American College of Radiology
ACR Appropriateness Criteria®

Acute Hand and Wrist Trauma

Variant 1: Acute blunt or penetrating trauma to the hand or wrist. 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 Varies 9 9 0 0 0 0 0 0 1 0 13
References Study Quality
11 (9167669) 4
13 (10350289) 3
14 (14573411) 3
15 (8430556) 4
16 (23047281) 4
17 (25455403) 4
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 12 0 0 0 1 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Strong Varies Varies Varies 1 1 12 0 1 1 0 0 0 0 0
References Study Quality
7 (9330135) 2
8 (16757766) 2
9 (9728159) 4
10 (11279570) 4
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 12 0 0 0 1 0 0 1 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 0 1 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 1 0 0
Tc-99m bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 0 0 0 0 0 0 0
Variant 2: Suspect acute hand or wrist trauma. Initial radiographs negative or equivocal. 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 area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 4 7 2
References Study Quality
12 (12594566) 3
22 (24651285) 4
23 (15618379) 2
24 (16118171) 1
25 (14600775) 3
26 (15232430) 4
27 (9638833) 4
Radiography area of interest repeat in 10-14 days Usually appropriate Limited Varies Varies Varies 8 8 0 0 0 0 3 0 4 4 3
References Study Quality
13 (10350289) 3
CT area of interest without IV contrast Usually appropriate Strong Varies Varies Varies 7 7 1 0 0 0 1 0 7 0 5
References Study Quality
7 (9330135) 2
8 (16757766) 2
18 (15290486) 4
19 (25455395) 4
20 (20385675) 4
21 (14623677) 4
22 (24651285) 4
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 11 2 1 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 11 0 1 0 0 2 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 10 0 1 0 1 1 1 0 0
Tc-99m bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 0 0 3 0 0 0 1
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 4 0 1 0 0 0 0
References Study Quality
28 (1806504) 3
29 (11959740) 3
Variant 3: Acute wrist fracture on radiographs. Suspect wrist tendon or ligament trauma. 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] 9 9 0 0 0 0 2 0 2 2 8
References Study Quality
33 (17449771) 1
37 (20467868) 4
45 (12773676) 3
46 (10194719) 2
47 (14610703) 2
48 (11584224) 2
MRI wrist without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 4 7
References Study Quality
35 (16508768) 4
36 (22959873) 3
37 (20467868) 4
38 (22582365) 4
39 (11162698) 4
40 (18762112) 2
41 (19098183) 2
42 (24436792) 2
43 (20012039) 4
44 (27726753) 4
CT arthrography wrist Usually appropriate Strong ☢ <0.1 mSv 7 7 0 0 0 0 4 0 6 4 0
References Study Quality
32 (18480484) 4
33 (17449771) 1
34 (17606063) 2
35 (16508768) 4
36 (22959873) 3
37 (20467868) 4
US wrist Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 5 1 5 1 1
References Study Quality
44 (27726753) 4
49 (16010593) 4
50 (21078815) 4
51 (15252095) 2
52 (14574517) 3
53 (18204008) 3
CT wrist with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 1 0 0 1 1 0 0
CT wrist without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 1 1 0 0
CT wrist without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 2 0 0 0
MRI wrist without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 0 2 1 0 0 1
Tc-99m bone scan wrist Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 0 0
Variant 4: Initial radiographs showing distal radioulnar joint or carpal malalignment in the absence of fracture. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT wrist without IV contrast bilateral Usually appropriate Limited ☢ <0.1 mSv 9 9 1 0 0 0 1 0 2 0 9
References Study Quality
54 (24951208) 4
55 (25148156) 4
MRI wrist without IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 4 2 5
MR arthrography wrist Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 3 1 2 4
References Study Quality
56 (22447235) 4
57 (27183404) 4
CT arthrography wrist May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 0 1 6 2 1 2 1
References Study Quality
56 (22447235) 4
57 (27183404) 4
MRI wrist without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 0 0 1 0 0 0
Tc-99m bone scan wrist Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
US wrist Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 1 0 1 0 1 0 0
CT wrist with IV contrast bilateral Usually not appropriate Limited ☢ <0.1 mSv 1 1 12 0 0 0 0 0 1 0 0
References Study Quality
54 (24951208) 4
55 (25148156) 4
CT wrist without and with IV contrast bilateral Usually not appropriate Limited ☢ <0.1 mSv 1 1 12 0 0 0 0 0 1 0 0
References Study Quality
54 (24951208) 4
55 (25148156) 4
Variant 5: Acute hand fracture on radiographs. Suspect hand tendon or ligament trauma. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 11
References Study Quality
58 (9867179) 3
59 (27726751) 4
60 (7992741) 4
61 (8686601) 3
62 (7997584) 3
63 (8327714) 2
US hand Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 1 3 3 3
References Study Quality
66 (11867797) 3
67 (16315116) 4
CT hand with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 1 0 0 1 0 0 0
CT hand without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 0 0 1 1 0 0 0
CT hand without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 1 0 0 0
MRI hand without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 1 0 0 0 1
References Study Quality
58 (9867179) 3
59 (27726751) 4
60 (7992741) 4
61 (8686601) 3
62 (7997584) 3
63 (8327714) 2
Tc-99m bone scan hand Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 0 0 0 0 0 0 0
Variant 6: Initial radiographs showing metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment in the absence of fracture. 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] 9 9 0 0 0 0 0 1 0 1 11
References Study Quality
58 (9867179) 3
69 (8623637) 4
70 (11012445) 3
73 (8029417) 3
74 (11818612) 3
US hand Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 0 5 3 2
References Study Quality
16 (23047281) 4
66 (11867797) 3
67 (16315116) 4
70 (11012445) 3
75 (12869687) 4
76 (10722814) 2
CT hand with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 1 0 0 0
CT hand without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 0 1 0 1 0 0 0
CT hand without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 1 0 0 0
MRI hand without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 0 0 0 0 1
References Study Quality
58 (9867179) 3
69 (8623637) 4
70 (11012445) 3
73 (8029417) 3
74 (11818612) 3
Tc-99m bone scan hand Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 0 0 0 0
Variant 7: Suspect penetrating trauma with a foreign body in the soft tissues in the hand or wrist. Initial radiographs are negative. 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 Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 2 1 9
CT area of interest without IV contrast Usually appropriate Expert Consensus Varies Varies Varies 7 7 1 0 0 0 3 1 2 3 3
MRI area of interest without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 3 3 2 1
MRI area of interest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 0 5 0 3 0 0 0 0
References Study Quality
82 (27631109) 2
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 12 0 1 1 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies Varies 1 1 11 0 0 0 0 1 1 0 0
Tc-99m bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 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.