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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to assessment and management in primary care. Br J Gen Pract 2015;65:610-2. Review/Other-Dx N/A To describe the assessment and management of elbow pain. No results stated in abstract. 4
2. Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. American Family Physician. 89(8):649-57, 2014 Apr 15. Review/Other-Dx N/A To review the causes and evaluation of patients with elbow pain. No results stated in abstract. 4
3. Kurppa K, Viikari-Juntura E, Kuosma E, Huuskonen M, Kivi P. Incidence of tenosynovitis or peritendinitis and epicondylitis in a meat-processing factory. Scand J Work Environ Health 1991;17:32-7. Review/Other-Dx 338 employees To define the incidence rates of tenosynovitis, peritendinitis, and epicondylitis in specified occupational categories, the typical duration of sick leaves, and the need for job transfers. No results stated in abstract. 4
4. Taljanovic MS, Hunter TB, Fitzpatrick KA, Krupinski EA, Pope TL. Musculoskeletal magnetic resonance imaging: importance of radiography. Skeletal Radiol. 2003;32(7):403-411. Observational-Dx 1,030 MSK MRI studies were performed in 1,002 patients To determine the usefulness of radiography for interpretation of musculoskeletal (MSK) magnetic resonance imaging (MRI) studies. Radiographs were essential, very important or added information in 61-75% of all MSK MRI cases. Radiographs were judged as essential for reading of MRI studies more often for trauma, infection/inflammation and tumors than for degenerative and miscellaneous/normal diagnoses (chi(2)=60.95, df=16, P<0.0001). The clinical information was rated as "essential" or "useful" significantly more often than not (chi(2)=93.07, df=16, P<0.0001). The clinical and MRI diagnoses were the same or partially concordant significantly more often for tumors than for trauma, infection/inflammation and degenerative conditions, while in the miscellaneous/normal group they were different in 64% of cases. When the diagnoses were different, there were more instances in which radiographs were not available. 3
5. O'Driscoll SW. Stress radiographs are important in diagnosing valgus instability of the elbow. J Bone Joint Surg Am. 2002;84-A(4):686; author reply 686-687. Review/Other-Dx N/A Comment on an article regarding long-term results of treatment of fractures of the medial humeral epicondyle in children. No results stated. 4
6. Molenaars RJ, Medina GIS, Eygendaal D, Oh LS. Injured vs. uninjured elbow opening on clinical stress radiographs and its relationship to ulnar collateral ligament injury severity in throwers. J Shoulder Elbow Surg. 29(5):982-988, 2020 May. Review/Other-Dx 74 patients To analyze the relationship between medial joint opening (gapping and excess opening) and ulnar collateral ligament (UCL) injury severity on magnetic resonance imaging, as well as to explore factors related to the unexpected finding of a greater opening of the uninjured elbow compared with the injured elbow (negative excess opening) with valgus stress radiography. Joint gapping was related to UCL injury severity (P = .003), and group-level comparison showed a difference among tear severity groups (P = .050). Excess opening was not significantly related to UCL injury severity (P = .109). A negative excess opening was observed in 22% of patients, but no factors corroborating guarding or a mechanical explanation were significant for a decreased medial joint opening of the injured elbow compared with the uninjured elbow. 4
7. Lee GA, Katz SD, Lazarus MD. Elbow valgus stress radiography in an uninjured population. Am J Sports Med. 1998;26(3):425-427. Review/Other-Dx 20 men (40 elbows) and 20 women (40 elbows) To examine valgus stress radiographs of men and women, none with a history of elbow trauma or instability. The increase in medial ulnohumeral gapping with either gravity or 5 pounds of stress was statistically significant at both extension and 30 degrees of flexion compared with the unstressed condition. The difference in ulnohumeral gapping between gravity stress and 5 pounds of valgus stress in extension and in 30 degrees of flexion was also significant. The authors found no differences with regard to hand dominance or sex. 4
8. Freed JH, Hahn H, Menter R, Dillon T. The use of the three-phase bone scan in the early diagnosis of heterotopic ossification (HO) and in the evaluation of Didronel therapy. Paraplegia. 1982;20(4):208-216. Review/Other-Dx 52 patients To investigate the use of a three-phase bone scan for early detection of HO formation and as a method of evaluating Didronel treatment. There were 23 patients in the series who either showed HO by X-ray on admission or developed HO on follow-up X-rays before beginning Didronel therapy. A three-phase bone scan revealed increased vascularity and accumulation of radioactivity on the bone scan in all areas of ossification on the X-ray and in some areas that did not appear to be involved. The other 29 patients had serial three-phase bone scans, X-ray study, and an alkaline phosphatase determination at approximately 2-week intervals. Didronel treatment was started as soon as the precursor phase of HO was demonstrated on the three-phase bone scan in most of these patients. Nine have not developed ossification that could be seen in X-rays during 3 months of continuing study. Six patients seen at follow-Up during the past year had known HO of 4 to 7 years duration. The three-phase bone scan was used to predict the maturity of HO in these patients. The study indicates that increased vascularity precedes rather than being secondary to HO formation as is suggested in the literature. Didronel treatment appears to be most effective if initiated during this precursor phase. 4
9. Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med. 2002;43(3):346-353. Review/Other-Dx N/A To review current concepts of classification, etiology, pathophysiology, diagnosis, and treatment of heterotopic ossification. Although clinically significant HO occurs infrequently, appropriate use of laboratory and imaging data, particularly alkaline phosphatase values, PGE2, and bone scintigraphy, permits early detection and more successful management of this fascinating yet troublesome ailment. For many patients at risk for HO, either a nonsteroidal anti-inflammatory drug or local radiation therapy is recommended. 4
10. Zubler V, Saupe N, Jost B, Pfirrmann CW, Hodler J, Zanetti M. Elbow stiffness: effectiveness of conventional radiography and CT to explain osseous causes. AJR Am J Roentgenol. 2010;194(6):W515-520. Observational-Dx 94 consecutive patients (71 men, 23 women; mean age, 41 years; range, 18-68 years) To evaluate the effectiveness of conventional radiography and CT for explaining the osseous causes of elbow stiffness. Analysis of loose bodies and osteophytes on conventional radiography and CT by two independent readers. Accuracy for detecting loose bodies was 67% with conventional radiography and 79% with CT. Accuracy for detecting osteophytes was 69% with conventional radiography and 76% with CT. CT more effective than conventional radiography. 2
11. Ouellette H, Kassarjian A, Tetreault P, Palmer W. Imaging of the overhead throwing athlete. Semin Musculoskelet Radiol. 2005;9(4):316-333. Review/Other-Dx N/A Review overhead throwing biomechanics as they relate to diagnostic imaging of throwing athletes. The elbow is typically injured secondary to excessive valgus forces during throwing. The UCL, ulnar nerve, and common flexor tendon origin are all at increased risk of injury. Capitellar osteochondral injuries and loose intra-articular bodies are also frequent. 4
12. Quinn SF, Haberman JJ, Fitzgerald SW, Traughber PD, Belkin RI, Murray WT. Evaluation of loose bodies in the elbow with MR imaging. J Magn Reson Imaging. 1994;4(2):169-172. Observational-Dx 20 patients Review of 20 patients with clinical suspicion of intra-articular body(s) that had both MRI of the elbow and subsequent arthroscopic surgery. MRI was compared with arthroscopic findings. Sensitivity for showing loose bodies with MRI was 100%, and the specificity was 67%. MRI was positive in 16 cases; only 14 were found to have loose body at surgery. MRI and arthroscopy were negative for loose body in four cases. 3
13. Grainger AJ, Elliott JM, Campbell RS, Tirman PF, Steinbach LS, Genant HK. Direct MR arthrography: a review of current use. Clin Radiol. 2000;55(3):163-176. Review/Other-Dx N/A Review use of MR arthrography throughout the body, including the elbow. MR arthrography is useful for demonstrating loose osteochondral fragments, loose bodies, and collateral ligament tears. 4
14. Steinbach LS, Palmer WE, Schweitzer ME. Special focus session. MR arthrography. Radiographics. 2002;22(5):1223-1246. Review/Other-Dx N/A Direct MR arthrography with injection of saline solution or diluted gadolinium can be useful for evaluating certain pathologic conditions in the joints. MR arthrography is useful for demonstrating ligamentous abnormality and bodies in the elbow joint. 4
15. Lee HI, Koh KH, Kim JP, Jaegal M, Kim Y, Park MJ. Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinico-radiologic correlation. J Shoulder Elbow Surg. 27(8):1349-1356, 2018 Aug. Review/Other-Dx 20 patients To characterize the clinical manifestations of this syndrome and to investigate the clinical outcomes of arthroscopic surgery. Plicae were located on the anterior side in 1 patient, on the posterior side in 15, and on both sides in 4. Radiocapitellar joint tenderness and pain with terminal extension were observed in 65% of patients. MRI showed enlarged plicae consistent with intraoperative findings. The mean plica thickness on MRI was 3.7 ± 1.0 mm, which was significantly thicker than the normal value. The mean lengths (mediolateral length, 9.4 ± 1.6 mm; anteroposterior length, 8.2 ± 1.7 mm) were also greater than the normal values. The visual analog scale score for pain decreased from 6.3 to 1.0 after surgery. The Mayo Elbow Performance Index and Disabilities of the Arm, Shoulder and Hand scores improved from 66 to 89 and from 26 to 14, respectively. 4
16. Theodoropoulos JS, Dwyer T, Wolin PM. Correlation of preoperative MRI and MRA with arthroscopically proven articular cartilage lesions of the elbow. Clin J Sport Med. 2012;22(5):403-407. Observational-Dx 31 patients To evaluate the usefulness of MRI in detecting elbow articular cartilage injuries through comparison of preoperative MRI and magnetic resonance arthrography (MRA) with arthroscopic findings. The accuracy of MRI was 45% for chondral injuries of the radius, 65% for the capitellum, 20% for the ulna, and 30% for the trochlea. The accuracy of MRA was 45% for chondral injuries of the radius, 64% for the capitellum, 18% for the ulna, and 27% for the trochlea. 2
17. Sonin AH, Tutton SM, Fitzgerald SW, Peduto AJ. MR imaging of the adult elbow. Radiographics. 1996;16(6):1323-1336. Review/Other-Dx N/A Review MRI elbow anatomy and illustrates the range of commonly encountered elbow abnormalities including: disruption/tear of ligaments/tendons, osteochondral injury and intra-articular bodies, and synovial-based processes. Illustrated the utility of MRI in a variety of disorders. 4
18. Mulligan SA, Schwartz ML, Broussard MF, Andrews JR. Heterotopic calcification and tears of the ulnar collateral ligament: radiographic and MR imaging findings. AJR Am J Roentgenol. 175(4):1099-102, 2000 Oct. Observational-Dx 42 patients Compare radiographic and MRI findings to describe the radiographic and MRI appearance of heterotopic calcification in the UCL. Of the 34 patients who underwent surgery, 26 patients (76%) had either partial or complete tears of the UCL. Heterotopic calcification in the UCL may be associated with partial or complete tears. The MRI detection of heterotopic calcification is less sensitive than that of radiography of the elbow. 3
19. Ammann W, Matheson GO. Radionuclide Bone Imaging in the Detection of Stress Fractures. Clinical Journal of Sport Medicine 1991;1:115-22. Review/Other-Dx N/A To review the use of radionuclide imaging for clinical diagnosis of overuse bone injuries. No results stated in abstract. 4
20. Anderson MW.. Imaging of upper extremity stress fractures in the athlete. [Review] [56 refs]. Clin Sports Med. 25(3):489-504, vii, 2006 Jul. Review/Other-Dx N/A To review the most common sites of stress injuries in the upper extremity, their underlying pathophysiology, and their spectrum of imaging findings. Although a three-phase bone scan is highly sensitive in this regard, MRI has become the study of choice at most centers. 4
21. Querellou S, Moineau G, Le Duc-Pennec A, et al. Detection of occult wrist fractures by quantitative radioscintigraphy: a prospective study on selected patients. Nucl Med Commun. 2009;30(11):862-867. Experimental-Dx 87 patients To determine the value of quantitative radioscintigraphy (QRS) in the diagnosis of wrist trauma occult fractures. From April 2006 to July 2008, 87 patients were enrolled (34 women, 53 men; median age 29 years; range, 15-87 years). Among the 46 pathologic bone scintigrams, 55 occult fractures were highlighted. At follow-up, none presented non-union. One had an undetermined QRS. Among the 40 negative results for QRS at follow-up, only one had a non-union. Sensitivity and negative predictive value were 97 and 98%, respectively for carpal fractures.This study highlights the benefit of QRS, which allows the detection of most occult carpal fractures and reduces the risks of complications such as pseudoarthritis. 3
22. Haapamaki VV, Kiuru MJ, Koskinen SK. Multidetector computed tomography diagnosis of adult elbow fractures. Acta Radiol. 2004;45(1):65-70. Review/Other-Dx 56 patients To assess acute phase multidetector CT findings in elbow traumas. A total of 65 fractures and 3 main fracture types were established: 16 (25%) ulnar coronoid process fractures, 13 (20%) radial head fractures, and 12 (18%) humeral supracondylar fractures. 3 main injury mechanisms were falling (38 (68%) patients), falling from high places (6 (11%) patients), and traffic accidents (5 (9%) patients). In 6 (11%) patients, multidetector CT revealed 13 occult fractures in the elbow joint compared to primary radiography. In 4 (7%) patients a displaced fracture fragment was detected in primary radiography, but the origin of the fragment was unclear. In all 4 cases, multidetector CT revealed the origin of the fragment. 4
23. Zuazo I, Bonnefoy O, Tauzin C, et al. Acute elbow trauma in children: role of ultrasonography. Pediatr Radiol. 2008;38(9):982-988. Observational-Dx 14 patients To evaluate the potential diagnostic role of US in children who have sustained elbow trauma with an elbow joint effusion but no fracture seen on initial radiographs. In 7 children US demonstrated a lipohaemarthrosis, and MRI demonstrated a cortical fracture in all these children. Conversely, among the 7 children with simple haemarthrosis seen on US, MRI did not identify a cortical fracture in 6 and demonstrated a cortical fracture in one. 2
24. Pienimaki TT, Takalo RJ, Ahonen AK, Karppinen JI. Three-phase bone scintigraphy in chronic epicondylitis. Arch Phys Med Rehabil. 2008;89(11):2180-2184. Observational-Dx 59 patients To assess the utility of 3-phase bone scintigraphy as a complementary diagnostic method in chronic epicondylitis. The bone uptake of (99m)Tc-HDP of the affected epicondyle was 33% and 17% higher in men and women, respectively, compared with the corresponding healthy epicondyle (P<.001 and P=.007). High bone uptake of (99m)Tc-HDP was associated with better work ability, grip strength, and muscle performance in both sexes but was not correlated with the pain measures. Blood flow phases had a positive correlation with the duration of symptoms and a negative correlation with the bone uptake of (99m)Tc-HDP, grip strength, and work ability. High bone uptake of (99m)Tc-HDP among patients with chronic epicondylitis was associated with better muscle strength, work ability, and arm function. In chronic cases, a higher degree of bone uptake of (99m)Tc-HDP may thus indicate a healing response in the bone tissue. 2
25. Herber S, Kalden P, Kreitner KF, Riedel C, Rompe JD, Thelen M. [MRI in chronic epicondylitis humeri radialis using 1.0 T equipment--contrast medium administration necessary?]. Rofo. 2001;173(5):454-459. Review/Other-Dx 42 patients and 10 elbow joints of healthy controls To evaluate the diagnostic value and confidence of contrast-enhanced MR imaging in patients with lateral epicondylitis in comparison to clinical diagnosis. In 39/42 patients the STIR sequence showed an increased SI of the common extensor tendon. Increased MR signal of the lateral collateral ligament combined with a thickening and a partial rupture or a full thickness tear have been observed in 15/42 cases. A bone marrow edema at the lateral epicondilus was noticed in 6 of the studied patients and a joint effusion in 18/42 patients. After administration of contrast media, the authors noticed an average increase of SI by about 150%. However, enhanced MR imaging did not provide additional information. 4
26. Cha YK, Kim SJ, Park NH, Kim JY, Kim JH, Park JY. Magnetic resonance imaging of patients with lateral epicondylitis: Relationship between pain and severity of imaging features in elbow joints. Acta Orthop Traumatol Turc. 53(5):366-371, 2019 Sep. Observational-Dx 51 patients To determine the inter- and intra-observer reliabilities of magnetic resonance imaging (MRI) for the diagnosis of lateral epicondylitis, to examine whether degree of common extensor tendon (CET) injury is related to other elbow abnormalities on MRI, and to investigate the correlation between elbow abnormalities on MRI and patients' symptoms. Various degrees of CET injuries were found in total of 51 patients. Radial collateral ligament and lateral ulnar collateral ligament (RCL/LCL) was the most common accompanying elbow abnormality other than CET injuries. Inter- and intra-observer agreements of CET and RCL/LUCL injuries on MRI were excellent. There were significant correlation between degrees of CET and RCL/LUCL injuries (correlation coefficient r = 0.667, p < 0.01) and between degree of RCL/LUCL injuries and visual analog 11-point pain box scale (VAS) scores (correlation coefficient r = 0.478, p = 0.033). 2
27. Miller TT, Shapiro MA, Schultz E, Kalish PE. Comparison of sonography and MRI for diagnosing epicondylitis. J Clin Ultrasound. 2002;30(4):193-202. Observational-Dx 11 patients Prospective study to compare the sensitivity and specificity of US with those of MRI in evaluating epicondylitis. Sensitivity for detecting epicondylitis ranged from 64% to 82% for US and from 90% to 100% for MRI. Specificity ranged from 67% to 100% for US and from 83% to 100% for MRI. Used as an initial imaging tool, US might be adequate for diagnosing this condition in many patients. 1
28. Kijowski R, De Smet AA. Magnetic resonance imaging findings in patients with medial epicondylitis. Skeletal Radiol. 2005;34(4):196-202. Review/Other-Dx 13 patients 26 controls A retrospective comparison of the MRI findings of patients with clinically diagnosed medial epicondylitis with the MRI findings of patients of similar age with no clinical evidence of medial epicondylitis. MRI findings of patients with clinically diagnosed medial epicondylitis included thickening and increased T1 and T2 signal intensity of the common flexor tendon and soft tissue edema around the common flexor tendon. The presence of intermediate to high T2 signal intensity or high T2 signal intensity within the common flexor tendon and the presence of paratendinous soft tissue edema were the most specific findings of medial epicondylitis on MRI. 4
29. Jeon JY, Lee MH, Jeon IH, Chung HW, Lee SH, Shin MJ. Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements. Eur Radiol. 28(3):972-981, 2018 Mar. Observational-Dx 60 patients To assess the implications of MR imaging with clinical history in lateral epicondylitis management by evaluating imaging and clinical features in patients with lateral epicondylitis treated conservatively or operatively. MRI-assessed CET and LCL complex abnormalities, muscle oedema, radiocapitellar joint widening, joint effusion/synovitis, pain frequency and intensity differed significantly between the two groups (p < .05) with increased severity in operative group. Persistent pain (OR 12.2, p < .01), CET abnormality on longitudinal plane (OR 7.5, p = .03 for grade 2; OR 22.4, p < .01 for grade 3) and muscle oedema (OR 6.7, p = .03) were major factors associated with operative treatment. Area under the ROC curve of predicted probabilities for combination of these factors was 0.83. 3
30. Festa A, Mulieri PJ, Newman JS, Spitz DJ, Leslie BM. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture. J Hand Surg [Am]. 35(1):77-83, 2010 Jan. Observational-Dx 22 partial and 24 complete distal biceps tendon ruptures To evaluate the effectiveness of MRI in diagnosing partial and complete distal biceps tendon ruptures as determined at the time of surgery. The overall sensitivity and specificity of MRI were 92.4% and 100%, respectively, in detecting distal biceps tendon ruptures. The sensitivity and specificity of MRI for complete tears were 100% and 82.8%, respectively. The sensitivity and specificity of MRI for partial tears were 59.1% and 100%, respectively. 3
31. Bachta A, Rowicki K, Kisiel B, et al. Ultrasonography versus magnetic resonance imaging in detecting and grading common extensor tendon tear in chronic lateral epicondylitis. PLoS ONE. 12(7):e0181828, 2017. Observational-Dx 58 patients To investigate the diagnostic performance and reliability of ultrasonography (US) in detecting and grading common extensor tendon (CET) tear in patients with chronic lateral epicondylitis (LE), using magnetic resonance imaging (MRI) as the reference standard. US showed moderate agreement with MRI in detecting and grading CET tear (? = 0.49). Sensitivity, specificity, and accuracy in CET tear detecting by US were 64.52%, 85.19%, and 72.73%, respectively. PPV and NPV of US were 83.33% and 67.65%, respectively. No patient with unconfirmed CET tear on US had high-grade CET tear on MRI. 2
32. Park G, Kwon D, Park J. Diagnostic confidence of sonoelastography as adjunct to greyscale ultrasonography in lateral elbow tendinopathy. Chin Med J. 127(17):3110-5, 2014. Observational-Dx 28 patients To investigate the diagnostic confidence of sonoelastography as an adjunct to greyscale ultrasonography in lateral elbow tendinopathy. Both the imaging methods had high sensitivity, specificity, and accuracy for diagnosing lateral elbow tendinopathy. Considering the clinical diagnosis of lateral elbow tendinopathy, sonoelastography showed significantly higher diagnostic accuracy (96.4%) than ultrasonography (89.5%, P < 0.01). Quantitative analysis showed objective interpretation of the sonoelastographic images that revealed greater intensity of green and blue pixels in symptomatic elbows (P < 0.01). 3
33. Arslan S, Karahan AY, Oncu F, Bakdik S, Durmaz MS, Tolu I. Diagnostic Performance of Superb Microvascular Imaging and Other Sonographic Modalities in the Assessment of Lateral Epicondylosis. J Ultrasound Med. 37(3):585-593, 2018 Mar. Observational-Dx 44 patients and 25 healthy participants To compare the diagnostic performance of different sonographic modalities for diagnosing lateral epicondylosis. When a cutoff value of hypoechogenicity was used for the mean strain ratio, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rates were 92.0%, 94%.0, 93.9%, 92.2%, and 93.0%, respectively. When a cutoff point of grade 1 was used, the sensitivity, specificity, PPV, NPV, and accuracy rates were 26.0%, 10.0%, 10.0%, 57.5%, and 63.0, for color Doppler imaging; 40.0%, 10.0%, 10.0%, 62.5%, and 70.0% for power Doppler imaging; and 84.0%, 94.0%, 93.0%, 85.5%, and 89.0% for SMI. When a cutoff value of 3.94 was used for the mean strain ratio, the sensitivity, specificity, PPV, NPV, and accuracy rates were 78.0%, 92.0%, 90.7%, 80.7%, and 85.0%, respectively. A statistically significant correlation was detected between SMI, strain elastography, and visual analog scale scores (P < .001). 2
34. de la Fuente J, Blasi M, Martinez S, et al. Ultrasound classification of traumatic distal biceps brachii tendon injuries. Skeletal Radiol. 47(4):519-532, 2018 Apr. Observational-Dx 120 patients To analyze ultrasound findings in patients with distal biceps brachii tendon (DBBT) injuries to assess the sensitivity of ultrasound in detecting the different forms of injury, and to compare ultrasound results with magnetic resonance imaging (MRI) and surgical results. For major DBBT injuries (complete tears and high-grade partial tears), the concordance study between exploration methods and surgical results found that ultrasound presented a slight statistically significant advantage over MRI (ultrasound: ? = 0.95-very good-95% CI 0.88 to 1.01, MRI: ? = 0.63-good-95% CI 0.42 to 0.84, kappa difference p < 0.01). Minor injuries, in which most tendon fibres remain intact (tendinopathies, elongations and low-grade partial tears), are the most difficult to interpret, as ultrasound and MRI reports disagreed in 12 out of 39 cases and no surgical confirmation could be obtained. 3
35. Lobo Lda G, Fessell DP, Miller BS, et al. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol. 200(1):158-62, 2013 Jan. Observational-Dx 45 consecutive elbow US cases with surgical confirmation and 6 cases of a clinically normal distal biceps tendon To determine the accuracy of US for distinguishing complete rupture of the distal biceps tendon vs partial tear and vs a normal biceps tendon. US showed 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete vs partial distal biceps tendon tears. Posterior acoustic shadowing at the distal biceps had sensitivity of 97% and accuracy of 91% for indicating complete tear vs partial tear and sensitivity of 97%, specificity of 100%, and accuracy of 98% for indicating complete tear vs normal tendon. 3
36. Campbell RE, McGhee AN, Freedman KB, Tjoumakaris FP. Diagnostic Imaging of Ulnar Collateral Ligament Injury: A Systematic Review. Am J Sports Med. 48(11):2819-2827, 2020 09. Review/Other-Dx 15 articles 4
37. Schwartz ML, al-Zahrani S, Morwessel RM, Andrews JR. Ulnar collateral ligament injury in the throwing athlete: evaluation with saline-enhanced MR arthrography. Radiology. 1995;197(1):297-299. Observational-Dx 40 patients Compare MRI findings with surgical findings to determine whether MR arthrography of the elbow can demonstrate precisely an UCL abnormality in the throwing athlete. 18 (95%) of 19 complete UCL tears and 6 (86%) of 7 partial UCL tears were diagnosed with MR arthrography. Two false-negative findings and no false-positive findings were obtained. MR arthrography useful for detection of incomplete ligament tears. 2
38. Magee T. Accuracy of 3-T MR arthrography versus conventional 3-T MRI of elbow tendons and ligaments compared with surgery. AJR Am J Roentgenol. 204(1):W70-5, 2015 Jan. Observational-Dx 54 patients To assess the accuracy of 3-T MR arthrography of the elbow vs conventional 3-T MRI of the elbow, compared with surgery. In 54 patients, the diagnoses made on MRI and MR arthrogram examinations were the same. In 16 patients, MR arthrogram examinations revealed additional findings that were not clearly seen on conventional MRI examinations. There were 6 full-thickness extensor tendon tears, 7 radial collateral ligament tears, and 3 partial-thickness ulnar collateral ligament tears seen on MR arthrography that were not well seen on conventional MRI. In 9 patients, MR arthrogram showed ligaments and tendons to be intact that appeared torn on conventional MRI. There were 6 UCLs and 3 common flexor tendons found to be intact on MR arthrography examination that appeared to be torn on conventional MRI. All MR arthrography findings were confirmed at surgery. 3
39. Roedl JB, Gonzalez FM, Zoga AC, et al. Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players. Radiology. 279(3):827-37, 2016 Jun. Observational-Dx 144 baseball players To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. 2
40. Kijowski R, Tuite M, Sanford M. Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves. [Review] [132 refs]. Skeletal Radiol. 34(1):1-18, 2005 Jan. Review/Other-Dx N/A Part II of this comprehensive review on MRI of the elbow discusses the role of MRI in evaluating patients with abnormalities of the ligaments, tendons, and nerves of the elbow. MRI is useful for detecting tears in the UCL and the LCL, for determining the extent of tendon pathology, for detecting tears of the biceps and triceps and evaluating nerve disorders of the elbow. 4
41. Steinbach LS, Schwartz M. Elbow arthrography. Radiol Clin North Am. 1998;36(4):635-649. Review/Other-Dx N/A Focuses on technique and capabilities of conventional, CT and MR arthrography. MR arthrography is useful for demonstrating loose osteochondral fragments, loose bodies, and collateral ligament tears. CT arthrography with air is recommended for loose bodies. 4
42. Lin DJ, Kazam JK, Ahmed FS, Wong TT. Ulnar Collateral Ligament Insertional Injuries in Pediatric Overhead Athletes: Are MRI Findings Predictive of Symptoms or Need for Surgery?. AJR Am J Roentgenol. 212(4):867-873, 2019 04. Observational-Dx 26 control subjects who were not overhead athletes and 97 overhead athletes. To determine whether ulnar collateral ligament (UCL) insertion below the articular margin (so-called T sign) exists in the pediatric population and whether MRI features can be used to identify insertional UCL injuries in overhead athletes that are symptomatic or require surgery. Mean insertion distance was greater in overhead athletes than in control subjects (1.42 vs 0.23 mm, p = 0.001) but not significantly different in athletes with symptoms compared with those without symptoms or in those who underwent operative treatment compared with those who did not. Mean UCL thickness was greater in overhead athletes than in control subjects (2.64 vs 1.74 mm, p < 0.0001), athletes with than those without symptoms (2.84 vs 2.41 mm, p = 0.005), and athletes who did versus those who did not undergo operative treatment (3.40 vs 2.73 mm, p = 0.011). Marrow (p = 0.002) and soft-tissue (p = 0.016) edema were found more frequently in athletes with symptoms. ROC analysis of UCL thickness and insertion distance as predictors of symptoms showed AUCs of 0.69 and 0.49, respectively. 3
43. Potter HG, Weiland AJ, Schatz JA, Paletta GA, Hotchkiss RN. Posterolateral rotatory instability of the elbow: usefulness of MR imaging in diagnosis. Radiology. 1997;204(1):185-189. Review/Other-Dx 9 controls; 9 patients To evaluate the efficacy of MRI in the assessment of the normal and abnormal ulnar band of the LCL for diagnosis of posterolateral rotatory instability. MRI is an effective tool in the preoperative diagnosis of posterolateral rotatory instability. This includes assessment of the ulnar band of the LCL. 4
44. Hackl M, Wegmann K, Ries C, Leschinger T, Burkhart KJ, Muller LP. Reliability of Magnetic Resonance Imaging Signs of Posterolateral Rotatory Instability of the Elbow. J Hand Surg [Am]. 40(7):1428-33, 2015 Jul. Observational-Dx Group 1: 30 patients with unstable elbows in which PLRI was confirmed by clinical examination and arthroscopy. Group 2: 30 patients, stable controls. To evaluate radiographic signs of posterolateral rotatory instability (PLRI) on magnetic resonance imaging (MRI). The goal was to establish objective radiographic criteria to aid in the diagnosis of PLRI. In the sagittal view through the radial head, average radiocapitellar incongruity differed significantly between groups 1 and 2. In addition, mean ulnohumeral incongruity in an axial view through the motion axis of the distal humerus showed significant differences between groups. Sagittal views through the tip of the coronoid and coronal views did not reveal significant differences in patients with unstable elbows compared with the control group. 3
45. Tai R, Bolinske T, Ghazikhanian V, Mandell JC. The association of the medial joint vacuum phenomenon with ulnar collateral ligament injury in symptomatic elbows of younger athletes. Skeletal Radiol. 47(6):795-803, 2018 Jun. Observational-Dx 241 consecutive elbow radiographic studies containing AP radiographs with valgus stress of both symptomatic and asymptomatic sides in 234 patients. To determine the prevalence of intra-articular gas (IAG) on elbow radiography and evaluate variables, including IAG, as predictors of UCL injury. IAG only manifested with valgus stress and was demonstrated in 30/482 (6.2%) valgus stress radiographs in 27/234 (11.5%) patients. Overall, 21/241 (8.7%) valgus stress radiographs of the symptomatic elbow demonstrated IAG in 21 patients. A total of 128/241 (53.1%) elbow studies had evidence of UCL injury. MJS IAG (p = 0.0147) and increased MJSD (p = 0.0088) were significantly associated with UCL injury. Patient gender, age, handedness, laterality, sport played, and absolute MJS were not associated with UCL injury. MJS IAG with valgus stress demonstrates a sensitivity of 11.7% and specificity of 98.3% in detecting UCL injury for the symptomatic elbow. 3
46. Park JY, Kim H, Lee JH, et al. Valgus stress ultrasound for medial ulnar collateral ligament injuries in athletes: is ultrasound alone enough for diagnosis?. J Shoulder Elbow Surg. 29(3):578-586, 2020 Mar. Observational-Dx 146 athletes To determine if valgus stress ultrasound would be useful for both identifying medial ulnar collateral ligament (MUCL) tears and assessing the severity of the tears. A higher degree of MUCL injury on MRI was associated with greater joint gapping in the medial elbow on stress ultrasound. At 30° of elbow flexion, the cutoff value for complete MUCL rupture was 0.5 mm (P < .001), with a sensitivity and specificity of 88.1% and 61.5%, respectively. At 90° of elbow flexion, the cutoff value for complete MUCL rupture was 1.0 mm (P < .001), with a sensitivity and specificity of 81.0% and 66.4%, respectively. 2
47. Spinner RJ, Hayden FR, Jr., Hipps CT, Goldner RD. Imaging the snapping triceps. AJR Am J Roentgenol. 1996;167(6):1550-1551. Review/Other-Dx 6 symptomatic and 1 asymptomatic; 12 volunteers Description of use of MRI to aid in delineating the etiology of the snapping elbow and assess the relationships of the medial triceps, ulnar nerve, and medial epicondyle in elbow flexion. MRI can reveal the anatomic structures that cause two snaps with elbow flexion. When clinically indicated, MRI with the elbow fully flexed should supplement standard elbow MRI. 4
48. Aggarwal A, Srivastava DN, Jana M, et al. Comparison of Different Sequences of Magnetic Resonance Imaging and Ultrasonography with Nerve Conduction Studies in Peripheral Neuropathies. World Neurosurg. 108:185-200, 2017 Dec. Observational-Dx 55 patients and 64 nerves To compare the sensitivity of high-resolution USG and MRI (3 T) with nerve conduction study (NCS), which is the gold standard. The diagnostic confidence of the turbo spin echo T2-weighted (T2W) MR sequence was seen to be highest, with a sensitivity of 95.31%, whereas it was 81.25% for USG. Continuity of the nerve in patients with traumatic neuropathy was seen in 65.7% and 62.86% (22/35) nerves on MRI and USG, respectively. T1-weighted and T2W MR sequences were seen to be equally effective in establishing the continuity of the nerve. Increase in the caliber/thickening was seen in 77% of cases on MRI and 73.8% of cases on USG. Neuroma formation was seen equally on both MR and USG in 60.66%. We consistently found low fractional anisotropy (FA) values at the site of disease. 2
49. Breitenseher JB, Kranz G, Hold A, et al. MR neurography of ulnar nerve entrapment at the cubital tunnel: a diffusion tensor imaging study. Eur Radiol. 25(7):1911-8, 2015 Jul. Observational-Dx 46 patients and 20 controls To assess the potential of DTI and tractography to identify, locate and quantify ulnar nerve damage in patients with clinically manifest ulnar neuropathy and compare these results to T2-w MR neurography and electrophysiology as the current gold standards. Patients showed a significant reduction of ulnar nerve FA values at the retrocondylar sulcus (p = 0.002) and the deep flexor fascia (p = 0.005). At tractography, a complete or partial discontinuity of the ulnar nerve was found in 26/40 (65%) of patients. Assessment of T2 neurography was most sensitive in detecting UNE (sensitivity, 91%; specificity, 79%), followed by tractography (88%/69%). 1
50. Keen NN, Chin CT, Engstrom JW, Saloner D, Steinbach LS. Diagnosing ulnar neuropathy at the elbow using magnetic resonance neurography. Skeletal Radiol. 2012;41(4):401-407. Observational-Dx 21 patients and 10 volunteers To evaluate the usefulness of elbow magnetic resonance neurography (MRN) in diagnosing ulnar neuropathy at the elbow. The mean ulnar nerve size in the symptomatic and normal groups was 0.12 and 0.06 cm(2) (P < 0.001). The mean relative signal intensity in the symptomatic and normal groups was 2.7 and 1.4 (P < 0.01). When using a size of 0.08 cm(2), sensitivity was 95% and specificity was 80%. 3
51. Vucic S, Cordato DJ, Yiannikas C, Schwartz RS, Shnier RC. Utility of magnetic resonance imaging in diagnosing ulnar neuropathy at the elbow. Clin Neurophysiol. 117(3):590-5, 2006 Mar. Observational-Dx 52 patients A retrospective, nonblinded study by a single observer to assess the sensitivity of MRI in diagnosing UNE, especially in cases where neurophysiologic studies were non-localizing, determine the spectrum of MRI abnormalities in patients presenting with symptoms and signs of UNE, assess whether MRI findings differ between grades of UNE severity; and to see if MRI findings give an input into the pathological mechanisms of UNE. The sensitivity of MRI at diagnosing UNE was higher than conventional nerve conduction studies, 90% vs 65%, respectively. In addition, the MRI studies were highly sensitive in patients with non-localizing UNE. 3
52. Hold A, Mayr-Riedler MS, Rath T, et al. 3-Tesla MRI-assisted detection of compression points in ulnar neuropathy at the elbow in correlation with intraoperative findings. J Plast Reconstr Aesthet Surg. 71(7):1004-1009, 2018 07. Observational-Dx 39 patients To validate preoperative 3-Tesla MRI results by comparing the MRI findings with the intraoperative aspects during endoscopic-assisted or open surgery. From a total of 41 elbows, there was a complete agreement in 27 (65.8%) cases and a partial agreement in another 12 (29.3%) cases. Cohen's kappa showed fair-to-moderate agreement. 3
53. Terayama Y, Uchiyama S, Ueda K, et al. Optimal Measurement Level and Ulnar Nerve Cross-Sectional Area Cutoff Threshold for Identifying Ulnar Neuropathy at the Elbow by MRI and Ultrasonography. J Hand Surg [Am]. 43(6):529-536, 2018 06. Observational-Dx 30 patients and 28 controls To analyze UNCSA by MRI and US in patients with UNE and in controls. The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm2) as well as for US (17 ± 7 mm2). A cutoff value of 11.0 mm2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients. 3
54. Beltran J, Rosenberg ZS. Diagnosis of compressive and entrapment neuropathies of the upper extremity: value of MR imaging. AJR. 1994; 163(3):525-531. Review/Other-Dx N/A To review value of MRI in the diagnosis of compressive and entrapment neuropathies. MRI is the best technique for accurate delineation of soft-tissue lesions, and is suitable for the diagnosis of compressive and entrapment neuropathies. 4
55. Bordalo-Rodrigues M, Rosenberg ZS. MR imaging of entrapment neuropathies at the elbow. [Review] [94 refs]. Magn Reson Imaging Clin N Am. 12(2):247-63, vi, 2004 May. Review/Other-Dx N/A Review normal anatomy, clinical features, and MRI assessment of nerve entrapment syndromes at the elbow. Specific MRI signs in association with clinical findings can supply an accurate diagnosis. 4
56. Chang KV, Wu WT, Han DS, Ozcakar L. Ulnar Nerve Cross-Sectional Area for the Diagnosis of Cubital Tunnel Syndrome: A Meta-Analysis of Ultrasonographic Measurements. Arch Phys Med Rehabil. 99(4):743-757, 2018 04. Meta-analysis Fourteen trials To examine the performance of sonographic cross-sectional area (CSA) measurements in the diagnosis of cubital tunnel syndrome (CuTS). Among different elbow levels, the between-group difference in CSA was the largest at the medial epicondyle (6.0mm2; 95% confidence interval [CI], 4.5-7.4mm2). The pooled mean CSA in participants without CuTS was 5.5mm2 (95% CI, 4.4-6.6mm2) at the arm level, 7.4mm2 (95% CI, 6.7-8.1mm2) at the cubital tunnel inlet, 6.6mm2 (95% CI, 5.9-7.2mm2) at the medial epicondyle, 7.3mm2 (95% CI, 5.6-9.0mm2) at the cubital tunnel outlet, and 5.5mm2 (95% CI, 4.7-6.3mm2) at the forearm level. The sensitivities, specificities, and diagnostic odds ratios pooled from 5 studies, using 10mm2 as the cutoff point, were .85 (95% CI, .78-.90), .91 (95% CI, .86-.94), and 53.96 (95% CI, 14.84-196.14), respectively. Good
57. Li XY, Yu M, Zhou XL, et al. A method of ultrasound diagnosis for unilateral peripheral entrapment neuropathy based on multilevel side-to-side image contrast. Math Biosci Eng. 16(4):2250-2265, 2019 03 15. Observational-Dx 62 patients and 30 controls To determine if a multilevel side-to-side image contrast ultrasound technique can address shortcoming for the diagnosis of unilateral peripheral entrapment neuropathy. According to the statistical analysis of 62 patients with CTS, CuTS or RNC, the diagnostic thresholds of the cross-sectional area swelling ratio (CSASR) for diagnosis of CTS, CuTS or RNC were 1.22, 1.51 and 1.50, respectively. The surgical therapeutic thresholds of CSASR for the treatment of CTS, CuTS and RNC were 1.48, 1.67 and 3.04, respectively. The diagnostic accuracy rate was 92.9%, and the accuracy for selecting the treatment method was 87.1%. All preoperative ultrasound findings were consistent with the intraoperative findings. 3
58. Pelosi L, Tse DMY, Mulroy E, Chancellor AM, Boland MR. Ulnar neuropathy with abnormal non-localizing electrophysiology: Clinical, electrophysiological and ultrasound findings. Clin Neurophysiol. 129(10):2155-2161, 2018 10. Observational-Dx 15 patients and 13 controls To investigate the utility of nerveultrasound in the diagnostic workup of patients withdiabetes mellitus who had ulnar neuropathy with abnor-mal non-localizing electrophysiology (NL-UN). Ultrasound showed: (a) focal nerve enlargement at the elbow (8/18 nerves), either alone (6) or superimposed upon diffuse nerve abnormality (2); (b) diffuse nerve enlargement without focal abnormality (8/18); (c) segmental abnormality in upper-arm or forearm without extrinsic nerve compression (2/18). 3
59. Deng H, Lu B, Yin C, et al. The Effectiveness of Ultrasonography in the Diagnosis of Spontaneous Hourglasslike Constriction of Peripheral Nerve in the Upper Extremity. World Neurosurg. 134:e103-e111, 2020 Feb. Observational-Dx 19 patients To investigate the ultrasonographic characteristics in hourglasslike constriction of peripheral nerve in the upper extremity and to evaluate the value of ultrasonography in the diagnosis. There were 22 affected nerves involved in 19 patients, including 17 radial neuropathies, 4 median neuropathies, and 1 musculocutaneous neuropathy. The accuracy rate of ultrasonography in diagnosing hourglasslike constriction of upper limb nerve was 87.93%. Ultrasonography showed that the constriction sites were completely consistent with the operation. The ultrasonography characteristics of hourglasslike constriction of upper limb nerves were hourglasslike nerve incompleteness or complete constriction, and the nerves at both ends were thickened, and no compression structure was seen around. All lesions with complete constriction diagnosed by ultrasonography were treated with resection of the lesion with or without graft. In addition, 71.43% with incomplete constriction were treated with neurolysis, and 28.57% with resection of the lesion with direct repair. 3
60. Jacobson JA, Jebson PJ, Jeffers AW, Fessell DP, Hayes CW. Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography--report of three cases. Radiology. 2001;220(3):601-605. Review/Other-Dx 3 patients Review cases of patients who underwent US evaluation of the elbow and subsequent open elbow surgery for symptomatic ulnar nerve dislocation. Dynamic US of the elbow was used to aid in the accurate diagnosis of and differentiation between ulnar nerve dislocation and snapping of the medial triceps muscle. 4
61. Park GY, Kim JM, Lee SM. The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow. Arch Phys Med Rehabil. 2004;85(6):1000-1005. Observational-Dx 13 patients Prospective study to evaluate and compare the morphologic changes of the UNE, using US, between patients with cubital tunnel syndrome and retrocondylar compression syndrome determined with electrodiagnosis. US detected the morphologic changes and the extent of the UNE. 3
62. Schertz M, Mutschler C, Masmejean E, Silvera J. High-resolution ultrasound in etiological evaluation of ulnar neuropathy at the elbow. Eur J Radiol. 95:111-117, 2017 Oct. Review/Other-Dx 234 arms of 117 individuals To assess and compare the relevance of morphological and dynamic variants of the UN (ulnar nerve) and its surrounding structures (UN abnormalities) in symptomatic and asymptomatic patients. Eighty-one percent of the arms with UNE compared to 40% of control (p=0.00001) showed UN abnormalities. While it was dislocated in 49% of arms with UNE compared to in 23% of control (p=0.004). 4
63. Paluch L, Noszczyk B, Nitek Z, Walecki J, Osiak K, Pietruski P. Shear-wave elastography: a new potential method to diagnose ulnar neuropathy at the elbow. Eur Radiol. 28(12):4932-4939, 2018 Dec. Experimental-Dx 34 patients and 38 healthy controls To verify if shear-wave elastography (SWE) can be used to diagnose ulnar neuropathy at the elbow (UNE). The secondary objective was to compare the cross-sectional areas (CSA) of the ulnar nerve in the cubital tunnel and to determine a cut-off value for this parameter accurately identifying persons with UNE. Patients with UNE presented with significantly greater ulnar nerve stiffness in the cubital tunnel than the controls (mean, 96.38 kPa vs. 33.08 kPa, p < 0.001). Ulnar nerve stiffness of 61 kPa, CT to DA stiffness ratio equal 1.68, and CT to MA stiffness ratio of 1.75 provided 100% specificity, sensitivity, positive and negative predictive value in the detection of UNE. Mean CSA of the ulnar nerve in the cubital tunnel turned out to be significantly larger in patients with UNE than in healthy controls (p < 0.001). A weak positive correlation was found in the UNE group between the ulnar nerve CSA and stiffness (R = 0.31, p = 0.008). 1
64. Paluch L, Noszczyk BH, Walecki J, Osiak K, Kicinski M, Pietruski P. Shear-wave elastography in the diagnosis of ulnar tunnel syndrome. J Plast Reconstr Aesthet Surg. 71(11):1593-1599, 2018 11. Observational-Dx 46 patients and 39 healthy controls To verify whether a quantitative analysis of the ulnar nerve stiffness by shear-wave elastography can be used to diagnose ulnar tunnel syndrome (UTS), an ulnar nerve neuropathy at Guyon's canal. Patients with UTS presented with significantly greater nerve stiffness than the controls (mean, 99.41 kPa vs. 49.08 kPa, P < 0.001). No significant intergroup differences were found in the nerve elasticity at DF and MF levels (P < 0.836 and P < 0.881, respectively). An ulnar nerve stiffness value of 80 kPa and G:DF and G:MF ratios equal to 1.5 provided 100% sensitivity, specificity, and positive and negative predictive values in the detection of the syndrome. The mean nerve cross-sectional area in the Guyon's canal was significantly greater in patients than in the controls (4.63 mm2, range, 2-7 mm2 vs. 3.23 mm2, range, 2-5 mm2, P < 0.001). 3
65. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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