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Appropriateness Criteria

Variant 1: Adult. Chronic hand or wrist pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 9 9 1 0 0 0 0 0 0 1 11
References Study Quality
12 (16932876) 4
11 (21078815) 4
10 (28399787) 4
9 (30171275) 4
8 (34602133) 4
7 (33021575) 4
6 (28737618) 4
US area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 2 0 4 3 2 2 0 0 0
References Study Quality
16 (31421023) 2
15 (28024659) 3
14 (23111854) 4
13 (32115082) 4
11 (21078815) 4
9 (30171275) 4
6 (28737618) 4
18 (34100996) 4
17 (29732587) 4
Radiographic arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 10 0 1 0 1 0 0 0 1
MR arthrography area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 1 0 0 0 0 0
Bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 0 0 0 0 0 0
CT arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 0 1 0 0 0 0 0 0
Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography wrist Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 4 1 3 1 3
References Study Quality
7 (33021575) 4
13 (32115082) 4
18 (34100996) 4
34 (26700348) 2
33 (31387739) 3
32 (27426979) Good
31 (23812413) 3
30 (10194719) 2
29 (28488454) 3
MRI wrist without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 5 7
References Study Quality
44 (34137663) 4
43 (27726753) 4
42 (17177022) 4
41 (26117527) 4
40 (34797695) 3
39 (32372253) 3
38 (29700613) 3
37 (28808768) 3
36 (18762112) 2
32 (27426979) Good
31 (23812413) 3
30 (10194719) 2
13 (32115082) 4
12 (16932876) 4
US wrist May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 3 4 1 2 2
References Study Quality
46 (20566255) 4
18 (34100996) 4
17 (29732587) 4
16 (31421023) 2
14 (23111854) 4
13 (32115082) 4
6 (28737618) 4
Radiography wrist additional views May be appropriate Limited ☢ <0.1 mSv 5 5 2 0 1 3 6 0 0 1 0
References Study Quality
18 (34100996) 4
CT arthrography wrist May be appropriate Limited ☢ <0.1 mSv 5 5 0 1 1 1 7 3 0 0 0
References Study Quality
6 (28737618) 4
18 (34100996) 4
23 (16304116) 2
22 (19233582) 3
21 (18480484) 4
CT wrist without IV contrast May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 2 0 7 4 1 0 0
References Study Quality
6 (28737618) 4
28 (26710736) 3
27 (26553886) 3
26 (33040956) 4
25 (27554667) 2
24 (16615200) 4
Radiographic arthrography wrist Usually not appropriate Limited ☢ <0.1 mSv 1 1 13 0 0 0 0 0 0 0 0
References Study Quality
45 (21467087) M
MRI wrist without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 1 2 0 3 0 0 0 0
References Study Quality
3 (36436971) 4
9 (30171275) 4
35 (16498112) 3
2 (37236743) 4
CT wrist with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 2 1 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 1 1 1 0 0 0 0 0
Bone scan wrist Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 9 1 2 1 1 0 0 0 0
References Study Quality
19 (12364624) 4
20 (19756904) M
Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI hand without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 5 1 1 4 3
References Study Quality
54 (33345693) 2
53 (32558377) 4
52 (30637474) 4
51 (15729562) 4
50 (11818612) 3
49 (27236512) 3
44 (34137663) 4
13 (32115082) 4
US hand May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 5 3 4 1 1
References Study Quality
6 (28737618) 4
17 (29732587) 4
16 (31421023) 2
15 (28024659) 3
14 (23111854) 4
13 (32115082) 4
MRI hand without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 4 1 0 1 6 1 1 0 0
References Study Quality
48 (30978394) 4
47 (28216312) 4
Radiographic arthrography hand Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 10 1 0 1 1 1 0 0 0
MR arthrography hand Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 0 0 1 1 0 0
CT hand with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 10 1 2 1 0 0 0 0 0
CT hand without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 10 1 2 0 1 0 0 0 0
CT hand without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 10 1 0 0 2 1 0 0 0
CT arthrography hand Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 2 1 0 0 1 0 0 0
Bone scan hand Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 1 2 1 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI wrist without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 2 8
References Study Quality
57 (17312277) 2
59 (20858790) 2
CT wrist without IV contrast Usually appropriate Limited ☢ <0.1 mSv 8 8 0 0 0 0 3 1 3 3 4
References Study Quality
27 (26553886) 3
28 (26710736) 3
MRI wrist without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 4 2 1 2
References Study Quality
58 (10628470) 2
57 (17312277) 2
US wrist Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 2 0 0 0 1 0 0
Radiographic arthrography wrist Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 2 0 0 1 0 0 0
MR arthrography wrist Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 1 1 1 1 0 0 0 1
References Study Quality
31 (23812413) 3
56 (17449771) 1
CT arthrography wrist Usually not appropriate Limited ☢ <0.1 mSv 1 1 8 0 2 1 1 1 0 1 0
References Study Quality
22 (19233582) 3
CT wrist with IV contrast Usually not appropriate Limited ☢ <0.1 mSv 1 1 7 4 1 0 0 1 0 0 0
References Study Quality
55 (30183133) 4
CT wrist without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 9 1 1 1 2 0 0 0 0
Bone scan wrist Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 1 2 0 0 0 1 0 0
Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 2 2 2 2
References Study Quality
74 (28666673) 4
73 (34812067) 3
72 (32323256) 4
71 (30635201) 2
70 (25187592) 2
69 (34261588) 4
68 (30702462) Good
67 (28947163) Good
66 (22244369) M
65 (20963527) M
60 (27869627) 4
MRI area of interest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 4 2 0 2
References Study Quality
64 (29799270) 1
63 (31126663) 2
62 (31396669) 1
61 (28075090) 4
60 (27869627) 4
Radiography wrist additional views Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 10 1 1 0 1 1 0 0 0
Radiographic arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 1 0 0 0 0
MR arthrography area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 0 0 1 0 0
Bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 3 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 1 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 0 1 1 0 0 0 0 0
CT arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 1 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 2 8
References Study Quality
6 (28737618) 4
13 (32115082) 4
46 (20566255) 4
80 (33934941) 2
79 (20033358) 3
78 (28960382) 1
77 (31351544) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 11
References Study Quality
13 (32115082) 4
43 (27726753) 4
76 (12740463) 4
77 (31351544) 4
MRI area of interest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 3 8 1 0 0 0
References Study Quality
43 (27726753) 4
75 (16941192) 3
Radiographic arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 0 0 1 0 0 0 0
MR arthrography area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 0 1 0 0 1 0 0
Bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 2 0 1 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 2 1 0 0 0 0 0 0
CT arthrography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.