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 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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.