American College of Radiology
ACR Appropriateness Criteria®

Chronic Wrist Pain

Variant 1: Chronic wrist pain. With or without prior injury. Best initial study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography wrist Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 2: Chronic wrist pain. Routine radiographs normal or nonspecific. Persistent symptoms. Next 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 12 0 0 2 0 0 0 0 0
Variant 3: Chronic wrist pain. Routine radiographs normal or nonspecific. Suspect inflammatory arthritis. Next 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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US wrist May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 9 2 0 0 1
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 13 0 0 1 0 0 0 0 0
Variant 4: Chronic wrist pain. Radiographs normal or show nonspecific arthritis. Exclude infection. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Aspiration wrist Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 3 6 0 1 0 3 1 1 0 1
US wrist May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 3 5 0 2 0 4 1 1 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 12 0 1 0 1 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 5: Ulnar-sided chronic wrist pain. Radiographs normal or nonspecific. Next 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist May be appropriate ☢ <0.1 mSv 5 5 1 0 0 1 7 1 3 1 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 5 0 4 2 1 2 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Radial-sided chronic wrist pain. Radiographs normal or nonspecific. Next 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist May be appropriate ☢ <0.1 mSv 6 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
US wrist May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 1 0 11 1 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 5 2 2 0 5 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Chronic wrist pain. Radiographs normal or nonspecific. Suspect Kienböck’s disease. Next 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 8: Chronic wrist pain. Kienböck’s disease on radiographs. Next 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 May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 9: Chronic wrist pain. Palpable mass or suspected occult ganglion cyst. Radiographs normal or nonspecific. Next 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 and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 13 0 1 0 0 0 0 0 0
Variant 10: Chronic wrist pain. Suspect occult fracture or stress fracture. Radiographs nondiagnostic. Next 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually appropriate ☢ <0.1 mSv 7 n/a 0 0 0 0 0 0 0 0 0
Radiography wrist additional views May be appropriate ☢ <0.1 mSv 6 6 0 0 0 0 4 5 2 0 2
Tc-99m bone scan with SPECT/CT wrist May be appropriate ☢☢☢ 1-10 mSv 5 5 0 0 1 1 8 0 2 0 1
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 13 0 0 0 1 0 0 0 0
Variant 11: Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next 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 Usually appropriate ☢ <0.1 mSv 8 8 1 0 0 0 1 0 3 3 6
MRI wrist without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 4 4 2
MRI wrist without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 5 3 1 1 3
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 10 1 1 0 1 0 1 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 13 0 1 0 0 0 0 0 0
Variant 12: Chronic wrist pain. Radiographs normal or nonspecific. Suspect carpal tunnel syndrome. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US wrist May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 3 0 1 3
MRI wrist without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 1 0 0 6 3 0 1 2
CT arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
CT wrist with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
CT wrist without IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 12 1 0 0 1 0 0 0 0
CT wrist without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
X-ray arthrography wrist Usually not appropriate ☢ <0.1 mSv 1 1 14 0 0 0 0 0 0 0 0
MR arthrography wrist Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
MRI wrist without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 10 0 1 0 2 0 0 0 0
Tc-99m bone scan wrist Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 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.