CT over MRI for surgical planning of complex, intra-articular distal radius fractures.

The diagnosis of distal radioulnar joint (DRUJ) subluxation is problematic. The symptoms and physical findings are often nonspecific, and the condition is difficult to confirm radiographically. Traumatic subluxation or dislocation of the DRUJ may occur as an isolated injury or be associated with other conditions. If optimum positioning of the wrist is not possible because of the injury or overlying cast, CT scanning is recommended. Both wrists should be scanned simultaneously in both pronated and supinated positions. While this examination can also be performed with MRI, repositioning the patient and scanning both wrists is logistically more complex, more time-consuming, and less comfortable with MRI compared to CT.

An additional fourth radiographic projection--an elongated PA view with approximately 30 degrees of cephalad beam angulation and the wrist positioned in 10 to 15 degrees of ulnar deviation--is recommended as a routine whenever there is clinical suspicion of a scaphoid fracture. However, scaphoid fractures are notoriously difficult to see on initial radiographs (regardless of the views), being radiographically occult in up to 20% of cases. Standard practice in patients with clinically suspected scaphoid fractures but normal initial radiographs is to apply a cast and to repeat the clinical evaluation and radiographs in 10 to 14 days, when resorption at the fracture line may make previously occult fractures visible. If the repeat radiographs are still normal, or equivocal at that time and there continues to be a strong clinical suspicion of scaphoid fracture, imaging with a second modality -- bone scintigraphy, CT, or MRI -- is indicated. There is little evidence favoring either scintigraphy or CT in this scenario, while a recent meta-analysis found that MRI is superior to scintigraphy for showing occult scaphoid fractures. A survey of worldwide institutions found that MRI is most commonly used in these cases, although many hospitals still do CT or scintigraphy, and the choice of modality often depends on local preferences, expertise, and equipment.

Recent studies have evaluated the role of tomography, ultrasonography, scintigraphy, CT, and MRI (with standard equipment or a dedicated, extremity-only scanner), in uncertain cases of scaphoid fracture at the time of or shortly after the initial injury. If one or more of these studies is sufficiently sensitive and specific, presumptive casting can be eliminated in normal cases, and definitive care can be instituted earlier for fractures.

A tomographic wrist examination using a Panorex machine has been suggested to help clarify cases where the initial four-view radiograph is suspicious, but the panoramic study requires a custom-built adaptor for the wrist, which limits its applicability. Bone scintigraphy, with either delayed images or blood pool images, can be used to identify or exclude radiographically occult scaphoid fractures, but this use of scintigraphy has been largely replaced by MRI, which is both more sensitive and more specific than scintigraphy. Scintigraphic false- positive diagnoses of carpal fractures occur due to bone contusions, osteoarthritis, avascular necrosis, and osteomyelitis, any of which may be radiographically occult. MRI evaluation for radiographically occult scaphoid fractures can be performed with high-field or low-field equipment, using a whole-body imaging system and appropriate local coil, or using a dedicated extremity MR scanner. Not only can MRI accurately show scaphoid fractures, but in cases where no scaphoid fracture is present, the MRI often demonstrate other, unsuspected fractures of the distal radius or carpus, or soft tissue injuries. In this role, MRI may be cost-effective, especially if immediate MR examination is performed in lieu of presumptive casting, if MRI is done with a limited protocol and at a reduced charge, and if the total cost of presumptive care, including productivity lost from work, is included in the analysis.

Ultrasonography with high-frequency transducers can identify some cases of radiographically occult scaphoid fractures; however, the current evidence does not support the routine use of sonography in these cases. Ultrasound (US) examination is not sensitive enough to preclude presumptive casting when no fracture is seen. Furthermore, US only interrogates the dorsal scaphoid waist, while a large proportion of wrists with clinically suspected occult scaphoid fractures in reality have a fracture of the distal radius or other carpal bone (or another portion of the scaphoid); all these cases would be missed if a negative ultrasound examination were used to avoid casting. CT examination is more sensitive and specific than scintigraphy for diagnosing radiographically occult scaphoid fractures, though it is less sensitive (and shows fewer additional fractures) than MRI in this situation. Nevertheless, the panel felt that CT is a reasonable alternative to immediate MRI with a claustrophobic patient or when there is a contraindication to MRI (in cases where a decision has been made not to apply a cast and repeat radiographs).

In summary, radiographically occult scaphoid fractures are relatively common and cause future morbidity when missed. In patients with a strong clinical suspicion of a scaphoid fracture but normal radiographs, the panel feels that either presumptive casting with repeated radiographs in 10 to 14 days or immediate MRI is equally acceptable strategies. The choice will depend on the age, hand dominance, and activity level of the patient, the availability of MRI, and local preferences. If repeat radiographs are normal and the patient remains symptomatic, further imaging is required, and the panel favors MRI as the study of choice. For patients with contraindications to MRI, CT is preferred to scintigraphy.

For the scaphoid bone, not only is identification of the fracture important, but many surgeons recommend immediate operative intervention for displaced scaphoid fractures. As little as 1 mm of displacement is important, resulting in a higher rate of nonunion and avascular necrosis. While CT scanning confined to the direct sagittal plane will underestimate radial or ulnar displacement of scaphoid fractures, evaluations with MRI or multiplanar and/or 3D reconstructions from multidetector CT are more sensitive than standard radiographs for showing small amounts of displacement. In cases where the position of the scaphoid fracture fragments is suspect despite normal radiographs, the panel recommends CT. Similarly, the panel recommends CT examination when there is a question about the age of a scaphoid fracture or its healing.

Compared with the scaphoid, the diagnosis of other carpal bone injuries is less problematic. In specific circumstances, however, supplemental studies in addition to the standard wrist examination are useful. Pisiform fractures are best seen on semisupinated anterior-posterior (AP) or carpal tunnel projections, which project the pisiform volar to the rest of the carpus. The same projections may also demonstrate fractures involving the hook of the hamate that are not visible on the standard radiographs. However, if radiographs fail to show a hamate fracture that is strongly suspected clinically, axial CT examination is indicated.

A standard three-view radiographic examination will reveal most fractures and dislocations of the metacarpals and phalanges. CT may be useful for surgical planning in fracture-dislocations of the carpometacarpal joints. For phalangeal injuries, some practices include a PA examination of the entire hand, while others limit the entire examination to the injured finger. An internally rotated oblique projection in addition to the standard externally rotated oblique may increase diagnostic confidence for phalangeal fractures. Unlike the case for the wrist, low-field MRI is less sensitive than radiographs for hand and finger fractures, and its role is limited to cases where specific abnormalities of the soft tissues – including the collateral ligaments, volar plates, tendons, and pulleys – would affect treatment.

Most fractures of the thumb will be visible on a two-view radiographic examination, although there is a slight increase in diagnostic yield with the addition of an oblique projection, which can be obtained together with a PA examination of the whole hand. Tears of the ulnar collateral ligament of the thumb metacarpophalangeal joint (gamekeeper injury) represent a special problem. Unless there is an associated bony avulsion of the distal metacarpal or proximal phalangeal base, the injury will be radiographically occult. In these cases, a stress examination of the joint with manually applied abduction stress (which can be applied by the patient or the examiner) may show subluxation compared to the contralateral, uninjured side, although there is a theoretical risk of converting a nondisplaced ulnar collateral ligament tear into a displaced one by a stress examination. More important for treatment planning is whether the adductor aponeurosis has become interposed between the torn, displaced ligament and its osseous attachment site--a so-called Stener lesion. Torn ligaments with a Stener lesion require operative repair, while most nondisplaced tears without an interposed aponeurosis will heal with conservative treatment. Conventional arthrography, US, MRI, and MR arthrography have each been advocated to distinguish ulnar collateral ligament tears with and without Stener lesions. The choice of which modality to use will depend on local availability and expertise.

Summary and Recommendations

Radiographs should be the first imaging study in patients with acute wrist, hand, or finger injuries, but the examination must include the correct radiographic projections, which in turn depends on an accurate, site-specific clinical history. Nondisplaced wrist fractures–especially those of the distal radius and scaphoid–may be radiographically occult initially; in cases where there is a strong clinical suspicion of a fracture despite normal radiographs, further evaluation with immobilization and repeat radiographs, CT, or MR imaging is indicated, depending on the clinical circumstances. CT has additional roles for evaluating the articular surfaces in intra-articular fractures and for detecting specific injuries, including fractures of the hook of the hamate, subluxations of the distal radioulnar joint, and fractures and dislocations of the metacarpal bases. For many indications, including scaphoid bone injuries and ligament injuries at the base of the thumb, MR imaging is the most sensitive examination.

Abbreviations

• AP, anterior-posterior
• CT, computed tomography
• MCP, metacarpophalangeal
• Med, medium
• Min, minimal
• MRI, magnetic resonance imaging
• NUC, nuclear medicine
• PA, posteroanterior
• Tc, technetium
• US, ultrasound

None provided

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 acute hand and wrist trauma

Scintigraphic false-positive diagnoses of carpal fractures occur due to bone contusions, osteoarthritis, avascular necrosis, and osteomyelitis.

Relative Radiation Level (RRL)

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 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. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see "Availability of Companion Documents" field).

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

• Rubin DA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 9 p. [53 references]

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

1998 (revised 2008)

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: David A. Rubin, MD; Richard H. Daffner, MD; Barbara N. Weissman, MD; D. Lee Bennett, MD; Judy S. Blebea, MD; Jon A. Jacobson, MD; William B. Morrison, MD; Charles S. Resnik, MD; Catherine C. Roberts, MD; Mark E. Schweitzer, MD; Leanne L. Seeger, MD; Mihra Taljanovic, MD; James N. Wise, MD; William K. Payne, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Rubin DA, Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 8 p. [47 references]

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 summary was updated by ECRI on July 31, 2002. The updated information was verified by the guideline developer on October 1, 2002. This NGC summary was updated by ECRI on January 4, 2006. The updated information was verified by the guideline developer on January 19, 2006. This summary was updated by ECRI Institute on June 25, 2009.