Diagnostic Imaging Guideline for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 2: Upper Extremity Disorders

Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines1 

An initial literature review considered 10 clinical questions pertaining to imaging of musculoskeletal conditions to evaluate the pertinence of developing diagnostic imaging guidelines. This initial review led to a research project divided into 9 phases: (1) literature search, (2) independent literature assessment, (3) guideline development specific recommendations, (4) first external review, (5) consensus panel (modified Delphi), (6) public website, (7) second external review, (8) final draft and grading of the recommendations, and (9) dissemination and implementation. Details of this study are published elsewhere.2

Focus 

These diagnostic imaging guidelines concern adult musculoskeletal disorders of the upper extremities where conventional radiography and specialized imaging studies are deemed useful for diagnostic purposes.

Objectives 

Reasons for developing these guidelines include assisting current and future health care providers to make appropriate use of imaging studies, providing indications for the need of imaging studies according to current literature and expert consensus, and assisting in optimizing the utilization of limited available resources. These proposed guidelines are intended to reduce unnecessary radiation exposure and the use of specialized imaging studies, increase examination precision and decrease health care costs–all without compromising quality of care.

Target Users/Setting 

Intended users of the guidelines are chiropractors and other primary health care providers prescribing diagnostic imaging studies. The setting in which these guidelines may be used include private clinics, outpatient clinics, and hospital emergency departments.

Target Population 

The patient population eligible for guideline recommendations are adult patients presenting with musculoskeletal disorders of the upper extremities. Children and pregnant patients are excluded from these guideline recommendations.

Developers 

The proposed guidelines are developed from the results of 9 distinct phases overseen by a research team composed of the 3 investigators with postgraduate education from 3 independent teaching institutions. The guidelines were further developed and peer-reviewed by more than 60 chiropractic clinicians, academics, researchers, and a group of physicians.

Evidence Collection 

Electronic searches in English and French language literature occurred, and cross-references were repeated on 3 different occasions between 2003 and 2006.

Methods for Synthesizing Evidence 

Recommendation Grading Criteria 

The evaluation tool used was designed by the Scottish Intercollegiate Guidelines Network (SIGN) and adapted by the Stroke Prevention and Educational Awareness Diffusion (SPREAD) group.5, 7

Patient Preferences 

Stakeholders and Editorial Independence 

Updating/Revision 

The literature review and the guidelines should be updated every 2 to 3 years.

Potential Benefits and Harm 

Selection of appropriate radiological imaging procedures for evaluation of patients with musculoskeletal disorders of the upper extremities; decrease unnecessary ionizing radiation exposure, decrease costs, and improve accessibility.

Dissemination/Implementation Considerations 

Publication, applying to National Guideline Clearinghouse, Posting of the electronic document on various Web sites (malpractice insurance carriers, outpatient teaching clinics); educational intervention strategies (e-learning, community pilot studies); referral guidelines reinforced by request checking and clinical management algorithms; promotion by national, provincial, and state organizations; and conferences.

Definitions, Patient Presentations, Recommendations, and Rationale 

These topics are integral parts of each 1 of the 3 diagnostic imaging guidelines: lower extremity disorders, upper extremity disorders, and spine disorders. Results of the 9 phases of the research project are published elsewhere.2

Preliminary Considerations and Disclaimer 

Are There Potential Risks Associated with Conventional Radiographs? 

Although somewhat controversial,19, 20, 21, 22 it is important to remember that health hazards of all forms of radiation are cumulative.22, 23, 24, 25, 26, 27, 28, 29 The Biological Effects of Ionizing Radiation (BEIR VII) 2005 report released by the National Academy of Sciences adds further support to the “linear-no-threshold” model of cancer risk from ionizing radiation exposure.30 In summary, this report concludes that ionizing radiation is dangerous even at low doses and that there are no safe limits. Given the potential risks associated with conventional radiographs, only appropriate clinical indications can justify its use. In this regard, the need to confirm pathology, to follow the evolution of a pathology possibly affecting therapy, or to identify a clinically suspected contraindication to manipulative therapy are the best-documented reasons. The benefits of all diagnostic studies must outweigh the risks and the inherent costs to the patient.9, 31, 32, 33, 34, 35, 36, 37, 38, 39

Table 1, Table 2, Table 3 list the patient presentations, recommendations, and comments regarding diagnostic imaging for upper extremity disorders. A list of abbreviations and glossary of terms used in the recommendations is in Appendix A. Appendix B provides a summary of the recommendations. Pertinent information for upper extremity disorders is presented in Appendix C. General indications for advanced imaging are in Appendix D. Typical effective ionized radiation dose for common imaging procedures are listed in Appendix E. Further recommended reading pertaining to magnetic resonance imaging of the upper extremity is offered in Appendix F.

Practical Applications 

•History taking and physical examination should be used to exclude red flags and serious injuries (fracture and/or dislocation).

•Physical examination is important for neurologic screening.

•These guidelines may assists with diagnostic triage (extremity pain with or without restriction of activity of daily living or presence of red flags).

•Radiographs are not initially indicated for nonspecific shoulder, elbow, wrist, and hand pain.

•Consider conventional radiograph after blunt trauma, and if there is no improvement after 4 weeks of consecutive care or increasing disability.

•Consider conventional radiography and specialized imaging in presence of red flags.

Table 1. Adult Shoulder Disorders

	Patient presentation	Recommendations	Comments
	Adult patients with full or limited movement and non traumatic shoulder pain of less than 4 wk duration40, 41	Radiographs not initially indicated (B)	Most cases of acute shoulder pain are of “mechanical” origin and can be managed as acute regional pain.41
	Information from the history may alert to the presence of a rare, underlying serious condition. The reliability and validity of individual features in histories have low diagnostic significance. History, type of pain, and site of pain are the most important features to direct the diagnostic strategy. Every age group exhibits typical specific shoulder problems and diseases.		Radiography is typically not useful for soft tissue disorders such as bursitis, tendinosis, capsulitis, glenoid cartilage tear, myofascial pain syndrome, polymyalgia rheumatica, or referred pain. Referred pain from the neck is common. Other sources include: chest wall, myocardium, and diaphragm.44
	A comprehensive assessment of shoulder outcomes would include a generic measure of health-related quality of life, a shoulder-specific measure of function, and a measure of patient satisfaction.42 See Appendix C [A] for details		Shoulder pain cumulative lifetime prevalence is ∼10%, making it the third most commonly experienced type of musculoskeletal pain, exceeded only by low back and neck pain. The prevalence is highest in the 40-65–year age bracket, among women, manual workers and certain ethnic groups. Point prevalence is between 6.9 and 26%, 1-mo prevalence is 18.6-31%, and 12-mo period prevalence is 16%-47%. Approximately 1% of the adult population is expected to visit a general practitioner annually for shoulder pain and the incidence of reported shoulder complaint is 19.0 per 1000 person-years. Fifty percent of acute shoulder pain resolves in 8-10 wk, but as many as 40% of cases may be persisting for longer than 1 year.
	Physical examination is used primarily to discriminate between articular involvement and referred pain. Examination should include the cervical spine, chest wall and elbow joint.
	Patients unlikely to require initial radiographic examination if there is: no precipitating fall; no sudden onset of pain or swelling; no palpable mass or deformity; no pain at rest; and normal ROM (adapted from Fraenkel 2000—prospective validation needed)43
	Poorer prognosis is associated with increasing age, female sex, severe or recurrent symptoms at presentation, higher shoulder disability score, and associated neck pain. A more favorable prognosis is associated with mild trauma or overuse before onset of pain, early presentation and acute onset.44, 45		In “well functioning” 70-79-year-old patients, neck and shoulder pain seem to occur in conjunction with pain in other joints and comorbidity. Nearly 20% reported having some shoulder pain for over 1-mo duration in the past year.41, 44, 45, 46, 47, 48
	See Appendix C [B]. Factors predicting chronic shoulder pain and risk factors for long-term employee absenteeism.
	General indications for radiographs include40, 41, 44, 49	If radiographs are indicated51: (C)	Critical exclusionary diagnoses include:
	• No response to care after 4 wk.		• Osteonecrosis
	• Significant activity restriction >4 wk	1. AP internal rotation	• Septic arthritis
	• Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)	2. AP external rotation	• Acute fractures and avulsion fractures
			• Malignant tumors
		3. Axillary view	• Pain radiating from the chest (myocardial ischemia)
	• Red flags indicators:	4. Y-scapula view
	○ Hx of cancer, S&S of cancer, unexplained deformity, palpable enlarging mass, or swelling, age >50 y, pain at rest, pain at multiple sites, unexplained weight loss, significant unexplained shoulder pain with no previous films (tumor?)	Additional views:	To visualize lung apices if suspect referred pain from pulmonary disease such as Pancoast's tumor or if referred from the neck
		PA chest view, cervical spine AP and lateral views	Grashey view: looks directly down the glenohumeral joint78
		Grashey view	Early access to specialized investigations is unlikely to improve management of a heterogeneous group of shoulder disorders that should usually be managed conservatively.44
	○ Red skin, fever, systemically unwell, immunosupression, penetrating wound, underlying disease process (infection?)	Special investigations not initially indicated: (B)	Specialist referral and specialized imaging recommended even if conventional radiographs are unremarkable if there is6, 41, 43, 44, 49, 50, 51, 52, 53, 54, 55, 56, 57:
	○ History of noninvestigated trauma, epileptic seizure, electrical shock, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Glenohumeral instability?) (see “Glenohumeral instability" and “Adult patients with significant shoulder/glenohumeral joint trauma")		• Pain and significant disability lasting over 6 mo, despite attention to occupation and sporting factors
			• In the absence of clinical improvement after 4 wk of therapy
	○ Trauma, acute disabling pain and significant weakness, positive drop arm test (acute rotator cuff tear?)		• If function does not improve or deteriorates
	○ Unexplained significant sensory or motor deficit (neurological lesion?)		• History of instability or acute, severe post-traumatic acromioclavicular pain
	N. B. Presence of a red flag alone may not necessarily indicate the need for radiography. Most patients with chronic shoulder pain can be adequately evaluated with history, physical examination, and then started on a treatment protocol. If this treatment fails to relieve the symptoms within 4 wk, advanced imaging with MRI may be indicated.50		• In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph.
			The choice of imaging modality can be based on factors such as the importance of ancillary clinical information (regarding lesions of the glenoid labrum, joint capsule, or surrounding muscle and bone), the presence of an implanted device, patient tolerance, and cost.
			• MRI is a sensitive diagnostic tool in secondary care and may increase specificity of Dx. MRI provides best imaging details for evaluation of shoulder pathology (osteonecrosis, marrow and joint disease including infection) but is rarely used in the acute setting.
			• While cost-effective, ultrasonography is operator-dependant; mostly useful for full-thickness rotator cuff tears
			• CT is useful for characterizing fractures if more information is needed (can show fracture complexity, displacement and angulation)
			Chest CT: in case of suspected Pancoast's tumor, CT of the chest is optimal
	Glenohumeral joint disorders
	Global pain and restriction of all activities and passive movements, restricted passive external rotation
	Consult specific clinical diagnoses and related patient presentations for additional help in decision making.
	Specific clinical diagnoses:
	1. Rotator cuff disorders (tendinopathy)40, 44, 58	Radiographs not initially indicated (D)	Radiological analysis in conditions such as subacromial impingement, pathologies of the rotator cuff, and acromioclavicular degeneration should be interpreted in the context of the symptoms and normal age-related changes. Degenerative changes including sclerosis of the medial end of the acromion and the distal end of the clavicle, inferior acromial and clavicular osteophytes, partial and full thickness tears are commonly found during imaging of asymptomatic people.44, 64 Most patients with rotator cuff disorders are older. Ruling out suspected comorbidities is important.
	MC cause of shoulder pain.
	Acute: any age; chronic usually >40 YOA
	• History may reveal occupational heavy lifting, or repetitive movements, especially above shoulder level; genetic susceptibility in some families	Early radiograph if soft tissue calcification is expected.
	• Pain on abduction with thumb down, worse against resistance and painful arc (70°-120°)
	• No history of dislocation, instability, surgery, violent trauma, or other shoulder disorder	If radiographs are indicated (D)
	Classified according to its clinical progression59:	1. AP internal rotation	Radiographs of subjects with a documented rotator cuff tear may have greater tuberosity abnormalities (sclerosis, osteophytes, subchondral cysts and osteolysis) not seen in asymptomatic subjects without a rotator cuff tear.64 Large lateral extension of the acromion appears to be associated with full-thickness tearing of the rotator cuff.65
	I Acute inflammation (tendinitis/bursitis)	2. AP external rotation
	II Degeneration/chronic inflammation (tendinitis)	3. Axillary view
	III Rupture and arthritis	Additional view:
	A. Impingement: night pain, upper arm pain and tenderness, cuff weakness, atrophy, painful arc, painful crepitation.	Y-scapula or A-C joint views
	High-sensitivity tests (0.8): Neer, Hawkins, horizontal adduction, Jobe, impingement sign and painful arc		Potential causes of primary impingement that may be assessed with radiographs include specifically: inferior A-C osteophytes and the type 3 acromion.
	High-specificity tests (0.8): drop arm test, Yergason, speed, passive external rotation52, 60, 61		1. Y-scapula view may show hooked (type 3) acromion
	*Physical examination for impingement syndrome, superior labral tears and rotator cuff tear equally effective as US or MRI59		2. In those with history of A-C joint disease or old trauma, A-C joint view may be part of the workup to R/O bony impingement58
	Differential Dx includes calcific tendinitis, cervical radiculitis and viral plexopathy	Special investigations (C)	A. Impingement is a dynamic process that may be assessed by US
	B. Rotator cuff tear: traumatic in young people and atraumatic in elderly; there is strong evidence that clinical tests are able to R/O full tears but have questionable value for partial tears:52 3 positive tests or 2 if >60 YOA is predictive of a tear: supraspinatus weakness, external rotation weakness, Hawkins.62, 63	MRI is gold standard. Routine preevaluation does not appear to have significant effect on treatment outcome.	B. Rotator cuff full and partial thickness tear: MRI, US are highly accurate for full-thickness tears but much less sensitive and specific for partial tears. MRA improves diagnostic accuracy. The size of rotator cuff tear and degree of fatty muscle degeneration appears to have the most pronounced influence on acromiohumeral distance. Quality of available studies on US is variable.6, 40, 52, 66, 67, 68, 69, 70
	See Appendix C [C] for proposed risk factors for upper extremity tendinopathy including personal, psychosocial, physical, and systemic risk factors.	In addition, abnormal rotator cuff appearance in asymptomatic patients >60 YOA is around 54%.40, 50, 64	C. Calcifying bursitis within cuff tendons: calcifying bursitis can cause severe pain. If conservative treatment fails, consider MRI and referring patient for calcium puncture aspiration under fluoroscopy guidance.71
	2. Adhesive capsulitis (frozen shoulder)	Radiographs not routinely indicated (D)	Radiographs are generally nonspecific (osteopenia may be present); a focal medial indentation along the proximal humeral neck has been reported for adhesive capsulitis. Radiographs are not generally useful to diagnose adhesive capsulitis, but may be used to exclude complicating factors.72
	• Onset typically between the ages of 40-65 y
	• Progressive deep joint pain and stiffness of spontaneous onset and restricted activities such as dressing
	• >50% Loss of passive abduction and external rotation,33 usually loss of all ROM, pain at end range, no local tenderness	Special investigations (D)	• MRI with direct or indirect arthrogram to be considered before manipulation; thickness of capsule and synovium of the axillary recess >3 mm appears to be useful criterion for the Dx of adhesive capsulitis on coronal oblique T2-weighted MRA images without fat suppression73, 74
	Usually idiopathic, but may follow prolonged immobilization, neck surgery, systemic disorders (diabetes), radiation therapy, and cerebral insult		Consider medical referral for distended arthrogram75 or intra-articular corticosteroid injection under fluoroscopy if conservative therapy fails.59
	3. Osteoarthritis (DJD)	Radiographs indicated if: (D)	Outcome from treatment not predicted by use of radiography
	Usually ≥60 years old, progressive pain, crepitus, decreased end-ROM, tender joint	• Unrelieved by 4 wk of conservative care	Possible radiographic findings: humeral osteophytes, narrowed joint space, irregularity of the humeral head, subchondral cysts, and sclerosis at the greater tuberosity in rotator cuff arthropathy
	Specific causes: rotator cuff arthropathy, after anterior dislocation, arthritis, chondrocalcinosis, syringomyelia, systemic disease (RA or AS), primary osteoarthritis (rare), osteonecrosis	• Suspected underlying specific cause (pathology)	Supraspinatus outlet view for hooked acromion or osteophytes76, 77
	Osteonecrosis risk factors that can then lead to DJD: prolonged glucocorticoids, anabolic steroid abuse, humeral head fracture, systemic lupus erythematosus, sickle-cell anemia59	1. AP internal rotation
		2. AP external rotation
		3. Axillary view
		4. Y-scapula view
		Additional view:
		Supraspinatus outlet view
	4. Glenohumeral joint inflammatory arthritis	Radiographs indicated (D)	Although uncommon, the glenohumeral joint may be involved in most forms of inflammatory arthritis. In RA, erosions are usually a late feature.
	Involved in most forms of inflammatory arthritis (RA, gout, reactive arthritis [Reiter's], JRA, AS)40, 49	1. AP internal rotation
	Critical differential Dx: septic arthritis	2. AP external rotation	Grashey view: looks directly down the glenohumeral joint78
	Suspected septic arthritis: prompt referral for joint aspiration recommended for Dx and treatment	3. Axillary view
		Additional view:
		Grashey view
		Special investigations (D/GPP)	Advanced imaging and rheumatologist referral recommended:
			• In suspected septic arthritis, consider MRI promptly for complete assessment of glenohumeral joint, preferably with intra-articular gadolinium.
	5. Glenohumeral instability40, 79	Radiographs indicated (D)	Radiologic findings may be normal or reveal signs of Bankart lesion, Hill-Sachs deformity, loss of joint space. or an anteroinferior glenoid calcification. Neither prereduction nor postreduction films are likely to affect management in emergency departments of patients with recurrent dislocation by an atraumatic mechanism.54, 83
	Usually between the ages of 20 and 35 y, Hx of dislocation or subluxation, positive apprehension sign	1. AP internal rotation
	Generalized ligamentous laxity (in multidirectional and voluntary instability)	2. AP external rotation
	Several types (categories):	3. Axillary view51
	Anterior (MC)	4. Y-scapula view	Acute anterior and posterior dislocation should be referred to an orthopedic specialist even if shoulder is reduced. The arm should be placed in a simple sling. It should be noted that some practitioners with specialized training such as sports or orthopedic diplomates can manage recurrent dislocations. Some also handle first-time dislocations.
	Posterior (dislocation often not recognized)
	Multidirectional
	Voluntary or habitual instability (may be associated with psychological disorders)
	Clinical assessment of joint position; excessive glenohumeral translation produces apprehension, pain, or dysfunction:
		Special investigations (C)	Advanced imaging and specialist referral recommended:
	Although not very sensitive, the anterior drawer, the apprehension, and the surprise tests are specific and predictive of traumatic anterior instability. Apprehension is a better criterion than pain. The relocation test adds little to the value of the tests.80, 81 Positive results suggest involvement of the anterior or the superior glenoid labrum, respectively.82		• In the acute setting, conventional MRI nicely shows labral, Bankart, ligamentous, and tendinous injuries that result from dislocations and can lead to instability. In the setting of chronic instability, MRA best evaluates these lesions. In the postoperative shoulder, multislice CT arthrography may be the modality of choice, but further investigation is needed.84
	Tears of the labrum, the capsule, or the glenohumeral ligaments can lead to pain, catching, popping or instability. The evidence suggests that clinical tests have moderate sensitivity and specificity for instability and labrum tears (quality of studies questionable)52		• Glenoid labrum and synovial cavity well delineated by arthrogram with CT and with MRI.40, 85 Gradient-echo MRI can show labrum without arthrography or proton density fat saturation protocols.6, 40
	Dislocation may result in rotator cuff tears in middle-age or older age groups. Patients may show ongoing symptoms of pain, weakness, and dysfunction.
	See Levine and Flatow62 for additional reading
	Adult patients with significant shoulder/glenohumeral joint trauma40, 44	Radiographs indicated (B)	• R/O fracture-dislocation in blunt trauma and concurrent nerve injuries, especially with anterior dislocation
	Radiographic examination is appropriate if there is trauma sufficient to produce fracture or dislocation with accompanying signs/symptoms compatible with fracture or dislocation.	1. AP neutral view (do not move the shoulder)	• Common occult fractures include avulsion (“flap”) fractures of the greater tuberosity (tubercle).
	• Loss of normal shape, palpable mass or deformity	2. Y-scapula view (lateral in scapular plane)	Y-scapula view: to visualize shoulder dislocation and fracture of the scapula; some dislocations may present subtle signs.
	• Examination is unable to localize anatomical structure responsible for patient symptoms.		Additional views should be taken if fracture is suggested but not found on initial views.
	• Severely restricted shoulder mobility	3. Axillary view (if possible)51
	• History of epileptic seizure or electrical shock
	Shoulder pain clinical decision rule* (adapted from Fraenkel43)	Additional view:x transthoracic lateral
	Patients unlikely to require initial radiographic examination if there is:	Special investigations40, 49 (D)	Advanced imaging and specialist referral recommended:
	1. No precipitating fall and no swelling, palpable mass or deformity;		Repeat films in 10 days if a fracture remains a possibility after normal initial evaluation or refer for CT scan. Callus formation or abnormal alignment may be present.88
	2. A fall, but no swelling, palpable mass or deformity, and no pain at rest		• MRI provides best imaging details for evaluation of shoulder pathology but is rarely used in acute setting.
	3. A fall and pain at rest, but no swelling, palpable mass or deformity and normal ROM		• US and CT arthrography both have a role in soft tissue injury evaluation.
	Clinical decision rule in suspected shoulder dislocation may include* 86:
	• First-time dislocation
	• Blunt trauma (fall >1 flight of stairs, assault, or motor vehicle crash)
	• When the clinician is uncertain of the joint position
	Clinical decision rule in suspected fracture-dislocation may include*87:
	• First-time dislocation
	• Blunt trauma (fall >1 flight of stairs, a fight/assault episode, or a motor vehicle crash
	• Age >40 y
	*Prospective validation needed
	A-C joint disorders	Radiographs not initially indicated in non traumatic origin (C)	The A-C joint is most commonly affected by osteoarthritis, posttraumatic arthritis, and distal clavicle osteolysis. Degenerative changes of the A-C joints are common in the asymptomatic population.40, 64, 89
	Teenage to 50 y of age. Usually secondary to trauma or osteoarthritis. Pain localized to the A-C joint and possible swelling.4
		If radiographs indicated (D)	To exclude an A-C joint separation. Determine normal variation in movement from injured side. There is no real benefit of conventional radiography for types I, II, and III A-C joint dislocations as they confirm the obvious and are normally treated conservatively. Types IV, V, and VI A-C joint dislocations should be referred to an orthopedic surgeon after conventional radiography.90, 91
	A. Acute A-C joint injuries have a limited differential Dx. Traumatic A-C joint injury frequently occurs with other fractures, dislocations, or soft tissue injury around the shoulder. Look for joint deformity, swelling and tenderness, superior clavicular pain, pain with cross body adduction.	AP view in a 15° cephalic angulation,
			The value of stress views remains uncertain.
	Critical differential Dx includes fracture/dislocation, vascular or neurological injuries and gross deformities of A-C joint suggesting high-grade injury.	Stress radiographs (bilateral comparison)57
			Conventional radiography may also help exclude posttraumatic osteolysis in “Weight lifter's shoulder.”
	B. Chronic injuries of the A-C joint also clearly diagnosed by appropriate physical examination and radiographs. Injury to 1 shoulder component predisposes to other shoulder injuries. A thorough examination may reveal other associated abnormalities that may not be part of the presenting complaint. Suspected isolated arthritis (sequela of type II A-C joint injury)	Special investigations (D)
			Conventional radiography is insensitive to A-C joint degenerative changes compared to MRI.92 Reactive bone edema on MRI is a more reliable predictor of symptomatic A-C joint pathology than degenerative changes seen on MRI and, when correlated with clinical examination, is reproducible.90 MRI also allows assessment of adjacent soft tissue structures and their effect on the underlying rotator cuff.92
	C. Impingement syndrome associated with inferior A-C osteophytes and type 3 acromion may be assessed using plain films		• CT/MRI useful for pathological/surgical cases, especially in separations of types IV-VI as vascular/ neurological complications can result.
			• US if CT and MRI not available93

Table 2. Adult Elbow Disorders

	Patient presentation	Recommendations	Comments
	Adult patients with full or limited movement and non traumatic elbow pain of less than 4-wk duration	Radiographs not initially indicated (C)	The incidence of elbow complaints is ∼7.2 per 1000 patients per year and the reported 12 month period prevalence is 11.2% in the Netherlands. Elbow pain accounts for 2%-3% of total lost workdays and 5%-6% of workers' compensation claims.47, 94
	The 2 important diagnoses to consider are lateral and medial epicondylitis. Elbow complaints seldom occur in isolation. Patients often complain of neck, shoulder, arm, or hand problems as well. A complete examination of the upper extremity, including the cervical spine, is recommended.47, 94
			Conventional radiographs usually nondiagnostic for:95
	See Appendix C for proposed risk factors for upper extremity tendinopathy including personal, psychosocial, physical, and systemic risk factors.		• Chronic epicondylitis
			• Suspected nerve entrapment or mass, collateral ligament tear, biceps tendon tear and/or bursitis
			Conventional radiographs may be diagnostic for:95
			• Osteochondral fractures
			• Intra-articular osteochondral body (IAB)
			• Osteochondritis dissecans
			• Heterotopic calcification of the ulnar ligament
	General indications for radiographs include40, 41, 49, 95, 96, 97:	Indicated before other imaging studies (B) AP in full extension, lateral at 90° and medial oblique views
	• No response to care after 4 wk;
	• Significant activity restriction >4 wk;	Additional views:
	• Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)	AP in pronation
	• Red flag indicators	Tangential (axial)
	○ Hx of cancer, S&S of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained elbow pain with no previous films (tumor?)
	○ Red skin, fever, systemically unwell (infection?)	Special investigations (C)	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is:95, 96
	○ History of non-investigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? instability?)		• Pain and significant disability despite attention to occupation and sporting factors
	○ Trauma, acute disabling pain and significant weakness		• In the absence of clinical improvement after 4 wk of therapy
	○ Unexplained significant sensory or motor deficit (neurological lesion?)		• If function does not improve or deteriorates
	N. B. Presence of a red flag alone may not necessarily indicate the need for radiography.		• History of instability or acute, severe posttraumatic injury
			• In presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph
			The choice of imaging modality can be based on factors such as the importance of ancillary clinical information (regarding lesions of the ligament, tendon, muscle, and nerve, or other soft-tissue abnormality such as masses about the elbow joint), the presence of an implanted device, patient tolerance, and cost.
			• High-field-strength MRI provides greater detail than mid-field or low-field MR systems. CT and US may be more optimal than a low-field magnet in evaluation of the elbow.96
			• There is a lack of studies showing the sensitivity and specificity of MRI in many of these cases.95
	Chronic elbow pain in the adult patient95, 97	Radiographs indicated (C)
	May be caused by a variety of osseous abnormalities, soft-tissue abnormalities, or both; exclusion of an abnormality with radiographs may be helpful when conservative therapy is planned. In some cases, the films may reveal the underlying cause (eg, intra-articular osteocartilaginous body, hydroxyapatite deposition or calcium pyrophosphate crystal deposition)	AP in full extension, lateral at 90° and medial oblique views
		Additional views (C)
		AP in pronation
		Tangential (axial)
		Special investigations (C)	Advanced imaging and specialist referral recommended:
			When the etiology is uncertain and the patient has failed appropriate conservative therapeutic trial (see recommendation above)95, 97
	Specific clinical diagnoses:
	1. Lateral epicondylitis (tennis elbow)	Radiographs not initially indicated (C)	Elbow radiographs are generally unremarkable in lateral epicondylitis; although up to 20% of patients can have calcification in the area of the epicondyle.95, 97
	Epicondylar pain and tenderness at the elbow laterally AND pain on resisted wrist extension—Cozen test: Sn: 0.73; Sp: 0.9795, 98		The incidence of lateral epicondylitis is 1%-3% in the general population, generally affecting older men, but the prevalence in high-risk groups is as high as 15%, with women >40 YOA commonly affected. Lateral epicondylitis results in an average of 12 wk of absenteeism in as many as 30% of persons afflicted.47, 95
	Differential diagnoses include lateral collateral ligament tear, radiocapitellar joint instability, bursitis, synovitis, arthritis, chondromalacia, osteochondritis dissecans, stenosis of the orbicular ligament, anconeus compartment syndrome, posterior interosseus nerve or radial nerve radiculopathy, and radial tunnel syndrome.95
		Special investigations not indicated (C)	• MRI and CT are usually not necessary in the clinical evaluation of lateral epicondylitis.94, 99 MRI may be helpful for confirming refractory cases and to exclude associated tendon and ligament tear.95
	2. Medial epicondylitis (Golfers' elbow)	Radiographs not initially indicated (C)	Elbow radiographs are generally unremarkable in medial epicondylitis, although up to 25% of patients can have calcification in the area of the epicondyle.94, 101
	Epicondylar pain and tenderness at the elbow medially AND pain on resisted wrist flexion.100		The prevalence of medial epicondylitis in a work population ranges from 4%-5% with an annual incidence estimate of 1.5%, accounting for 10%-20% of all epicondylitis Dx94
	Differential diagnoses include medial collateral ligament instability or tear, ulnar trochlear synovitis, chondromalacia, arthritis, and cervical radiculopathy.94	Special investigations not indicated (C)	• MRI and CT are usually not necessary in the clinical evaluation of medial epicondylitis. MRI may be helpful for confirming refractory cases and to exclude associated tendon and ligament tear.95
	Adult patients with localized elbow pain after trauma1	Radiographs indicated (C)	Conventional radiography remains the mainstay of imaging when evaluating elbow trauma. Injury may result from direct trauma or force that is transmitted axially from the wrist and forearm.104
		AP in full extension, lateral at 90° and medial oblique views57	Routine reevaluation is not indicated in cases of joint effusion without evidence of fracture.6, 40
	Elbow extension test: the inability to fully extend the elbow is a reliable indicator of osseous/joint injury (Sn: 0.97; Sp: 0.69)102
		Additional views (C)	To reveal joint effusion, fracture/dislocation (look for a displaced anterior fat pad outward from the humerus [“sail sign"]). A significant joint effusion is associated with a radial head fracture in 80% of cases. A visible posterior fat pad should be considered a radial head fracture until proven otherwise.
	Instability tests—lateral pivot-shift apprehension test (most sensitive), lateral pivot-shift test, posterolateral rotary drawer test, stand up test103	AP in pronation
		Tangential view (axial)	• MRI is increasingly used for the determination of associated injuries of the lateral and medial collateral ligaments and cartilage
		Lateral stress view
		Special investigations (GPP)
	Diffuse non-specific pain in the forearm (or wrist)	Radiographs not initially indicated (D)	Proximal causes of forearm and wrist pain such as cervical spine and brachial plexus disorders need to be considered. Electrodiagnostic studies may be useful if pain of peripheral origin.
	Pain in the absence of a specific Dx (sometimes includes: loss of function, weakness, cramp, muscle tenderness, allodynia, slowing of fine movements)100
	Forearm pain following trauma	Radiographs indicated (D)	Typically, imaging of the forearm is limited to conventional radiography. Common fractures include Colles', (distal radius and ulna), Smith's (reverse Colles' fracture), Galeazzi's (fracture-dislocation of the distal radius/ulna), nightstick fracture (mid ulnar shaft fracture), and Monteggia fracture (proximal ulnar shaft fracture and displaced radius).104
	Forearm views should be ordered when there is suspicion of abnormality to the mid portion of the radius or ulna. Suspected trauma to either the wrist or elbow requires views of the involved anatomical region.100, 103, 104	AP and lateral views.

Table 3. Adult wrist and hand disorders

	Patient presentation	Recommendations	Comments
	Adult patients with non traumatic localized wrist and hand pain symptoms105, 106	Radiographs not initially indicated (D)	The reported 12 month period prevalence of wrist and hand pain symptoms is 17.5% in the Netherlands.47
	Obtaining a thorough history is essential. Age should be considered, particularly when evaluating chronic wrist pain, because there is a direct relationship between age and cartilage and ligament attrition.107		Ganglion cysts occur 70% of the time on the dorsum of the wrist but can occur on the volar region in the area of the trapeziotrapezoid joint. Imaging is generally not helpful.108
	Standard views of the wrist (flexed fingers) differ from standard views of the hand (fanned fingers).
	General indications for radiographs include40, 41, 49, 106, 109:	If radiographs are indicated (C)	Conventional radiography should be the study of choice and can identify many areas of pathology.
	• No response to care after 4 wk	PA, lateral, and medial oblique views of the wrist or hand
	• Significant activity restriction >4 wk		Critical differential Dx:
	• Nonmechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)—eg, Keinbock's disease	Additional views:	• Osteonecrosis
	• Red flag indicators	Radial and ulnar deviation views or clenched fist views are reserved for more subtle problems107	• Septic arthritis
	○ S&S of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained wrist pain with no previous films (tumor?)		• Osteomyelitis
	○ Red skin, fever, systemically unwell (infection?)		• Acute fractures and avulsion fractures
	○ History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) (see ‘Acute wrist trauma')		• Malignant tumors
	○ Trauma, acute disabling pain and significant weakness	Special investigations (D)
	○ Unexplained significant sensory or motor deficit (neurological lesion at the wrist?)	The combination of standard radiographs and US can diagnose a wide variety of disorders.110	Careful Hx, physical examination, radiograph, US and bone scan usually establish a Dx (definite Dx in 60%, probable Dx in 20%). Additional imaging (arthrography, MRI and CT) increased definite Dx to 80%.100, 112
	○ Suspected associated inflammatory arthropathies of wrist and hand.	MRI is the procedure of choice to exclude osteonecrosis, marrow and joint disease including infection.111
			Advanced imaging and specialist referral recommended:
	Specific indications for radiographs include106:		Some lesions cannot be detected by US (carpal ligaments and triangular fibrocartilage tears as well as cartilage and bone marrow disease) and require advanced modalities (CT, MRI, CT arthrography, and MRA).100, 106, 110
	• Non-investigated chronic wrist and hand pain
	• Multiple sites of DJD as visualized on radiographs		• MRI may be useful for TFCC lesions, carpal ligamentous injuries such as the scapholunate and lunotriquetral ligaments, ulnar impaction syndrome, occult fractures, bone marrow abnormalities, and soft tissue abnormalities but lack sensitivity or accuracy for cartilage defects in the distal radius, scaphoid, lunate, or triquetrum.113, 114
	• Possible TFCC abnormality		• CT to evaluate osseous and articular morphology, healing, cysts, and tumors
	• Possible wrist instability, including perilunate instability, dorsal and volar intercalated segmental instability, scapholunate advanced collapse, scapholunate dissociation, ulnar translocation of the wrist104, 105, 106, 109 (see ‘Acute wrist trauma')		• Bone scan may be useful in assessing AVN and neoplasm.104
	• Possible operative candidate
	See Appendix C [C] for proposed risk factors for upper extremity pain and sickness absence including personal, psychosocial, physical, and systemic risk factors.
	Consult clinical presentation with related specific clinical diagnoses for additional help in decision making.
	Specific clinical diagnoses:
	1. Tendinopathy of the wrist	Radiographs not initially indicated (D)	There is poor evidence to suggest secondary signs on imaging unless associated with arthropathy.
	Tendinosis* and paratendinitis** (stenosing tenosynovitis) are responsible for most clinical disorders of tendons in the upper extremity.115
		If radiographs are indicated (D)	Consider conventional radiography, in persistent painful “soft tissue injuries,” not only to exclude bony injury but also to aid Dx of rare cases of acute spontaneous calcific peritendinitis of the hand and wrist.116
	The Dx of tendinopathy is based primarily on the history and physical examination. Pain and tenderness over a specific tendon or tendon group are the hallmarks of this condition. Other findings include localized swelling, impaired function, crepitus, pain with passive stretching of the tendon, and positive provocative testing. Tendinosis, however, can be asymptomatic.94	PA, lateral, and medial oblique views of the wrist
			While 60% of all cases of tendinopathy are not work related,56 a significant increase in the number of successful work related claims is reported in several countries.117
	* Tendinosis: intratendinous degeneration (commonly caused by aging, microtrauma, vascular compromise)
	** Paratendinitis: inflammation of the outer layer of the tendon (paratenon) alone.
	2. De Quervain's tenosynovitis 2(stenosing tenosynovitis or tenovaginitis)	Radiographs not initially indicated (D)	Proposed physical risk factors94, 100, 117:
			Repetitive, forceful, radial deviation of the wrist with abduction and extension of the thumb and rapid rotational movements of the forearm with repetitive movement and forceful ulnar deviation at the wrist. Associated activities and occupations for De Quervain's include prolonged piano-playing, sewing, knitting, and weaving, carrying heavy object, farm labor, working on a grinding or buffing machine.
	The MC tendinopathy in the wrist predominantly affecting women (10 times more then men), aged 30-50 y; remains a clinical Dx with no indication for routine imaging.94		Nonoccupational risk factors include RA and hormonal changes associated with pregnancy and menopause.
	Pain over the radial styloid and tender swelling of first extensor compartment and either pain reproduced by resisted thumb extension or positive Finkelstein's test.	Special investigations (D)	• Some studies have explored the use of high-resolution US and MRI, but further studies are needed to validate these techniques.104
	Associated symptoms include warmth and crepitus.100
	Differential diagnoses include: osteoarthritis of the 1st carpometacarpal joint, Wartenberg's syndrome, Kienbock's disease, triscaphoid arthritis, and intersection syndrome.94
	∼1/3 of patients may have associated conditions, such as cervical spondylosis, CTS, ganglion, trigger fingers, lateral epicondylitis, and RA.94
	3. Carpal Tunnel Syndrome (CTS)100, 118, 119	Radiographs not initially indicated (C)	MC nerve compression disorder of the upper extremity. Prevalence of 3% among women and 2% among men. Peak prevalence among females ≥55 YOA.119
	Clinical examination and electrodiagnostic studies have been considered the gold standard for Dx of CTS.		Proposed risk factors100, 117:
	Pain or paraesthesia or sensory loss in median nerve distribution in at least 2 of the first 4 fingers (Se: 0.83; Sp:0.45) and either one positive Tinel's (Sn: 0.34; Sp: 0.84, positive PV: 62%, positive LR: 2.3) or Phalen's test (Sn: 0.56-0.63, Sp:0.72-0.83, positive PV: 60%, positive LR: 2.0), Thenar atrophy (Sn: 0.12, Sp:0.99, positive PV: 91%, positive LR: 13), female gender, obesity (BMI≥30), worsening of symptoms at night/awakening, or abnormal nerve conduction time.		Jobs with repetitive forceful gripping; high force and high frequency of repetition; vibration tools; activities that frequently flex or extend the wrist
	Clinical prediction rule (level IV)120:
	1. Age >45 y		Sensory and motor nerve conduction studies have a relatively high sensitivity and modest specificity to assess/document functional status of neurological elements.121, 122
	2. Shaking hands for symptom relief
	3. Reduced median sensory field of thumb	Special investigations (D)	• Advanced imaging reserved for patients with equivocal presentation or with diabetes and diffuse peripheral neuropathy that confounds electrodiagnostic studies.123 MRI may be used to image anatomical abnormality (eg. space-occupying lesion such as a ganglion).114 US may be a useful alternative.57 High-resolution sonography may show median nerve enlargement and accentuated hypoechogenicity.124
	4. Wrist-ratio index (carpal canal volume) >.67
	5. SSS score (Brigham and Women Hospital) >1.9
	Likelihood of CTS increase with no. of positive tests (18.3 or 90% when all 5 tests positive)
	4. Osteoarthritis	Radiographs not initially indicated (D)	It is common to have incomplete concordance between pathological changes, radiographic and clinical features in OA.
	MC locations—1st carpometacarpal joints, distal interphalangeal joints. Less commonly , triscaphe (scaphoid-trapezium-trapezoid) and at the wrist (post traumatic), radiocarpal.100
	History:
	• >50 YOA
	• Morning joint stiffness <30 min
	Physical examination:
	• Crepitation
	• Bony tenderness
	• Bony enlargement
	• No palpable warmth
	Other characteristics include: long-standing pain, no extra-articular symptoms; non-responsive to NSAID or corticosteroid medication; relieved with rest; deformity or fixed contracture, joint effusion; insidious onset.125
	5. Inflammatory or crystal induced arthropathy40, 100, 126 Gout, CPPD, etc (excluding RA)	Radiographs indicated (C)	Findings consistent with inflammatory arthritis: erosions of periarticular/articular surfaces and intra-articular radiodensities associated with erosion and joint effusion
		PA, lateral, and medial oblique of the wrist and hand
	Dx of inflammatory arthritis is primarily based on history and physical examination:		Critical differential Dx100:
	• Unrelenting morning stiffness >30 min		• Septic arthritis
	• Pain at rest		• Osteomyelitis
	• Pain or stiffness better with light activity (during remission)
	• Polyarticular involvement, especially the hands	Special investigations (C)	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
	• Palpable warmth		• If routine radiographs are normal or nondiagnostic, MRI is the study of choice.40, 128 biopsy/aspiration to R/O infection.106
	• Joint effusion		• Gadolinium-enhanced MRI of the hand and wrist is a superior technique for detection of tenosynovitis in inflammatory arthritis.129
	• Diffuse tenderness
	• Decreased ROM
	• Fever/chills or other systemic symptoms
	• Responsive to NSAID or corticosteroid medication
	• Flexion contracture in long standing arthritis.
	See Kainberger et al127 for imaging strategies for baseline documentation of polyarticular involvement.
	6. RA40	Radiographs indicated (C)	Findings consistent with inflammatory arthritis: erosions of periarticular/ articular surfaces and intra-articular radiodensities associated with erosion and joint effusion.
		PA, lateral, and medial oblique views of the wrists and hands
	Symmetrical polyarticular involvement of wrist, metacarpophalangeal and proximal interphalangeal finger joints.	(Norgaard's/ball catcher projection)133	Radiographs of the hands, feet, and chest are recommended at the initial evaluation. Radiographs of the feet and hands should be repeated annually for the first 3 y of disease evolution, and thereafter as deemed appropriate.130
	The total number of affected joints increases over the 1st year of illness.100		In suspected RA, feet radiographs may show erosions even when symptomatic hand (s) appear normal in 23-36% of cases in first 2-3 y of disease.130
	The evaluation and monitoring of RA should be based on a systematic evaluation of a minimum set of parameters including joint pain and inflammation, the patient's global assessment of pain, global assessment of disease, functional disability, acute phase reactants, and radiologic evidence of damage.130		Cervical spine involvement occurs in over half of patients with RA and atlantoaxial subluxation (AAS) develops in over 12% of patients with RA. There is a strong correlation between a Larson erosion score for hand and wrist joint damage >50, RA duration of >10 y, disease onset before age 50, number of previous disease modifying drugs and RA related surgery and AAS. It is important to recognize that many patients acquire AAS in the first 3 y of their disease, but neurological impairments develop after a mean period of 18 y (range, 4-50 y).139, 140, 141, 142
	RA diagnostic criteria (≥4 of 7 required)131, 132:
	• Morning joint stiffness >1 h	Special investigations40, 134, 135, 136 (C)	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
	• Arthritis involving ≥3 joints for at least 6 wk	MRI highly sensitive and often more specific than US; detection of synovial pannus, erosions, cartilage loss, small subchondral cysts and marrow edema distribution
	• Hand arthritis (wrist, MCP, PIP)	MRI, US, and NM all show joint effusion.137, 138	Unless aimed at some specific medical procedure, special investigations should be minimized unless they have some value for the patient.
	• Symmetric arthritis
	• Rheumatoid nodules		• MRI is the modality of choice in early Dx and management of RA.143 MRI helps differentiate erosive from nonerosive disease.127
	• Serum RH factor
	• Radiographic changes		• US more sensitive to detect erosion
			• NM more sensitive for suspected joint infection. (osteomyelitis)135
	7. Osteonecrosis (AVN)	Radiographs indicated (C)	Late effects of AVN may be seen on conventional radiography with increased density.104
		PA, lateral, and medial oblique
	• Keinbock's disease is AVN with associated deformity of the lunate bone.	Special investigations (D)	Advanced imaging and specialist referral recommended:
	AVN is a potentially serious consequence of carpal fracture, particularly of the scaphoid.	MRI modality of choice to evaluate bone marrow changes in early stages.114	MRI, CT, bone scan (high sensitivity but low specificity); gadolinium-enhanced MRI is considered to be the best technique for detecting established AVN.114
	Nonmechanical pain144
	○ Unrelenting pain at rest
	○ Constant or progressive symptoms and signs
	○ Pain not reproduced on assessment
	○ Swelling, tenderness
	8. Chronic Regional Pain Syndrome (CRPS)144	Radiographs indicated (D)	Diffuse osteopenia seen in 70% of cases144
	Synonyms:	PA, lateral, and medial oblique
	• Reflex sympathetic dystrophy syndrome	Special investigations (D)	Advanced imaging and specialist referral recommended:
	• Sudek's atrophy		• MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities.
			• 3-Phase NM scan recommended if radiograph is not diagnostic (Sn: 0.10; Sp: 0.8; positive predictive value: 54%; negative predictive value: 100%)145
	At least 4 of the following must be present in order for a Dx of CRPS to be made145:
	Examination findings
	• Temperature/color change
	• Edema
	• Trophic skin, hair, nail growth abnormalities
	• Impaired motor function
	• Hyperpathia/allodynia
	• Sudomotor changes
	Associated conditions:
	• Fractures or other trauma
	• CNS and spinal disorders
	• Peripheral nerve injury
	9. Suspected Triangular Fibrocartilage Complex (TFCC*) lesion (articular disk)104	Radiographs Indicated (D)	Examine radiographs for ulnar variance, DJD of the distal radioulnar joint, instability of the lunate-triquetrum or scapholunate areas, chondromalacia, of the lunate or ulnar head, and either dorsiflexed or volar flexed intercalated segmental instability.104
	Typically produces ulnar-sided wrist pain, which may become chronic and associated with clicking or popping sounds with certain movements.	PA, lateral, and medial oblique104
	Lesions of the TFCC can be traumatic or degenerative, with the incidence of degenerative lesions increasing with age.	Special investigations (D)	Advanced imaging and specialist referral recommended:
	* The TFCC consists of the triangular fibrocartilage, the dorsal and palmar radioulnar ligaments, the ulnocarpal meniscal homologue, the dorsal and palmar ulnocarpal ligament, the sheath of the extensor carpi ulnaris tendon and the capsule of the distal radioulnar joint.		• MRI and Gadolinium-enhanced MRI.114
	10. Stenosing Tenosynovitus (trigger finger of TF)	Radiographs not initially indicated (D)	A staging system for trigger finger has been proposed based on the grade of mechanical involvement noted on examination: from normal finger movements (stage 1) to locked finger in flexion or extension (stage 6). Each stage may be painless or painful. Essentially, only digits locked in flexion require surgical intervention.96
	Intermittent, troublesome locking of the digit in flexion.100
	Trigger finger is more common in women 40-60 YOA and in patients with diabetes, RA, gout, and other connective tissue disorders.146
	The Dx is essentially clinical, radiographs are unnecessary. Patients typically present with an insidious onset of morning pain and snapping, clicking, locking, or stiffness in the affected digit. A painful nodule may be palpable at the distal palmar crease. The nodule may move during active movement.94
	Acute wrist trauma in the adult patient40, 104, 105, 106, 109, 147	Radiographs indicated (C)	In females over 50 YOA, life time estimated risk of osteoporotic wrist fractures is 16%71
		PA, lateral and pronation-oblique views (medial oblique) of the wrist57
	The following evaluation helps predict or R/O fractures when no deformity is present:148		Fractures may not be visible at initial presentation; repeated films after 10-14 d if a fracture remains a possibility or before proceeding with special investigation.157
	• Pain on passive and active motion	A. Additional views (D)	Because the wrist has a complicated anatomy with many structures overlying each other (particularly on the lateral view), it is prudent, as in all other situations, to have radiographs of traumatic wrist injuries carefully scrutinized by a radiologist to confirm that a pathologic condition has not been missed.104
	• Localized tenderness and edema	1. PA ulnar deviation (20°)149
	• Pain with grip and resisted supination.	2. Lateral and oblique152	In suspected carpal instability due to abnormally wide scapholunate space, consider adding palmar flexion and dorsiflexion views of the wrist in the lateral projection on either conventional radiography or fluoroscopy. Search for proximal migration of capitate and opening and closing of the scapholunate joint on radial and ulnar deviation views.158, 159
		3. Maximal wrist extension and ulnar deviation153
	A. Scaphoid fracture:		Advanced imaging and specialist referral recommended:
	Accounts for 70%-80% of all carpal fractures. MC in young active males. Risks of non-union, arthrosis and AVN:149	B. Additional views (D)	• Increasing use of MRI as only examination for*:
	• Anatomical snuffbox tenderness	Stress radiographs154, 155 (include PA w/ closed fist to stress scapholunate ligament)156	• Scaphoid fractures
	• Longitudinal thumb compression		• Pisiform and hamate
	• Resisted supination	Special investigations (C)	• Scaphotrapezium-trapezoid joint
	High sensitivity, specificity, and predictive value150, 151		• Scapholunate instability
			* Nearly 100% sensitive and specific6, 40, 149
	AVN and nonunion are potentially serious consequences of carpal fracture, particularly of the scaphoid.
			• CT scan is valid for demonstrating or ruling out a scaphoid fracture and is superior to NM.160
	B) Suspected lunate instability:		• Consider bone scan (NM) in persistent cases of post traumatic wrist pain even if repeat radiographs are normal due to false negative rates of radiography for carpal fracture.161
	Pain centered over the dorsal wrist immediately ulnar to the extensor carpi radialis tendons
	Pain and abnormal movement noted on Watson test; *specialized testing may be indicated earlier in such case
	Acute hand and finger trauma in the adult patient162	Radiographs indicated (D)	Common fractures encountered in the hand include: Bennet's fracture, Rolando's fracture, Pseudo-Bennett's fracture, Gamekeeper's thumb, Mallet finger, phalangeal fractures, Flexor digiturum profundus avulsion163
		1. Hand: PA, lateral and pronation-oblique (medial oblique)
	Traumatic injuries to the hand can be evaluated routinely by conventional radiography.104
		2. Isolated finger: PA, lateral, pronation-oblique (AP for the thumb)
		Additional views: stress view of the thumb (GPP)	Stress view to identify gamekeeper's thumb (possible avulsion fracture of the proximal phalangeal base of the thumb) is now considered contraindicated in case of a Stener lesion.
		Special investigations (D)	Advanced imaging and specialist referral recommended:
			• Consider advanced imaging (MRI, US, or arthrography) in suspected Stener lesion (entrapment of the ulnar collateral ligament) with gamekeeper's fractures.164

Appendix A. List of Abbreviations and Glossary for Upper Extremity Disorders 

A-C joint: Acromio-clavicular joint

AP: Anteroposterior

AS: Ankylosing spondylitis

Osteonecrosis: Avascular necrosis

CPPD: Calcium pyrophosphate dihydrate crystal deposition disease

CNS: Central nervous system

CRPS: Complex regional pain syndrome

CT: Computed tomography

CTS: Carpal tunnel syndrome

DJD: Degenerative joint disease

Dx: Diagnosis

GHQ questionnaire: General Health Questionnaire History

IAB: Intra-articular osteocartilagenous body

JRA: Juvenile rheumatoid arthritis

MC: Most common

MRA: Magnetic resonance arthrography

MRI: Magnetic resonance imaging

NM: Nuclear medicine (bone scan)

PA: Posteroanterior

ROM: Range of motion

R/O: Rule out

RA: Rheumatoid arthritis

Sp: Specificity

Sn: Sensitivity

SSS: Symptom Severity Scale

Tendinosis: Degeneration of tendons and of tendon muscle attachments

TF: Trigger finger

TFCC: Triangular fibrocartilage complex

US: Ultrasound

X-ray: Plain film radiograph

YOA: years of age

>: Greater than

≥: Equal or greater than

ψ: psychology/psychiatry

Appendix B. Summary of Recommendations 

Table 1. Summary of recommendations—adult shoulder disorders

	Patient presentation	Recommendations
	Adult patients with full or limited movement and nontraumatic shoulder pain of less than 4-wk duration	Radiographs not initially indicated (B)
	Patients unlikely to require initial radiographic examination if: no precipitating fall, no sudden onset of pain or swelling, no palpable mass or deformity; no pain at rest, and normal ROM (adapted from Fraenkel et al43—prospective validation needed)
	General indications for radiographs include:	If radiographs are indicated (D)
	• No response to care after 4 wk	AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)
	• Significant activity restriction >4 wk
	• Nonmechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)	Additional views: PA chest view, cervical spine AP and lateral views, Grashey view
	• Red flags indicators:
		Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)
	Most patients with chronic shoulder pain can be adequately evaluated with a history, physical examination, and plain radiographs.	• Pain and significant disability lasting over 6 mo, despite attention to occupation and sporting factors
		• In the absence of clinical improvement after 4 wk of therapy
		• If function does not improve or deteriorates
		• History of instability, or acute, severe post-traumatic acromioclavicular pain
		• In presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph
		Special investigations (B)
		MRI, ultrasonography, CT
	Glenohumeral joint disorders
	Consult specific clinical diagnoses and related patient presentations for additional help in decision making.
	Specific clinical diagnoses:
	1. Rotator cuff disorders (tendinopathy)	Radiographs not initially indicated (D)
	MC cause of shoulder pain	Early radiograph if soft tissue calcification is expected
	Classified according to its clinical progression:	If radiographs are indicated (D)
	I. Acute inflammation (tendinitis/bursitis)	AP internal rotation, AP external rotation, axillary view
	II. Degeneration/chronic inflammation (tendinitis)
	III. Rupture and arthritis	Additional view: Neer's view (y-scapula) or A-C joint views
	A. Impingement: night pain, upper arm pain and tenderness, cuff weakness, atrophy, painful arc, painful crepitation
	High-sensitivity tests (0.8): Neer, Hawkins, horizontal adduction, Jobe, impingement sign and painful arc;	Special investigations (C)
		MRI is gold standard.
	High-specificity tests (0.8): drop arm test, yergason, speed, passive external rotation.	A. Impingement is a dynamic process which may be assessed by US
	B. Rotator cuff tear: traumatic in young people and atraumatic in elderly; there is strong evidence that clinical tests are able to rule-out full tears but have questionable value for partial tears: 3 positive tests or 2 if >60 YOA is predictive of a tear: supraspinatus weakness, external rotation weakness, Hawkins	B. Rotator cuff full and partial thickness tear: MRI, US, MRA improves diagnostic accuracy
		C. Calcifying bursitis within cuff tendons: MRI
	2. Adhesive capsulitis (frozen shoulder)	Radiographs not routinely indicated (D)
	• Onset typically between the ages of 40-65 y
	• Progressive deep joint pain and stiffness of spontaneous onset and restricted activities	Special investigations (D)
		• MRI with direct or indirect arthrogram
	• >50% loss of passive abduction and external rotation, usually loss of all ROM, pain at end range, no local tenderness	• Distended arthrogram
	3. Osteoarthritis (DJD)	Radiographs indicated if (D)
	Usually ≥60 YOA, progressive pain, crepitus, decreased end-ROM, tender joint	• Unrelieved by 4 wk of conservative care
		• suspected underlying specific cause (pathology)
		AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)
		Additional view: supraspinatus outlet view
	4. Glenohumeral joint inflammatory arthritis	Radiographs indicated (D)
	Involved in most forms of inflammatory arthritis (RA, gout, reactive arthritis [Reiter's], JRA, AS)
		AP internal rotation, AP external rotation, axillary view
		Additional view: Grashey view
		Advanced imaging and specialist referral recommended (D=GGP)
		In suspected septic arthritis, consider MRI promptly for complete assessment of glenohumeral joint, preferably with intraarticular gadolinium
	5. Glenohumeral instability	Radiographs indicated (D)
	Usually between the ages of 20 and 35 y, Hx of dislocation or subluxation, apprehension sign	AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)
	Generalized ligamentous laxity (in multidirectional and voluntary instability)	Advanced imaging and specialist referral recommended (C)
		• Acute setting: conventional MRI
		• Chronic instability: MRA
		• Postoperative shoulder, multislice CT arthrography
	Adult patients with significant shoulder/glenohumeral joint trauma	Radiographs indicated (B)
	Radiographic examination is appropriate if there is trauma sufficient to produce fracture, or dislocation, with accompanying signs/symptoms compatible with fracture or dislocation.	AP neutral view (do not move the shoulder), Y-scapula view (lateral in scapular plane), axillary view (if possible)
	• Loss of normal shape, palpable mass or deformity	Additional view: transthoracic lateral
	• Severely restricted shoulder mobility
	• Examination is unable to localize anatomical structure responsible for patient symptoms	Advanced imaging and specialist referral recommended (D)
	• History of epileptic seizure or electrical shock	Repeat films in 10 days if a fracture remains a possibility after normal initial evaluation or refer for CT scan. Callus formation or abnormal alignment may be present.
		• MRI
	Clinical decision rule in suspected shoulder dislocation may include*:	• US and CT arthrography
	• First-time dislocation
	• Blunt trauma (fall >1 flight of stairs, assault, or motor vehicle crash)
	• When the clinician is uncertain of the joint position
	Clinical decision rule in suspected fracture-dislocation may include*:
	• First-time dislocation
	• Blunt trauma (fall >1 flight of stairs, a fight/assault episode, or motor vehicle crash) or a motor vehicle crash
	• Age >40 y
	* Prospective validation needed
	A-C joint disorders	Radiographs not initially indicated in non traumatic origin (D)
	Teenage to 50 yoa; usually secondary to trauma or osteoarthritis; pain localized to the AC joint and possible swelling
		If radiographs indicated (D)
		AP view in a 15° cephalic angulation,
		Stress radiographs (bilateral comparison): the value of stress views remains uncertain.
		Special investigations (D)
		• CT/MRI useful for pathological/surgical cases, especially in separations of types IV-VI as vascular/neurological complications can result
		• US if CT and MRI not available

Table 2. Summary of Recommendations—Adult Elbow Disorders

	Patient presentation	Recommendations
	Adult patients with full or limited movement and nontraumatic elbow pain of less than 4 wk duration	Radiographs not initially indicated (C)
	General indications for radiographs include:	Indicated before other imaging studies (B)
	• No response to care after 4 wk	AP in full extension, lateral at 90° and medial oblique views
	• Significant activity restriction >4 wk
	•Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)	Additional views: AP in pronation, tangential (axial)
	• Red flag indicators
	— Hx of cancer, S&S of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained elbow pain with no previous films (tumor?)
		Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)
	— Red skin, fever, systemically unwell (infection?)	• Pain and significant disability despite attention to occupation and sporting factors
	—History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?)	• In the absence of clinical improvement after 4 wk of therapy
	— Trauma, acute disabling pain and significant weakness	• If function does not improve or deteriorates
	— Unexplained significant sensory or motor deficit (neurological lesion?)	• History of instability, or acute, severe posttraumatic injury
		• In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph
		• High-field-strength MRI provides greater detail than mid-field or low-field MR systems.
		• CT and US may be more optimal than a low-field magnet in evaluation of the elbow.
	Chronic elbow pain in the adult patient	Radiographs indicated (C)
		AP in full extension, lateral at 90° and medial oblique views
		Additional views: AP in pronation, tangential (axial)
		Medical referral recommended and advanced imaging recommended (C)
		When the etiology is uncertain and the patient has failed appropriate conservative therapeutic trials (see recommendation above).
	Specific clinical diagnoses:
	1. Lateral epicondylitis (tennis elbow)	Radiographs not initially indicated (C)
	Epicondylar pain AND tenderness at the elbow laterally AND pain on resisted wrist extension—Cozen test:	Special investigations not indicated (C)
	2. Medial epicondylitis (Golfers' elbow)	Radiographs not initially indicated (D)
	Epicondylar pain AND tenderness at the elbow medially AND pain on resisted wrist flexion.	Special investigations not indicated (C)
	Adult patients with localized elbow pain following trauma	Radiographs indicated (C)
		AP in full extension, lateral at 90° and medial oblique views
	Elbow extension test: the inability to fully extend the elbow is a reliable indicator of osseous/joint injury
		Additional views (C): AP in pronation, tangential view (axial), lateral stress view
	Instability tests—lateral pivot-shift apprehension test (most sensitive), lateral pivot-shift test, posterolateral rotary drawer test, and stand up test
		Special investigations (GPP)
		• Increasing use of MRI for the determination of associated injuries of the lateral and medial collateral ligaments and cartilage
	Diffuse non-specific pain in the forearm (or wrist)	Radiographs not initially indicated (D)
	Forearm pain following trauma	Radiographs indicated (D)
		AP and lateral views.

Table 3. Summary of Recommendations—Adult Wrist and Hand Disorders

	Patient Presentation	Recommendations
	Adult patients with nontraumatic localized wrist and hand pain symptoms	Radiographs not initially indicated (D)
	General indications for radiographs include:	If radiographs are indicated (C)
	• No response to care after 4 wk	PA, lateral, and medial oblique views of the wrist
	• Significant activity restriction >4 wk
	• Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)—eg, Keinbock's disease	Additional views: radial and ulnar deviation views or clenched fist views are reserved for more subtle problems
	• Red flag indicators
	○ S&S of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained wrist pain with no previous films (tumor?)	Special investigations (D)
	○ Red skin, fever, systemically unwell (infection?)	• The combination of standard radiographs and US can diagnose a wide variety of disorders.
	○ History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) (Trauma section)
		• MRI is the procedure of choice to exclude osteonecrosis, marrow, and joint disease including infection.
	○ Trauma, acute disabling pain and significant weakness
	○ Unexplained significant sensory or motor deficit (neurological lesion at the wrist?)
	○ Suspected associated inflammatory arthropathies of wrist and hand
	Specific indications for radiographs include:
	• Noninvestigated chronic wrist and hand pain
	• Multiple sites of DJD as visualized on radiographs
	• Possible TFCC abnormality
	• Possible wrist instability, including perilunate instability, dorsal and volar intercalated segmental instability, scapholunate advanced collapse, scapholunate dissociation, ulnar translocation of the wrist—Trauma section
	• Possible operative candidate
	Consult clinical presentation with related specific clinical diagnoses for additional help in decision making
	Specific clinical diagnoses:
	1. Tendinopathy of the wrist	Radiographs not initially indicated (D)
	Pain and tenderness over a specific tendon or tendon group are the hallmarks of this condition. Other findings include localized swelling, impaired function, crepitus, pain with passive stretching of the tendon, and positive provocative testing. Tendinosis, however, can be asymptomatic.
		If radiographs are indicated (D)
		PA, lateral, and medial oblique views of the wrist
		Consider conventional radiography, in persistent painful “soft tissue injuries,” not only to exclude bony injury but also to aid Dx of rare cases of acute spontaneous calcific peritendinitis of the hand and wrist
	2. De Quervain's tenosynovitis (stenosing tenosynovitis or tenovaginitis)	Radiographs not initially indicated (D)
	Pain over the radial styloid AND tender swelling of first extensor compartment AND EITHER pain reproduced by resisted thumb extension OR positive Finkelstein's test
	Associated symptoms include warmth and crepitus63
	3. CTS	Radiographs not initially indicated (C)
	Pain OR paraesthesia OR sensory loss in median nerve distribution in at least 2 of the first 4 fingers AND either one positive Tinel's or Phalen's, Thenar atrophy, female gender, obesity (body mass index ≥30), worsening of symptoms at night/awakening, or abnormal nerve conduction time
	Clinical prediction rule (level IV):	Special investigations (D)
	1. Age >45 y	Advanced imaging reserved for patients with equivocal presentation or with diabetes and diffuse peripheral neuropathy that confounds electrodiagnostic studies
	2. Shaking hands for symptom relief	• MRI may be used to image anatomical abnormality (eg, space-occupying lesion such as a ganglion).
	3. Reduced median sensory field of thumb	• US may be a useful alternative.
	4. Wrist ratio index (carpal canal volume) >.67	• High-resolution sonography may show median nerve enlargement and increased hypoechogenicity
	5. SSS score (Brigham and Women Hospital) >1.9
	Likelihood of CTS increase with number of positive tests (18.3 or 90% when all 5 tests positive)
	4. Osteoarthritis	Radiographs not initially indicated (D)
		It is common to have incomplete concordance between pathologic changes, radiographic and clinical features in OA.
	1. History: age >50 y, morning joint stiffness <30 min
	2. Physical examination: crepitation, bony tenderness, bony enlargement, no palpable warmth
	Other characteristics include: long standing pain, no extraarticular symptoms; nonresponsive to NSAID or corticosteroid medication; relieved with rest; deformity or fixed contracture, joint effusion; insidious onset
	5. Inflammatory or crystal induced arthropathy (excluding RA)	Radiographs indicated (C)
	Gout, CPPD, etc	PA, lateral, and medial oblique of the wrist and hand
	Dx of inflammatory arthritis is primarily based on history and physical examination:	Special investigations (C)
	• Unrelenting morning stiffness >30 min	• If routine radiographs are normal or nondiagnostic, MRI is the study of choice; biopsy/aspiration to R/O infection
	• Pain at rest	• Gadolinium-enhanced MRI of the hand and wrist is a superior technique for detection of tenosynovitis in inflammatory arthritis
	• Polyarticular involvement, especially the hands
	• Pain or stiffness better with light activity (during remission)
	• Palpable warmth
	• Joint effusion
	• Diffuse tenderness
	• Decreased ROM
	• Fever/chills or other systemic symptoms
	• Responsive to NSAID or corticosteroid medication
	• Flexion contracture in long-standing arthritis
	6. RA	Radiographs indicated (C) PA, lateral, and medial oblique views of the wrists and hands 1(Norgaard's/ball catcher projection)
	Symmetrical involvement of wrist, metacarpophalangeal and proximal interphalangeal finger joints	Radiographs of the hands, feet, and chest are recommended at the initial evaluation
	RA diagnostic criteria (≥4/7 required):	Special investigations (C)
	• Morning joint stiffness >1 h	• MRI is the modality of choice in early Dx and management of RA. MRI helps differentiate erosive from nonerosive disease.
	• Arthritis involving ≥3 joints for at least 6 wk
	• Hand arthritis (wrist, MCP, PIP)
	• Symmetric arthritis
	• Rheumatoid nodules
	• Serum Rh factor
	• Radiographic changes
	7. Osteonecrosis (AVN)	Radiographs indicated (C)
		PA, lateral, and medial oblique
	Nonmechanical pain
	• Unrelenting pain at rest	Special investigations (D)
	• Constant or progressive symptoms and signs	MRI modality of choice to evaluate bone marrow changes in early stages.
	• Pain not reproduced on assessment
	• Swelling, tenderness
	8. CRPS	Radiographs indicated (D)
	Synonyms:	PA, lateral, and medial oblique
	• Reflex sympathetic dystrophy
	• Sudek's atrophy	Special investigations (D)
		• MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities
	At least 4 of the following must be present in order for a Dx of CRPS to be made:	• 3-phase NM scan recommended if radiograph is not diagnostic
	Examination findings
	• Temperature/color change
	• Edema
	• Trophic skin, hair, nail growth abnormalities
	• Impaired motor function
	• Hyperpathia/allodynia
	• Sudomotor changes
	Associated conditions:
	• Fractures or other trauma
	• CNS and spinal disorders
	• Peripheral nerve injury
	9. Suspected TFCC lesion (articular disk)	Radiographs indicated (D)
	Typically produces ulnar-sided wrist pain, which may become chronic and associated with clicking or popping sounds with certain movements	PA, lateral, and medial oblique
		Special investigations (D)
		MRI and gadolinium-enhanced MRI
	10. TF (stenosing tenosynovitis)
	Intermittent, troublesome locking of the digit in flexion. More common in women 40-60 YOA and in patients with diabetes, RA, gout, and other connective tissue disorders	Radiographs not initially indicated (D)
	Patients typically present with an insidious onset of morning pain and snapping, clicking, locking, or stiffness in the affected digit. A painful nodule may be palpable at the distal palmar crease. The nodule may move during active movement
	Acute wrist trauma in the adult patient	Radiographs indicated (C)
		PA, lateral and pronation-oblique views (medial oblique) of the wrist
	The following evaluation helps predict or R/O fractures when no deformity is present:
	Pain on passive and active motion	A. Additional views (D) PA ulnar deviation (20°), lateral oblique, maximal wrist extension and ulnar deviation
	Localized tenderness and edema
	Pain with grip and resisted supination	B. Additional views (D) stress tests (include PA with closed fist to stress scapholunate ligament)
	A. Carpal navicular (scaphoid) fracture:	Special investigations (C)
	Accounts for 70%-80% of all carpal fractures; MC in young active males	Increasing use of MRI as only examination for:
	Anatomical snuffbox tenderness	• Scaphoid fractures
	Longitudinal thumb compression	• Pisiform and hamate
	Resisted supination	• Scaphotrapezium-trapezoid joint
		• Scapholunate instability
	B. Suspected lunate instability:
	Pain centered over the dorsal wrist immediately ulnar to the extensor carpi radialis tendons; pain and abnormal movement noted on Watson test;. Specialized testing may be indicated earlier in such case.
	Acute hand and finger trauma in the adult patient	Radiographs indicated (D)
	Traumatic injuries to the hand can be evaluated routinely by conventional radiography.	1. Hand: PA, lateral and pronation-oblique (medial oblique)
		2. Isolated finger: PA, lateral, pronation-oblique (AP for the thumb)
		Additional views (GPP) Stress view of the thumb to identify gamekeeper's thumb (possible avulsion fracture of the thumb proximal phalangeal base)
		Special investigations (D)
		Consider advanced imaging (MRI, US, or arthrography) in suspected Stener lesion (entrapment of the ulnar collateral ligament) with gamekeeper's fractures.

Appendix C. Pertinent Clinical Information 

Shoulder disorders

A. Comprehensive assessment of shoulder outcomes

A comprehensive assessment of shoulder outcomes would include a generic measure of health-related quality of life, a shoulder-specific measure of function, and a measure of patient satisfaction. The American Shoulder and Elbow Surgeons (ASES) subjective shoulder scale has overall acceptable psychometric performance (Test-Retest Reliability, Internal Consistency, Content Validity, Criterion Validity, Construct Validity, Responsiveness) for outcome assessment in patients with shoulder instability, rotator cuff disorder, and glenohumeral arthritis.a

The ASES shoulder scale contains both a patient-derived subjective assessment and a physician-derived objective assessment. The subjective patient self-report section consists of 2 equally weighted domains, pain and function. Pain is recorded on an ordinal scale, ranging from 0 to 10, and accounts for 50% of the overall ASES score. Function accounts for the other 50% of the overall score and is divided into 10 questions with regard to difficulty with putting on a coat, sleeping on the affected side, washing the back or putting on a bra, managing toileting, combing hair, reaching a high shelf, lifting 10 lb (4.5 kg) above the shoulder, throwing a ball overhead, participating in work, and participating in sports.b

High mechanical exposure in both sexes is associated with heightened risk for neck and shoulder pain. In women, job strain, psychological job demands, and low job decision latitude correlate with increased risk.c

B. Factors predicting chronic shoulder pain and risk factors for long-term employee absenteeism.

Factors predicting chronic shoulder pain may include the followingd:

Risk factors for long-term employee absenteeism may includee,f:

C. Proposed risk factors for upper extremity tendinopathy include the followingf,g:

References

a. Kocher MS, Horan MP, Briggs KK, Richardson TR, O'Holleran J, Hawkins RJ. Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons Subjective Shoulder Scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg 2005; 87-A (9): 2006-2011.

b. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, Iannotti JP, Mow VC, Sidles JA, Zuckerman JD. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3:347-52.

c. Östergren PO, Hanson BS, Balogh I, Ektor-Anderson J, Isacsson A, Örbaek P, Winkel J, Isacsson SO. Incidence of shoulder and neck pain in a working population: effect modification between mechanical and psychosocial exposure at work? Results from a 1-year follow up of the Malmö shoulder and neck study cohort. J Epidemiol Community health 2005;59:721-728.

d. Macfarlane GJ, Hunt IM, Silman AJ. Predictors of chronic shoulder pain: a population based prospective study. J Rheumatol 1998; 25(8):612-5.

e. van des Windt DA, Thomas E, Pope DP et al. Occupational risk factors for shoulder pain: a systematic review. Occupational and Environmental Med 2000; 57:433-42.

f. Bongers PM, Kremer AM, ter Laak J. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist?: A review of the epidemiological literature. Am J Ind Med. 2002, 41(5):315-42

g. Wainstein JL, Nailor TE. Tendinitis and tendinosis of the elbow, wrist, and hands. Clin Occup Environ Med 2006; 5 (2) 299-322.

Appendix D. General Indications for Advanced Imaging in Extremity Disorders 

	Indications	MRI	CT	NM	US
	Evaluation of neoplasm detected on conventional radiographs	++	+
	Determining skeletal distribution of neoplasms or other multifocal skeletal disease			++
	Internal joint derangements	++	+		+
	Inflammatory arthritis	+	+	+	++
	Evaluation of soft tissue injury, tendon pathology, calcified bursitis	++			++
	Osteomyelitis	++	+	++
	Fluid collections or infections in joints or extra-articular soft tissues; unexplained soft tissue mass	++			++
	Osteonecrosis	++	+	+
	Complicated fractures	+	++
	Suspected stress, occult fracture	+	+	++
	Complicated disease processes or findings unexplained by more conservative tests	+	+

++, first choice; +, second choice (must be determined on a case-by-case basis)a,b,c

a. Adapted with permission from Peterson C. Canadian Guidelines for Imaging. 2002 (unpublished)

b. Santiago RC, Gimenez CR, McCarthy K. Imaging of osteomyelitis and musculoskeletal soft tissue infections: current concepts. Rheum Dis Clin North Am. 2003; 29(1):89-109.

c. Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am 2001; 39(2):191-201.

Appendix E. Typical Effective Ionized Radiation Dose for Common Imaging Procedures* 

	Class	Typical effective dose (mSv)	Examples
	0	0	US, MRI
	I	<1	Radiograph: cervical and thoracic spine, extremities, pelvis, and lungs
	II	1-5	Lumbar spine radiograph, NM, cervical spine CT
	III	5-10	Chest and abdomen CT

*Classification of the typical effective dose of ionizing radiation from common imaging procedures. Adapted from: European Commission. Radiation Protection 118. Referral guidelines for imaging in conjunction with the UK Royal College of Radiologists; Italy 2001. p. 21.

Appendix F. Additional Reading Recommended on MRI 

• Wessely MA, Hurtgen-Grace KL, Grenier JM. Elbow MRI. Part 1: Normal imaging appearance of the elbow. Clin Chiropr 2006;9:198-205

• Wessely MA, Grenier JM. Elbow MRI. Part 2: The imaging of common disorders affectngh the elbow region. Clin Chiropr 2007;10:43-9

• Wessely MA, Grenier JM. MR imaging of the wrist and hand–A review of the normal imaging appearance with an illustration of common disprders affecting the wrist and hand. Clin Chiropr 2007;10(3):156-64

• Scordilis PJ, Grenier JM, Wessely MA. Shoulder MRI. Part 1: Basic overview. Clin Chiropr 2005;8:93-101.

• Grenier JM, Scordilis PJ, Wessely MA. Shoulder MRI. Part 2: Overview of common pathological conditions. Clin Chiropr 2005;9:151-60.

Appendix G. Acknowledgments 

The authors express their sincere appreciation to all Delphi panelists (phase 5), external reviewers (phases 4 and 7), and to the quality of literature assessors (phase 2): Jeffrey Cooley, Jonathon Egan, Michael Morgan, Julie O'Shaughnessy, and Jason Napuli, whose significant contributions were essential in the completion of this project. We are grateful to chiropractic college presidents for recommending faculty members for the Delphi panel. We have appreciated the feedback received by colleagues in the field during and after the worldwide consultation on the Web (Phase 6). Many thanks to Dr. Andre Cardin of Université du Québec à Trois-Rivières for his significant input in the initial draft (phase 3), Dr. Michelle Wessely of the Institut Franco-Europeen de Chiropratique and Dr. Julie-Marthe Grenier of Université du Québec à Trois-Rivières for their valuable editorial input, and to Drs. Carlo Ammendolia, DC, PhD, Joe Lemire DC, MSc, John Triano, DC, PhD, and Jacques Duranceau, MD for providing constructive advice. The authors are indebted to those who assisted us during all or part of the project, including Drs. Mark Laudadio, DC, Christian Eid, DC, Julie Roy, DC, Nicholas Beaudoin, and Mme Valérie Lambert, academic and technology support, Computer system development division at UQTR. Finally, we would like to thank Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical Research Project Manager, Managing Editor, Cochrane Back Review Group, Institute for Work and Health for her valuable advice and pertinent comments and suggestions as a public representative. We further apologize, once again, to those who experienced temporary technical difficulties with the evaluation questionnaires at the onset of Website consultations (Delphi, Public and External review).

We wish to acknowledge all Delphi panelists who have dedicated their time to this project. The following is a list of Delphi panelists who have agreed to be acknowledged for their significant contribution to the research project.

Allan Adams, DC, MSEd

Texas, USA, Texas Chiropractic College (Academic and Researcher)

Peter Aker, DC, MSc, FCCS, FCCRS

Ontario, CANADA (Clinician and Researcher)

Thomas F. Bergmann, DC

Minnesota, USA, Professor, Northwestern Health Sciences University (Academic, Clinician)

Douglas G. Brandvold, DC British Columbia, CANADA (Clinician)

Jane Cook, DC, DACBR

Bournemouth, UK, Anglo European Chiropractic College (Academic)

Jeffrey Cooley, DC, DACBR

Perth, West Australia, Senior Lecturer, Murdoch University (Academic)

Vince DeBono, DC

Illinois, USA, Dean of Clinics, National University of Health Sciences (Academic, Clinician)

Martin Descarreaux, DC PhD

Quebec, Canada, Université du Québec à Trois-Rivières (Researcher, Academic and Clinician)

Renee DeVries, DC, DACBR

Minnesota, USA, Associate Professor and Consulting Radiologist, Northwestern Health Sciences University (Academic)

Shawn Dill, DC Professor

California, USA, Life College Chiropractic West (Academic and Clinician)

Paul Dougherty, DC, FACO

New York, USA, New York Chiropractic College (Academic)

Dennis Enix, DC, MBAcMissouri, USA, Associate Professor of Research, Logan College of Chiropractic (Researcher and Clinician)

Francis Fontaine, DC, MD

Quebec, Canada, Lecturer, Université du Québec à Trois-Rivières (Clinician)

Simon Forster, DC DACBO

Texas, USA (Clinician)

Edward Fritsch, DC

Texas, USA, Texas Chiropractic College (Academic and Clinician)

Bryan Gatterman, DC, DACBR

California, USA, Life West Chiropractic College (Academic and Clinician)

Claude Gauthier, DC

Quebec, Canada (Clinician)

Kristin L. Grace, DC DACBR

Hastings, New Zealand, Senior lecturer, New Zealand Chriopractic College (Academic and Clinician)

Gary Greenstein, DC

Connecticut, USA, University of Bridgeport (Academic)

Julie-Marthe Grenier, DC, DACBR

Quebec, Canada, Université du Québec à Trois-Rivières (Academic, Research)

Mitchell Haas, DC, MA

Oregon, USA, Dean of Research, Western States Chiropractic College (Academic and Researcher)

Michael W. Hall, DC, DABCN

Texas, USA, Associate Professor, Parker College of Chiropractic (Academic and Clinician)

Jan Hartvigsen, DC, PhD

Odense, Denmark, Dean of Research, University of Southern Denmark (Academic and Researcher)

William Hsu, DC, DACBR

Ontario, Canada, Associate Professor, Canadian Memorial Chiropractic College (Academic)

Eric Jackson, DC FCCRS

Ontario, Canada (Clinician)

Amanda Kimpton, BAppSc(Chiro), PhD

Victoria, Australia, RMIT University (Academic and Clinician)

Dana J. Lawrence, DC, FICC

Iowa, USA, Associate Professor

Palmer Chiropractic College (Academic and Researcher)

Douglas Lawson, BA, DC

Alberta, Canada (Researcher and Clinician)

Kathleen Linaker, DC, DACBR, Assistant

Georgia, USA, Professor, Director Clinic Radiology, Life University College of Chiropractic (Academic, Clinician)

Tracey Littrell, DC, DACBR

Iowa, USA, Associate Professor, Diagnosis and Radiology, Palmer-Davenport Chiropractic College (Academic)

Stephan Mayer, BSc, DC

California, USA, Chair of Diagnostic Sciences and Associate Academic Dean, Cleveland Chiropractic College (Academic)

Ian D. McLean, DC, DACBR

Iowa, USA, Professor, Clinical Radiologist Professor, Director of Clinical Radiology and Chiropractic Residencies, Palmer-Davenport Chiropractic College (Academic and Clinician)

Timothy J. Mick, DC, DACBR, FICC

Minnesota, USA, Associate Professor Director- Radiological Consultation Services, Northwestern Health Sciences University (Academic)

Silvano Mior, DC, FCCS

Ontario, Canada, Canadian Memorial Chiropractic College (Researcher and Clinician)

Tom Molyneux, DipAppSc (H Biology), DipAppSc(Chiro), BAppSc(Chiro), DACBR, FACCR, GradDipTertEd.

Victoria, Australia, RMIT University (Academic)

William E. Morgan, DC

Maryland, USA, Adjunct Professor, New York College of Chiropractic, National University of Health Sciences (Clinician)

Elli Morton, DC

British Columbia, Canada (Clinician)

Greg Norton, DC, FACO, FIACN

Iowa, USA (Clinician)

Sandra O’Connor, DC, DACBR, FCCR

Ontario, Canada (Clinician)

Rosemary Pace, RN, DipAppSc(MedRad), MEd (ICT), MBus, GradDipEd, GradDipBus

Victoria, Australia, RMIT University (Academic and Researcher)

Joseph Pfeifer, DC

New York, USA, New York Chiropractic College (Academic)

John Pikula, FCCR(C), FCCS(C), FCCO(C)

Ontario, Canada (Clinician)

Brock Potter, DC

British Columbia, Canada (Clinician)

Tania C. Pringle, BPE, BA, DC, DACBR, FCCR(C)

Ontario, CANADA, Assistant Professor, Canadian Memorial Chiropractic College (Academic)

Serge Roux, DC, DABCO

Quebec, Canada (Clinician)

Peter Scordilis, DC

New Jersey, USA (Clinician)

Paul Sherman, DC, Assistant Professor

Connecticut, USA, University of Bridgeport College of Chiropractic (Academic and Clinician)

Thomas A. Souza, DC, DACBSP

California, USA, Dean of Academic Affairs, Palmer Chiropractic College West (Academic and Clinician)

John Stites, DC, DACBR

Iowa, USA, Palmer Chiropractic College (Academic)

Rand Swenson, DC, MD, PhD

New Hampshire, USA, Associate Professor of Anatomy and of Medicine, Chairman, Department of Anatomy, Dartmouth Medical School (Academic, Clinician)

John Sweaney, AM, DC

New South Wales, Australia, Chiropractic Education Consultant (Clinician)

Cliff Tao, DC, DACBR

California, USA (Clinician)

Jeffrey Thompson, DC, DACBR

Texas, USA (Clinician and Researcher)

Jann Thulien, DC, DACBR

Ontario, Canada (Clinician)

Michelle A. Wessely, BSc, DC, DACBR

Paris, France, Professor, Head of Radiology and Clinical Research, Institut Franco-Europeen de Chiropratique (Academic and Clinician)

Michael Whitehead, BS, DC, DACBR

Missouri, USA, Chair of Diagnostic Sciences, Cleveland Chiropractic College (Academic and Clinician)

DELPHI PROCESS ADVISORS

Meridel I Gatterman, MA, DC, MEd,

Colorado, USA, Chiropractic Educational Consultant

Peter Miller, BSc, MSc, FCC (Orth)

Bournemouth, UK, Anglo-European College of Chiropractic