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ORIGINAL ARTICLES

DIAGNOSTIC IMAGING GUIDELINE FOR MUSCULOSKELETAL

COMPLAINTS IN ADULTS—AN EVIDENCE-BASED

APPROACH—PART 2: UPPER EXTREMITY DISORDERS

André E. Bussières, DC,a Cynthia Peterson, DC, RN, MMedEd,b and John A.M. Taylor, DCc

a Professor, ChiTrois-Rivières, Qu

b Professor, CanOntario, Canada.

c Professor ofYork.

Submit requestDépartement chiroC.P. 500, Trois-Riv(e-mail: andre.bus

Paper submitte2007; accepted Oc

0161-4754/$34Copyright © 20doi:10.1016/j.jm

2

ABSTRACT

Purpose: To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primarycare providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders.Methods: A comprehensive search of the English and French language literature was conducted using a combinationof subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracystudies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention andEducational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiationprotection 118) coordinated by the European Commission served as the initial template. The first draft was sent for anexternal review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders inchiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on theindications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors andby chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.Dissemination and implementation strategies are discussed.Results: Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided,supported by over 126 primary and secondary citations. The overall quality of available literature is low, however.On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommenda-tions. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines andimplementation feasibility.Conclusions: The guidelines are intended to be used in conjunctionwith sound clinical judgment and experience and should beupdated regularly. Future research is needed to validate their content. (J Manipulative Physiol Ther 2008;31:2-32)
Key Indexing Term: Diagnostic Imaging; Radiology, Diagnostic x-ray; Radiography; Practice Guideline; Guideline;Adult; Musculoskeletal System; Pain; Upper Extremity; Shoulder; Elbow; Wrist; Hand; Trauma
REPORTING OF TOPICS INCLUDED IN THE DEVELOPMENT OF the pertinence of developing diagnostic imaging guidelines.

THE DIAGNOSTIC IMAGING PRACTICE GUIDELINES1

An initial literature review considered 10 clinical questionspertaining to imaging of musculoskeletal conditions to evaluate

ropractic Department, Université du Québec àébec, Canada.adian Memorial Chiropractic College, Toronto,

Radiology, D'Youville College, Buffalo, New

s for reprints to: André Bussières, DC, Professor,pratique, Université du Québec à trois-Rivières,ières, Québec, Canada G9A [email protected]).d July 15, 2007; in revised form September 27,tober 14, 2007..0008 by National University of Health Sciences.pt.2007.11.002

This initial review led to a research project divided into 9phases: (1) literature search, (2) independent literature assess-ment, (3) guideline development specific recommendations, (4)first external review, (5) consensus panel (modified Delphi), (6)public website, (7) second external review, (8) final draft andgrading of the recommendations, and (9) dissemination andimplementation. Details of this study are published elsewhere.2

FOCUS

These diagnostic imaging guidelines concern adultmusculoskeletal disorders of the upper extremities whereconventional radiography and specialized imaging studiesare deemed useful for diagnostic purposes.

OBJECTIVES

Reasons for developing these guidelines include assistingcurrent and future health care providers to make appropriate

mailto: [email protected]

mailto: [email protected]

http://dx.doi.org/10.1016/j.jmpt.2007.11.002

3Bussières et alJournal of Manipulative and Physiological TherapeuticsDiagnostic Imaging Upper Extremity DisordersVolume 31, Number 1

use of imaging studies, providing indications for the need ofimaging studies according to current literature and expertconsensus, and assisting in optimizing the utilization oflimited available resources. These proposed guidelines areintended to reduce unnecessary radiation exposure and theuse of specialized imaging studies, increase examinationprecision and decrease health care costs–all withoutcompromising quality of care.

TARGET USERS/SETTING

Intended users of the guidelines are chiropractors and otherprimary health care providers prescribing diagnostic imagingstudies. The setting in which these guidelines may be usedinclude private clinics, outpatient clinics, and hospital emer-gency departments.

TARGET POPULATION

The patient population eligible for guideline recommen-dations are adult patients presenting with musculoskeletaldisorders of the upper extremities. Children and pregnantpatients are excluded from these guideline recommendations.

DEVELOPERS

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

EVIDENCE COLLECTION

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

METHODS FOR SYNTHESIZING EVIDENCE

a) Literature search and independent literature assessment ofspinal disorders: Quality of diagnostic accuracy studies(QUADAS),3 Appraisal of Guidelines Research andEvaluation (AGREE),4 and Stroke Prevention andEducational Awareness Diffusion (SPREAD).5

b) Initial draft: template based on European Commissionclassification (2001).6

c) Expert consensus: a 2-round modified Delphi processwas used to generate consensus among an internationalpanel of over 60 experts in musculoskeletal disorders.

RECOMMENDATION GRADING CRITERIA

The evaluation tool used was designed by theScottish Intercollegiate Guidelines Network (SIGN) and

adapted by the Stroke Prevention and EducationalAwareness Diffusion (SPREAD) group.5,7

PATIENT PREFERENCES

Condition-specific imaging guidelinesIntegral to evidence-based health care, decisions regard-

ing the use of imaging studies should be based on the bestavailable evidence and the experience and judgment of theclinician while considering patient preference. A publicmember reviewed all documents and provided commentsand suggestions.

STAKEHOLDERS AND EDITORIAL INDEPENDENCE

Pre-release ReviewBefore the release of the guidelines, the reliability of

proposed recommendations was tested on specialists bothin chiropractic and in medicine as well as on fieldchiropractors.

Potential Conflict of InterestThe research team involved in the development of these

guidelines declares no existing or potential conflict ofinterest. No investigators have received nor will receiveany personal financial benefits or derive any salary fromthis project.

Funding Sources/Sponsors1. Canadian Memorial Chiropractic College Post Grad-

uate Education and Research (2005)2. National Institutes of Health Student Grant (2006)3. Canadian Chiropractic Protective Association (2006)

UPDATING/REVISION

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

POTENTIAL BENEFITS AND HARM

Selection of appropriate radiological imaging proceduresfor evaluation of patients with musculoskeletal disorders ofthe upper extremities; decrease unnecessary ionizing radia-tion exposure, decrease costs, and improve accessibility.

DISSEMINATION/IMPLEMENTATION CONSIDERATIONS

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

4 Journal of Manipulative and Physiological TherapeuticsBussières et alJanuary 2008Diagnostic Imaging Upper Extremity Disorders

DEFINITIONS, PATIENT PRESENTATIONS,RECOMMENDATIONS, AND RATIONALE

These topics are integral parts of each 1 of the 3diagnostic imaging guidelines: lower extremity disorders,upper extremity disorders, and spine disorders. Results of the9 phases of the research project are published elsewhere.2

PRELIMINARY CONSIDERATIONS AND DISCLAIMER

What is the Role of These Guidelines?These evidence-based diagnostic imaging practice

guidelines are intended to assist primary care providersand students in decision making regarding the appropriateuse of diagnostic imaging for specific clinical presenta-tions. The guidelines are intended to be used inconjunction with sound clinical judgment and experience.For example, other special circumstances for radiographicimaging studies may include: patient unable to give areliable history, crippling cancer phobia focused on backpain, need for immediate decision about career or athleticfuture or legal evaluation, history of significant radio-graphic abnormalities elsewhere reported to patient but nofilms or reliable report reasonably available, and history offinding from other studies (eg, nuclear medicine or chestimaging) that requires radiograph for correlation.8 Appli-cation of these guidelines should help avoid unnecessaryradiographs, increase examination precision, and decreasehealth care costs without compromising the quality of care.

The descriptions of clinical presentations and proposedclinical diagnostic criteria, recommendations for imagingstudies, and the comments provided throughout this docu-ment are a synthesis of the vast body of literature consultedbefore and during the various phases of this research project.Where the literature was found to be of poor quality orabsent, consensus based on expert opinion was used.Although the investigators and collaborators carefullysearched for all relevant articles, it is probable that somehave been missed. Furthermore, as many new importantstudies are published in the near future, these will beincorporated in subsequent revisions of the guidelines, andrecommendations may change accordingly.

What These Guidelines Do and What They Do Not DoThese guidelines are intended to address issues faced by

first contact professionals only. These guidelines do notaddress all possible conditions associated with musculoske-letal disorders, only those that account for the majority ofinitial visits to a practitioner.

Like other diagnostic tests, imaging studies shouldonly be considered if (a) they yield clinically importantinformation beyond that obtained from the history andphysical examination, (b) this information can poten-tially alter patient management, and (c) this altered

management has a reasonable probability to improvepatient outcomes.9-11

Investigators and collaborators in the development ofthese imaging guidelines believe that liability insurancecompanies, third party payers, and courts of law should notrely solely on descriptions of patient presentations, proposedrecommendations, and/or corresponding comments foundthroughout the documents, as patient presentations are uniqueand the application of any guideline always requires clinicaljudgment and thus needs to be considered in the propercontext. In addition, laws and regulations may vary betweengeographical regions and should be considered whenapplying the proposed indications for any imaging study.

What is Evidence-Based Health Care?Evidence-Based is About Tools, Not About Rules.12 Evidence-based

health care is an approach in which clinicians and healthcare professionals utilize the current best evidence inmaking decisions about the care of patients. It involvescontinuously and systematically searching, appraising, andincorporating contemporaneous research findings intoclinical practice. The overall goal is improving patientcare through life-long learning.12,13

Potential DisagreementsThere are several reasons for disagreement within a

guideline development group. These include differences ininterpretation of the research literature, differences inpersonal experience, and different perceptions of the inherentrisks and benefits of a procedure.14 Divergent or competingguidelines on similar topics serve only to further confuse andfrustrate practitioners.15 In addition, the continued lack ofunity among chiropractors hinders its growth by limitingintegration and cooperation within of the greater health caresystem. Readers of any guidelines are advised to criticallyevaluate the methods used as well as the content of therecommendations before adopting them for use in practice.16

Standard Patient Management ActivitiesStandard patient management activities, including diag-

nostic assessment and follow-up, are integral components ofevery patient encounter.17 Initial triage of patients withmusculoskeletal disorders is a constant recommendation ofvarious clinical guidelines.18 Imaging studies are used mostpractically as confirmation studies once a working diagnosisis determined. The objective is to determine the presence ofclinical indicators of serious pathologies (red flags) requiringdiagnostic imaging, specialist referral, or urgent surgicalintervention. When a practitioner recommends that a radio-graph or other diagnostic imaging study be performed, andthe patient refuses, the patient should be advised of theassociated risks and implications, and this should berecorded in the patient's records.

Table 1. Adult Shoulder Disorders

Patient presentation Recommendations Comments

Adult patients with full or limited movement and nontraumatic shoulder pain of less than 4 wk duration40,41

Radiographs notinitially indicated (B)

Most cases of acute shoulder pain are of “mechanical” origin andcan 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 ofindividual features in histories have low diagnosticsignificance. History, type of pain, and site of pain are the mostimportant features to direct the diagnostic strategy. Every agegroup exhibits typical specific shoulder problems and diseases.

Radiography is typically not useful for soft tissue disorders suchas bursitis, tendinosis, capsulitis, glenoid cartilage tear,myofascial pain syndrome, polymyalgia rheumatica, or referredpain. Referred pain from the neck is common. Other sourcesinclude: chest wall, myocardium, and diaphragm.44

A comprehensive assessment of shoulder outcomes wouldinclude a generic measure of health-related quality of life,a shoulder-specific measure of function, and a measure ofpatient satisfaction.42 See Appendix C [A] for details

Shoulder pain cumulative lifetime prevalence is ∼10%, makingit the third most commonly experienced type of musculoskeletalpain, exceeded only by low back and neck pain. The prevalenceis highest in the 40-65–year age bracket, among women, manualworkers and certain ethnic groups. Point prevalence is between6.9 and 26%, 1-mo prevalence is 18.6-31%, and 12-mo periodprevalence is 16%-47%. Approximately 1% of the adultpopulation is expected to visit a general practitioner annually forshoulder pain and the incidence of reported shoulder complaint is19.0 per 1000 person-years. Fifty percent of acute shoulder painresolves in 8-10 wk, but as many as 40% of cases may bepersisting for longer than 1 year.

Physical examination is used primarily to discriminatebetween articular involvement and referred pain.Examination should include the cervical spine, chestwall and elbow joint.

Patients unlikely to require initial radiographic examinationif there is: no precipitating fall; no sudden onset of pain orswelling; 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 shoulderdisability score, and associated neck pain. A more favorableprognosis is associated with mild trauma or overuse beforeonset of pain, early presentation and acute onset.44,45

In “well functioning” 70-79-year-old patients, neck and shoulderpain seem to occur in conjunction with pain in other joints andcomorbidity. Nearly 20% reported having some shoulder pain forover 1-mo duration in the past year.41,44-48

See Appendix C [B]. Factors predicting chronic shoulder painand risk factors for long-term employee absenteeism.

General indications for radiographs include40,41,44,49 If radiographs areindicated51: (C)

Critical exclusionary diagnoses include:• No response to care after 4 wk. • Osteonecrosis• Significant activity restriction N4 wk 1. AP internal rotation • Septic arthritis• Non mechanical pain (unrelenting pain at rest, constant or

progressive symptoms and signs, pain not reproducedon assessment)

2. AP externalrotation

• 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 N50 y, pain atrest, pain at multiple sites, unexplained weight loss,significant unexplained shoulder pain with no previousfilms (tumor?)

Additional views: To visualize lung apices if suspect referred pain from pulmonarydisease such as Pancoast's tumor or if referred from the neckPA chest view,

cervical spine APand lateral views

Grashey view: looks directly down the glenohumeral joint78

Grashey viewEarly access to specialized investigations is unlikely to improvemanagement of a heterogeneous group of shoulder disordersthat should usually be managed conservatively.44○ Red skin, fever, systemically unwell, immunosupression,

penetrating wound, underlying disease process (infection?)Special investigationsnot initially indicated:(B)

Specialist referral and specialized imaging recommendedeven if conventional radiographs are unremarkable ifthere is6,41,43,44,49-57:

○ 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/glenohumeraljoint 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-traumaticacromioclavicular pain

N. B. Presence of a red flag alone may not necessarily indicatethe need for radiography. Most patients with chronicshoulder pain can be adequately evaluated withhistory, physical examination, and then started ona treatment protocol.If this treatment fails to relieve the symptomswithin 4 wk, advanced imaging with MRI maybe indicated.50

• In presence of a potentially serious pathology as suggestedby the patient history, examination and/or radiograph.The choice of imaging modality can be based on factors suchas the importance of ancillary clinical information (regardinglesions of the glenoid labrum, joint capsule, or surroundingmuscle and bone), the presence of an implanted device, patienttolerance, and cost.

• MRI is a sensitive diagnostic tool in secondary care and mayincrease specificity of Dx. MRI provides best imaging details


Table 1 (continued)


for evaluation of shoulder pathology (osteonecrosis, marrowand joint disease including infection) but is rarely used in theacute 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 isneeded (can show fracture complexity, displacement andangulation)

Chest CT: in case of suspected Pancoast's tumor, CT of thechest is optimal

Glenohumeral joint disordersGlobal pain and restriction of all activities and passive

movements, restricted passive external rotation

Consult specific clinical diagnoses and related patientpresentations for additional help in decision making.

Radiographs notinitially indicated

Radiological analysis in conditions such as subacromialimpingement, pathologies of the rotator cuff, and

Specific clinical diagnoses: (D) acromioclavicular degeneration should be interpreted in the1. Rotator cuff disorders (tendinopathy)40,44,58 Early radiograph

if soft tissuecalcification is

context of the symptoms and normal age-related changes.Degenerative changes including sclerosis of the medial end ofthe acromion and the distal end of the clavicle, inferior acromialand clavicular osteophytes, partial and full thickness tears arecommonly found during imaging of asymptomatic people.44,64

Most patients with rotator cuff disorders are older.Ruling out suspected comorbidities is important.Radiographs ofsubjects with a documented rotator cuff tear mayhave greater tuberosity abnormalities (sclerosis, osteophytes,subchondral cysts and osteolysis) not seen in asymptomatic

MC cause of shoulder pain.Acute: any age; chronic usually N40 YOA• History may reveal occupational heavy lifting, or

repetitive movements, especially above shoulderlevel; genetic susceptibility in some families

expected.

If radiographs areindicated (D)1. AP internal rotation

• Pain on abduction with thumb down, worse againstresistance and painful arc (70°-120°)

• No history of dislocation, instability, surgery, violenttrauma, or other shoulder disorder

2. AP external rotation3. Axillary view

Classified according to its clinical progression59: Additional view: subjects without a rotator cuff tear.64 Large lateralextension of the acromion appears to be associated withfull-thickness tearing of the rotator cuff.65

Potential causes of primary impingement that may be assessedwith radiographs include specifically: inferior A-C osteophytesand the type 3 acromion.

I Acute inflammation (tendinitis/bursitis) Y-scapula or A-CII Degeneration/chronic inflammation (tendinitis) joint viewsIII Rupture and arthritisA. 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 arc1. Y-scapula view may show hooked (type 3) acromion2. 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 bonyHigh-specificity tests (0.8): drop arm test, Yergason, speed,passive external rotation52,60,61 impingement 58

*Physical examination for impingement syndrome, superior labraltears and rotator cuff tear equally effective as US or MRI59

A. Impingement is a dynamic process that may be assessed by USDifferential Dx includes calcific tendinitis, cervicalradiculitis and viral plexopathy

Special investigations(C) B. Rotator cuff full and partial thickness tear: MRI, US are highly

accurate for full-thickness tears but much less sensitive andspecific for partial tears. MRA improves diagnostic accuracy.

B. Rotator cuff tear: traumatic in young people andatraumatic in elderly; there is strong evidence thatclinical tests are able to R/O full tears but havequestionable value for partial tears:52 3 positive testsor 2 if N60 YOA is predictive of a tear: supraspinatusweakness, external rotation weakness, Hawkins.62,63

MRI is gold standard.Routine preevaluationdoes not appear tohave significant effecton treatment outcome.

The size of rotator cuff tear and degree of fatty muscledegeneration appears to have the most pronounced influence onacromiohumeral distance. Quality of available studies on US isvariable.6,40,52,66-70

See Appendix C [C] for proposed risk factors for upperextremity tendinopathy including personal, psychosocial,physical, and systemic risk factors.

In addition, abnormalrotator cuff appearancein asymptomaticpatients N60 YOA isaround 54%.40,50,64

C. Calcifying bursitis within cuff tendons: calcifying bursitis cancause severe pain. If conservative treatment fails, consider MRIand referring patient for calcium puncture aspiration underfluoroscopy guidance.71

2. Adhesive capsulitis (frozen shoulder) Radiographs notroutinely indicated(D)

Radiographs are generally nonspecific (osteopenia may bepresent); a focal medial indentation along the proximal humeralneck has been reported for adhesive capsulitis. Radiographs arenot generally useful to diagnose adhesive capsulitis, but may beused 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

• N50% Loss of passive abduction and external rotation,33

usually loss of all ROM, pain at end range, nolocal tenderness

Special investigations(D)

•MRI with direct or indirect arthrogram to be considered beforemanipulation; thickness of capsule and synovium of the axillaryrecess N3 mm appears to be useful criterion for the Dx ofadhesive capsulitis on coronal oblique T2-weighted MRA

(continued on next page)


Table 1 (continued)


images without fat suppression73,74

Usually idiopathic, but may follow prolongedimmobilization, neck surgery, systemic disorders(diabetes), radiation therapy, and cerebral insult

Consider medical referral for distended arthrogram75 orintra-articular corticosteroid injection under fluoroscopyif conservative therapy fails.59

3. Osteoarthritis (DJD) Radiographsindicated if: (D)

Outcome from treatment not predicted by use of radiographyUsually ≥60 years old, progressive pain, crepitus,decreased end-ROM, tender joint • Unrelieved by 4 wk

of conservative care

Possible radiographic findings: humeral osteophytes, narrowedjoint space, irregularity of the humeral head, subchondral cysts,and sclerosis at the greater tuberosity in rotator cuff arthropathySpecific causes: rotator cuff arthropathy, after anterior

dislocation, arthritis, chondrocalcinosis, syringomyelia,systemic disease (RA or AS), primary osteoarthritis(rare), osteonecrosis

• Suspectedunderlying specificcause (pathology)

Supraspinatus outlet view for hooked acromionor osteophytes76,77

Osteonecrosis risk factors that can then lead to DJD:prolonged glucocorticoids, anabolic steroid abuse,humeral head fracture, systemic lupuserythematosus, sickle-cell anemia59

1. AP internal rotation2. AP external rotation3. Axillary view4. Y-scapula viewAdditional view:Supraspinatusoutlet view

4. Glenohumeral joint inflammatory arthritis Radiographsindicated (D)

Although uncommon, the glenohumeral joint may be involved inmost forms of inflammatory arthritis. In RA, erosions are usuallya 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 jointaspiration recommended for Dx and treatment

3. Axillary viewAdditional view:Grashey viewSpecial investigations(D/GPP)

Advanced imaging and rheumatologist referral recommended:• In suspected septic arthritis, consider MRI promptlyfor complete assessment of glenohumeral joint, preferablywith intra-articular gadolinium.

5. Glenohumeral instability40,79 Radiographsindicated (D)

Radiologic findings may be normal or reveal signs ofBankart lesion, Hill-Sachs deformity, loss of joint space.or an anteroinferior glenoid calcification. Neither prereductionnor postreduction films are likely to affect managementin emergency departments of patients with recurrentdislocation by an atraumatic mechanism.54,83

Usually between the ages of 20 and 35 y, Hx of dislocationor subluxation, positive apprehension sign 1. AP internal rotation

Generalized ligamentous laxity (in multidirectional andvoluntary instability)

2. AP externalrotation

Several types (categories): 3. Axillary view51

Anterior (MC) 4. Y-scapula view Acute anterior and posterior dislocation should be referred to anorthopedic specialist even if shoulder is reduced. The arm shouldbe placed in a simple sling. It should be noted that somepractitioners with specialized training such as sports ororthopedic diplomates can manage recurrent dislocations.Some also handle first-time dislocations.

Posterior (dislocation often not recognized)MultidirectionalVoluntary or habitual instability (may be associated withpsychological disorders)

Clinical assessment of joint position; excessive glenohumeraltranslation produces apprehension, pain, or dysfunction: Special investigations

(C)Advanced imaging and specialist referral recommended:

Although not very sensitive, the anterior drawer, theapprehension, and the surprise tests are specific and predictiveof traumatic anterior instability. Apprehension is a bettercriterion than pain. The relocation test adds little to the value ofthe tests.80,81 Positive results suggest involvement of theanterior or the superior glenoid labrum, respectively.82

• In the acute setting, conventional MRI nicely showslabral, Bankart, ligamentous, and tendinous injuries thatresult from dislocations and can lead to instability. In thesetting of chronic instability, MRA best evaluates theselesions. In the postoperative shoulder, multislice CTarthrography may be the modality of choice, but furtherinvestigation is needed.84

Tears of the labrum, the capsule, or the glenohumeralligaments can lead to pain, catching, popping or instability.The evidence suggests that clinical tests have moderatesensitivity and specificity for instability and labrumtears (quality of studies questionable)52

• Glenoid labrum and synovial cavity well delineated byarthrogram with CT and with MRI.40,85 Gradient-echo MRIcan show labrum without arthrography or proton densityfat saturation protocols.6,40

Dislocation may result in rotator cuff tears in middle-age orolder age groups. Patients may show ongoing symptoms ofpain, weakness, and dysfunction.

See Levine and Flatow62 for additional reading


Table 1 (continued)


Adult patients with significant shoulder/glenohumeraljoint trauma40,44

Radiographsindicated (B)

• R/O fracture-dislocation in blunt trauma and concurrent nerveinjuries, especially with anterior dislocation

Radiographic examination is appropriate if there is traumasufficient to produce fracture or dislocationwith accompanyingsigns/symptoms compatible with fracture or dislocation.

1. AP neutral view(do not move theshoulder)

• Common occult fractures include avulsion (“flap”) fractures ofthe greater tuberosity (tubercle).

• Loss of normal shape, palpable mass or deformity 2. Y-scapula view(lateral in scapularplane)

Y-scapula view: to visualize shoulder dislocation and fracture ofthe scapula; some dislocations may present subtle signs.

• Examination is unable to localize anatomical structureresponsible for patient symptoms.

Additional views should be taken if fracture is suggested but notfound 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* (adaptedfrom Fraenkel43)

Additional view:xtransthoracic lateral

Patients unlikely to require initial radiographicexamination if there is: Special

investigations40,49

(D)

Advanced imaging and specialist referral recommended:1. No precipitating fall and no swelling, palpable mass ordeformity;

Repeat films in 10 days if a fracture remains a possibility afternormal initial evaluation or refer for CT scan. Callus formation orabnormal alignment may be present.882. A fall, but no swelling, palpable mass or deformity, and

no pain at rest • MRI provides best imaging details for evaluation of shoulderpathology 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 injuryevaluation.Clinical decision rule in suspected shoulder dislocation may

include* 86:• First-time dislocation• Blunt trauma (fall N1 flight of stairs, assault, or motor

vehicle crash)• When the clinician is uncertain of the joint positionClinical decision rule in suspected fracture-dislocation may

include*87:• First-time dislocation• Blunt trauma (fall N1 flight of stairs, a fight/assault episode,

or a motor vehicle crash• Age N40 y*Prospective validation needed

A-C joint disorders Radiographs notinitially indicated innon traumaticorigin (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 commonin the asymptomatic population.40,64,89

Teenage to 50 y of age. Usually secondary to trauma orosteoarthritis. Pain localized to the A-C joint andpossible swelling.4

If radiographsindicated (D)

To exclude an A-C joint separation. Determine normal variationin movement from injured side. There is no real benefit ofconventional radiography for types I, II, and III A-C jointdislocations as they confirm the obvious and are normally treatedconservatively. Types IV, V, and VI A-C joint dislocations shouldbe referred to an orthopedic surgeon after conventionalradiography.90,91

A. Acute A-C joint injuries have a limited differential Dx.Traumatic A-C joint injury frequently occurs with otherfractures, dislocations, or soft tissue injury around theshoulder. Look for joint deformity, swelling andtenderness, superior clavicular pain, pain with crossbody 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 jointsuggesting high-grade injury.

Stress radiographs(bilateral comparison)57

Conventional radiography may also help excludeposttraumatic osteolysis in “Weight lifter's shoulder.”

B. Chronic injuries of the A-C joint also clearly diagnosed byappropriate physical examination and radiographs. Injuryto 1 shoulder component predisposes to other shoulderinjuries. A thorough examination may reveal otherassociated abnormalities that may not be part of thepresenting complaint. Suspected isolated arthritis(sequela of type II A-C joint injury)

Special investigations(D)

Conventional radiography is insensitive to A-C joint degenerativechanges compared to MRI.92 Reactive bone edema on MRI is a morereliable predictor of symptomatic A-C joint pathology thandegenerative changes seen on MRI and, when correlated with clinicalexamination, is reproducible.90MRI also allows assessment of adjacentsoft tissue structures and their effect on the underlying rotator cuff.92

C. Impingement syndrome associated with inferior A-Costeophytes and type 3 acromion may be assessedusing plain films • CT/MRI useful for pathological/surgical cases, especially in

separations of types IV-VI as vascular/ neurologicalcomplications can result.

• US if CT and MRI not available93


Table 2. Adult Elbow Disorders


Adult patients with full or limited movement and nontraumatic elbow pain of less than 4-wk duration

Radiographs not initiallyindicated (C)

The incidence of elbow complaints is ∼7.2 per1000 patients per year and the reported 12 monthperiod prevalence is 11.2% in the Netherlands. Elbow painaccounts for 2%-3% of total lost workdays and 5%-6%of workers' compensation claims.47,94

The 2 important diagnoses to consider are lateral andmedial epicondylitis. Elbow complaints seldom occur inisolation. Patients often complain of neck, shoulder,arm, or hand problems as well. A complete examinationof 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 upperextremity tendinopathy including personal,psychosocial, physical, and systemic risk factors.

• Chronic epicondylitis• Suspected nerve entrapment or mass, collateral ligamenttear, biceps tendon tear and/or bursitisConventional 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 include40,41,49,95-97: Indicated before otherimaging studies (B) APin full extension, lateralat 90° and medialoblique views

• No response to care after 4 wk;• Significant activity restriction N4 wk;

Additional views:

• Non mechanical pain (unrelenting pain at rest, constantor progressive symptoms and signs, pain not reproducedon assessment)

AP in pronation• Red flag indicatorsTangential (axial)○ Hx of cancer, S&S of cancer, unexplained deformity,

palpable enlarging mass, or swelling, significantunexplained elbow pain with no previous films (tumor?)○ Red skin, fever, systemically unwell (infection?)

Special investigations (C) Advanced imaging and specialist referral recommendedeven if conventional radiographs are unremarkable ifthere 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 tooccupation and sporting factors

○ Trauma, acute disabling pain and significant weakness • In the absence of clinical improvement after 4 wk oftherapy○ Unexplained significant sensory or motor deficit

(neurological lesion?) • If function does not improve or deterioratesN. 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 suggestedby the patient history, examination, and/or radiographThe choice of imaging modality can be based on factorssuch as the importance of ancillary clinical information(regarding lesions of the ligament, tendon, muscle, andnerve, or other soft-tissue abnormality such as masses aboutthe 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 moreoptimal than a low-field magnet in evaluation of theelbow.96

• There is a lack of studies showing the sensitivity andspecificity 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 anabnormality with radiographs may be helpful whenconservative therapy is planned. In some cases, thefilms may reveal the underlying cause (eg,intra-articular osteocartilaginous body,hydroxyapatite deposition or calciumpyrophosphate crystal deposition)

AP in full extension,lateral at 90° andmedial oblique viewsAdditional views (C)AP in pronationTangential (axial)

Special investigations (C) Advanced imaging and specialist referral recommended:When the etiology is uncertain and the patient has failedappropriate conservative therapeutic trial (seerecommendation above)95,97


Table 2 (continued)


Specific clinical diagnoses:1. Lateral epicondylitis (tennis elbow) Radiographs not initially

indicated (C)Elbow radiographs are generally unremarkable in lateralepicondylitis; although up to 20% of patients canhave calcification in the area of the epicondyle.95,97

Epicondylar pain and tenderness at the elbow laterallyAND 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 theprevalence in high-risk groups is as high as 15%, withwomen N40 YOA commonly affected. Lateral epicondylitisresults in an average of 12 wk of absenteeism in as many as30% of persons afflicted.47,95

Differential diagnoses include lateral collateral ligamenttear, radiocapitellar joint instability, bursitis, synovitis,arthritis, chondromalacia, osteochondritis dissecans,stenosis of the orbicular ligament, anconeuscompartment syndrome, posterior interosseus nerveor radial nerve radiculopathy, and radial tunnelsyndrome.95

Special investigationsnot indicated (C)

• MRI and CT are usually not necessary in the clinicalevaluation of lateral epicondylitis.94,99 MRI may behelpful for confirming refractory cases and to excludeassociated tendon and ligament tear.95

2. Medial epicondylitis (Golfers' elbow) Radiographs notinitially indicated(C)

Elbow radiographs are generally unremarkable in medialepicondylitis, although up to 25% of patients can havecalcification in the area of the epicondyle.94,101

Epicondylar pain and tenderness at the elbow mediallyAND pain on resisted wrist flexion.100

The prevalence of medial epicondylitis in a work populationranges from 4%-5% with an annual incidence estimate of1.5%, accounting for 10%-20% of all epicondylitis Dx94Differential diagnoses include medial collateral ligament

instability or tear, ulnar trochlear synovitis,chondromalacia, arthritis, and cervical radiculopathy.94

Special investigationsnot indicated (C)

• MRI and CT are usually not necessary in the clinicalevaluation of medial epicondylitis. MRI may be helpfulfor confirming refractory cases and to exclude associatedtendon and ligament tear.95

Adult patients with localized elbow pain after trauma1 Radiographs indicated(C)

Conventional radiography remains the mainstay of imagingwhen evaluating elbow trauma. Injury may result fromdirect trauma or force that is transmitted axially from thewrist and forearm.104

AP in full extension,lateral at 90° and medialoblique 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 theelbow 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 adisplaced anterior fat pad outward from the humerus[“sail sign"]). A significant joint effusion is associatedwith a radial head fracture in 80% of cases. A visibleposterior fat pad should be considered a radial headfracture until proven otherwise.

Instability tests—lateral pivot-shift apprehensiontest (most sensitive), lateral pivot-shift test,posterolateral rotary drawer test, stand up test103

AP in pronationTangential view (axial)

• MRI is increasingly used for the determinationof associated injuries of the lateral and medialcollateral ligaments and cartilage

Lateral stress view

Special investigations(GPP)

Diffuse non-specific pain in the forearm (or wrist) Radiographs not initiallyindicated (D)

Proximal causes of forearm and wrist pain such as cervicalspine and brachial plexus disorders need to be considered.Electrodiagnostic studies may be useful if pain ofperipheral 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 conventionalradiography. Common fractures include Colles', (distal radiusand ulna), Smith's (reverse Colles' fracture), Galeazzi's(fracture-dislocation of the distal radius/ulna), nightstickfracture (mid ulnar shaft fracture), and Monteggia fracture(proximal ulnar shaft fracture and displaced radius).104

Forearm views should be ordered when there is suspicion ofabnormality to the mid portion of the radius or ulna.Suspected trauma to either the wrist or elbow requiresviews of the involved anatomical region.100,103,104

AP and lateral views.


Table 3. Adult wrist and hand disorders


Adult patients with non traumatic localized wristand hand pain symptoms105,106

Radiographs not initiallyindicated (D)

The reported 12 month period prevalence of wrist andhand pain symptoms is 17.5% in the Netherlands.47

Obtaining a thorough history is essential. Age shouldbe considered, particularly when evaluating chronicwrist pain, because there is a direct relationshipbetween age and cartilage and ligament attrition.107

Ganglion cysts occur 70% of the time on the dorsum ofthe wrist but can occur on the volar region in the area ofthe trapeziotrapezoid joint. Imaging is generally nothelpful.108

Standard views of the wrist (flexed fingers) differ fromstandard views of the hand (fanned fingers).

General indications for radiographsinclude40,41,49,106,109:

If radiographs are indicated (C) Conventional radiography should be the study ofchoice and can identify many areas of pathology.

• No response to care after 4 wkPA, lateral, and medial obliqueviews of the wrist or hand

• Significant activity restriction N4 wk Critical differential Dx:• Nonmechanical pain (unrelenting pain at rest,constant or progressive symptoms and signs, painnot reproduced on assessment)—eg, Keinbock'sdisease

Additional views: • Osteonecrosis

• Red flag indicators

Radial and ulnar deviation viewsor clenched fist views are reservedfor more subtle problems107

• Septic arthritis

○ S&S of cancer, unexplained deformity, palpableenlarging mass, or swelling, significant unexplainedwrist pain with no previous films (tumor?)

• Osteomyelitis

○ Red skin, fever, systemically unwell (infection?)

• Acute fractures and avulsion fractures

○ History of noninvestigated trauma, loss of mobilityin undiagnosed condition, loss of normal shape(unreduced dislocation? Instability?)(see ‘Acute wrist trauma')

• Malignant tumors

○ Trauma, acute disabling pain and significantweakness

Special investigations (D)

○ Unexplained significant sensory or motor deficit(neurological lesion at the wrist?)

The combination of standardradiographs and US can diagnosea wide variety of disorders.110

Careful Hx, physical examination, radiograph, US andbone 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 arthropathiesof wrist and hand.

MRI is the procedure of choice toexclude osteonecrosis, marrow andjoint disease includinginfection.111

Advanced imaging and specialist referralrecommended:

Specific indications for radiographs include106:

Some lesions cannot be detected by US (carpalligaments and triangular fibrocartilage tears as well ascartilage and bone marrow disease) and requireadvanced modalities (CT, MRI, CT arthrography, andMRA).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, carpalligamentous injuries such as the scapholunate andlunotriquetral ligaments, ulnar impaction syndrome,occult fractures, bone marrow abnormalities, and softtissue abnormalities but lack sensitivity or accuracy forcartilage 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 perilunateinstability, dorsal and volar intercalated segmentalinstability, scapholunate advanced collapse,scapholunate dissociation, ulnar translocation ofthe wrist104-106,109 (see ‘Acute wrist trauma')

• Bone scan may be useful in assessing AVN andneoplasm.104

• Possible operative candidate

See Appendix C [C] for proposed risk factors for upperextremity pain and sickness absence including personal,psychosocial, physical, and systemic risk factors.

Consult clinical presentationwith related specific clinicaldiagnoses for additional help in decision making.

Specific clinical diagnoses:

1. Tendinopathy of the wrist Radiographs not initiallyindicated (D)

There is poor evidence to suggest secondary signs onimaging unless associated with arthropathy.Tendinosis* and paratendinitis** (stenosing

tenosynovitis) are responsible for most clinicaldisorders of tendons in the upper extremity.115 If radiographs are indicated (D)

Consider conventional radiography, in persistentpainful “soft tissue injuries,” not only to excludebony injury but also to aid Dx of rare cases of acutespontaneous calcific peritendinitis of the hand andwrist.116

The Dx of tendinopathy is based primarily on the historyand physical examination. Pain and tenderness over aspecific tendonor tendon group are the hallmarks of thiscondition. Other findings include localized swelling,impaired function, crepitus, painwith passive stretchingof the tendon, and positive provocative testing.Tendinosis, however, can be asymptomatic.94

PA, lateral, and medial obliqueviews of the wrist

While 60% of all cases of tendinopathy are not workrelated,56 a significant increase in the number ofsuccessful work related claims is reported in severalcountries.117


Table 3 (continued)


* Tendinosis: intratendinous degeneration (commonlycaused by aging, microtrauma, vascular compromise)

** Paratendinitis: inflammation of the outer layer of thetendon (paratenon) alone.

2. De Quervain's tenosynovitis 2(stenosingtenosynovitis or tenovaginitis)

Radiographs not initiallyindicated (D)

Proposed physical risk factors94,100,117:Repetitive, forceful, radial deviation of the wrist withabduction and extension of the thumb and rapidrotational movements of the forearm with repetitivemovement and forceful ulnar deviation at the wrist.Associated activities and occupations for DeQuervain's include prolonged piano-playing, sewing,knitting, and weaving, carrying heavy object, farmlabor, working on a grinding or buffing machine.

The MC tendinopathy in the wrist predominantlyaffecting women (10 times more then men), aged 30-50 y; remains a clinical Dx with no indication forroutine imaging.94

Nonoccupational risk factors include RA and hormonalchanges associated with pregnancy and menopause.

Pain over the radial styloid and tender swelling of firstextensor compartment and either pain reproduced byresisted 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 areneeded to validate these techniques.104

Associated symptoms include warmth and crepitus.100

Differential diagnoses include: osteoarthritis of the1st carpometacarpal joint, Wartenberg's syndrome,Kienbock's disease, triscaphoid arthritis, andintersection syndrome.94

∼1/3 of patients may have associated conditions, suchas cervical spondylosis, CTS, ganglion, triggerfingers, lateral epicondylitis, and RA.94

3. Carpal Tunnel Syndrome (CTS)100,118,119 Radiographs not initiallyindicated (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 havebeen considered the gold standard for Dx of CTS.

Proposed risk factors100,117:Pain or paraesthesia or sensory loss in median nervedistribution 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), Thenaratrophy (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 andhigh frequency of repetition; vibration tools; activitiesthat frequently flex or extend the wrist

Clinical prediction rule (level IV)120:1. Age N45 y

Sensory and motor nerve conduction studies have arelatively high sensitivity and modest specificity toassess/document functional status of neurologicalelements.121,122

2. Shaking hands for symptom relief3. Reduced median sensory field of thumb

Special investigations (D) • Advanced imaging reserved for patients withequivocal presentation or with diabetes and diffuseperipheral neuropathy that confounds electro-diagnostic studies.123 MRI may be used to imageanatomical abnormality (eg. space-occupying lesionsuch as a ganglion).114 US may be a usefulalternative.57 High-resolution sonography mayshow median nerve enlargement and accentuatedhypoechogenicity.124

4. Wrist-ratio index (carpal canal volume) N.675. SSS score (Brigham and Women Hospital) N1.9

Likelihood of CTS increase with no. of positive tests(18.3 or 90% when all 5 tests positive)

4. Osteoarthritis Radiographs not initiallyindicated (D)

It is common to have incomplete concordance betweenpathological changes, radiographic and clinical featuresin OA.

MC locations—1st carpometacarpal joints, distalinterphalangeal joints. Less commonly , triscaphe(scaphoid-trapezium-trapezoid) and at the wrist (posttraumatic), radiocarpal.100

History:• N50 YOA• Morning joint stiffness b30 min



Table 3 (continued)


Physical examination:• Crepitation• Bony tenderness• Bony enlargement• No palpable warmth

Other characteristics include: long-standing pain, noextra-articular symptoms; non-responsive to NSAIDor corticosteroid medication; relieved with rest;deformity or fixed contracture, joint effusion;insidious onset.125

5. Inflammatory or crystal inducedarthropathy40,100,126

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 andjoint effusion

PA, lateral, and medial oblique ofthe wrist and hand

Dx of inflammatory arthritis is primarily based onhistory and physical examination:

Critical differential Dx100:

• Unrelenting morning stiffness N30 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 referralrecommended even if conventional radiographsare unremarkable:

• Palpable warmth • If routine radiographs are normal or nondiagnostic,MRI is the study of choice.40,128 biopsy/aspiration toR/O infection.106

• Joint effusion

• Gadolinium-enhanced MRI of the hand and wrist is asuperior technique for detection of tenosynovitis ininflammatory 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 strategiesfor baseline documentation of polyarticularinvolvement.

6. RA40 Radiographs indicated (C) Findings consistent with inflammatory arthritis:erosions of periarticular/ articular surfaces and intra-articular radiodensities associated with erosion andjoint effusion.

PA, lateral, and medial obliqueviews of the wrists and hands

Symmetrical polyarticular involvement of wrist,metacarpophalangeal and proximal interphalangealfinger joints. (Norgaard's/ball catcher

projection)133

Radiographs of the hands, feet, and chest arerecommended at the initial evaluation. Radiographsof the feet and hands should be repeated annually forthe first 3 y of disease evolution, and thereafter asdeemed appropriate.130

The total number of affected joints increases over the1st year of illness.100

In suspected RA, feet radiographs may show erosionseven when symptomatic hand (s) appear normal in23-36% of cases in first 2-3 y of disease.130

The evaluation and monitoring of RA should be basedon a systematic evaluation of a minimum set ofparameters including joint pain and inflammation,the patient's global assessment of pain, globalassessment of disease, functional disability, acutephase reactants, and radiologic evidence ofdamage.130

Cervical spine involvement occurs in over half ofpatients with RA and atlantoaxial subluxation(AAS) develops in over 12% of patients withRA. There is a strong correlation between a Larsonerosion score for hand and wrist joint damage N50,RA duration of N10 y, disease onset before age 50,number of previous disease modifying drugs andRA related surgery and AAS. It is important torecognize that many patients acquire AAS in thefirst 3 y of their disease, but neurologicalimpairments develop after a mean period of 18 y(range, 4-50 y).139-142

RA diagnostic criteria (≥4 of 7 required)131,132:• Morning joint stiffness N1 h• Arthritis involving ≥3 joints for at least 6 wk• Hand arthritis (wrist, MCP, PIP)• Symmetric arthritis• Rheumatoid nodules• Serum RH factor• Radiographic changes


Table 3 (continued)


Special investigations40,134-136 (C) Advanced imaging and specialist referralrecommended even if conventional radiographsare unremarkable:

MRI highly sensitive and oftenmore specific than US; detection ofsynovial pannus, erosions, cartilageloss, small subchondral cysts andmarrow edema distributionMRI, US, and NM all show jointeffusion.137,138

Unless aimed at some specific medical procedure,special investigations should be minimized unless theyhave some value for the patient.

• MRI is the modality of choice in early Dx andmanagement of RA.143 MRI helps differentiateerosive from nonerosive disease.127

• 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 conventionalradiography with increased density.104PA, lateral, and medial oblique•Keinbock's disease is AVNwith 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 toevaluate bone marrow changes inearly stages.114

MRI, CT, bone scan (high sensitivity but lowspecificity); gadolinium-enhanced MRI is consideredto be the best technique for detecting establishedAVN.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 referralrecommended:

• Sudek's atrophy

• MRI is useful in detecting numerous soft tissue andearlier bone and joint processes that are not depictedoras well characterized with other imaging modalities.

• 3-Phase NM scan recommended if radiograph is notdiagnostic (Sn: 0.10; Sp: 0.8; positive predictivevalue: 54%; negative predictive value: 100%)145

At least 4 of the following must be present in order for aDx 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 thedistal radioulnar joint, instability of the lunate-triquetrum or scapholunate areas, chondromalacia, ofthe lunate or ulnar head, and either dorsiflexed or volarflexed intercalated segmental instability.104

Typically produces ulnar-sided wrist pain, which maybecome chronic and associated with clicking orpopping sounds with certain movements.

PA, lateral, and medial oblique104

Lesions of the TFCC can be traumatic or degenerative,with the incidence of degenerative lesions increasingwith age.

Special investigations (D) Advanced imaging and specialist referralrecommended:

* The TFCC consists of the triangular fibrocartilage, thedorsal and palmar radioulnar ligaments, the ulnocarpalmeniscal homologue, the dorsal and palmar ulnocarpalligament, the sheath of the extensor carpi ulnaristendon and the capsule of the distal radioulnar joint.

• MRI and Gadolinium-enhanced MRI.114



Table 3 (continued)


10. Stenosing Tenosynovitus (trigger finger of TF) Radiographs not initiallyindicated (D)

A staging system for trigger finger has been proposedbased on the grade of mechanical involvement noted onexamination: from normal finger movements (stage 1)to locked finger in flexion or extension (stage 6). Eachstage may be painless or painful. Essentially, onlydigits locked in flexion require surgical intervention.96

Intermittent, troublesome locking of the digit inflexion.100

Trigger finger is more common in women 40-60 YOAand in patients with diabetes, RA, gout, and otherconnective tissue disorders.146

The Dx is essentially clinical, radiographs areunnecessary. Patients typically present with aninsidious onset of morning pain and snapping,clicking, locking, or stiffness in the affected digit.A painful nodule may be palpable at the distalpalmar crease. The nodule may move during activemovement.94

Acutewrist trauma in the adult patient40,104-106, 109, 147 Radiographs indicated (C) In females over 50 YOA, life time estimated risk ofosteoporotic wrist fractures is 16%71PA, lateral and pronation-oblique

views (medial oblique) of thewrist57

The following evaluation helps predict or R/O fractureswhen no deformity is present:148

Fractures may not be visible at initial presentation;repeated films after 10-14 d if a fracture remains apossibility or before proceeding with specialinvestigation.157

• Pain on passive and active motion

A. Additional views (D) Because the wrist has a complicated anatomy withmany structures overlying each other (particularly onthe lateral view), it is prudent, as in all other situations,to have radiographs of traumatic wrist injuries carefullyscrutinized by a radiologist to confirm that a pathologiccondition 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 widescapholunate space, consider adding palmar flexion anddorsiflexion views of the wrist in the lateral projectionon either conventional radiography or fluoroscopy.Search for proximal migration of capitate and openingand closing of the scapholunate joint on radial and ulnardeviation views.158,159

3. Maximal wrist extension andulnar deviation153

A. Scaphoid fracture:

Advanced imaging and specialist referralrecommended:

Accounts for 70%-80% of all carpal fractures. MC inyoung active males. Risks of non-union, arthrosisand AVN:149

B. Additional views (D)

• Increasing use of MRI as only examination for*:

• Anatomical snuffbox tenderness

Stress radiographs154,155 (includePA w/ closed fist to stress scapho-lunate 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 consequencesof carpal fracture, particularly of the scaphoid.

• CT scan is valid for demonstrating or ruling out ascaphoid fracture and is superior to NM.160

B) Suspected lunate instability:Pain centered over the dorsal wrist immediately ulnar to

the extensor carpi radialis tendonsPain and abnormal movement noted on Watson test;

* specialized testing may be indicated earlier in suchcase

• Consider bone scan (NM) in persistent cases of posttraumatic wrist pain even if repeat radiographs arenormal due to false negative rates of radiography forcarpal fracture.161


Table 3 (continued)


Acute hand and finger trauma in theadult patient162

Radiographs indicated (D) Common fractures encountered in the hand include:Bennet's fracture, Rolando's fracture, Pseudo-Bennett'sfracture, Gamekeeper's thumb,Mallet finger, phalangealfractures, Flexor digiturum profundus avulsion163

1. Hand: PA, lateral andpronation-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 thethumb)

Additional views: stress view ofthe thumb (GPP)

Stress view to identify gamekeeper's thumb (possibleavulsion fracture of the proximal phalangeal base of thethumb) is now considered contraindicated in case of aStener lesion.

Special investigations (D) Advanced imaging and specialist referralrecommended:• Consider advanced imaging (MRI, US, or arthro-

graphy) in suspected Stener lesion (entrapment ofthe ulnar collateral ligament) with gamekeeper'sfractures.164


Duration of DisordersIn clinical practice, musculoskeletal disorders are generally

divided into categories according to the duration of the patientcomplaint on initial presentation. These diagnostic imagingguidelines therefore consider the following categories ofclinical presentations: acute extremity disorder (b4 weeksduration), subacute extremity disorder (4-12 weeks duration),and persistent/chronic extremity disorder (N12 weeksduration).

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 neurologicscreening and to discriminate between articularinvolvement and referred pain.

• These guidelines may assist with diagnostictriage (extremity pain with or without restric-tion of activity of daily living or presence ofred flags).

• Radiographs are not initially indicated for nonspe-cific shoulder, elbow, wrist, and hand pain.

• Consider conventional radiography after blunttrauma, and if there is no improvement after4 weeks of conservative care or increasingdisability.

• Consider conventional radiography and specializedimaging in the presence of red flags.

Are There Potential Risks Associated with Conventional Radiographs?Although somewhat controversial,19-22 it is important to

remember that health hazards of all forms of radiation arecumulative.22-29 The Biological Effects of Ionizing Radiation(BEIRVII) 2005 report released by the National Academy ofSciences adds further support to the “linear-no-threshold”model of cancer risk from ionizing radiation exposure.30 Insummary, this report concludes that ionizing radiation isdangerous even at low doses and that there are no safe limits.Given the potential risks associated with conventionalradiographs, only appropriate clinical indications can justifyits use. In this regard, the need to confirm pathology, to followthe evolution of a pathology possibly affecting therapy, or toidentify a clinically suspected contraindication to manipula-tive therapy are the best-documented reasons. The benefits ofall diagnostic studies must outweigh the risks and the inherentcosts to the patient.9,31-39

Tables 1-3 list the patient presentations, recommenda-tions, and comments regarding diagnostic imaging for upperextremity disorders. A list of abbreviations and glossary ofterms 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 advancedimaging are in Appendix D. Typical effective ionizedradiation dose for common imaging procedures are listedin Appendix E. Further recommended reading pertaining tomagnetic resonance imaging of the upper extremity isoffered in Appendix F.

ACKNOWLEDGMENT

We are appreciative of the efforts of the many people whoassisted in this process, listed in Appendix G.


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152. Daffner RH, Emmerling EW, Buterbaugh GA. Proximal anddistal oblique radiography of the wrist: value in occultinjuries. J Hand Surg [Am] 1992;17:499-503.

153. Wollstein R, Wandzy N, Mastlla DJ, Carlson L, Watson HK.A radiographic view of the Scaphotrapezium-Trapezoid joint.The Journal of Hand Surgery 2005;30A:1161-3.

154. Özçelik A, Günal İ, Köse N. Stress views in the radiographyof scapholunate instability. Eur J Radiol 2005;56:358-61.

155. Schädel-Höpfner M, Böhringer G, Gotzen L, Click I. Tractionradiography for the diagnosis of scapholunate ligament tears.J Hand Surg [Br] 2005;30B:464-7.

156. Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging—orthopaedics. Philadelphia, Pa: Elsevier; 2004. p. 38.

157. Newberg A, Dalinka MK, Alazraki N, Berquist TH, DaffnerRH, DeSmet AA, et al. Acute hand and wrist trauma.American College of Radiology. ACR AppropriatenessCriteria. Radiology 2000;215(Suppl):375-8.

APPENDIX A. LIST OF ABBREVIATIONS AND GLOSSARY FOR UA-C joint: Acromio-clavicular jointAP: AnteroposteriorAS: Ankylosing spondylitisOsteonecrosis: Avascular necrosisCPPD: Calcium pyrophosphate dihydrate cryCNS: Central nervous systemCRPS: Complex regional pain syndromeCT: Computed tomographyCTS: Carpal tunnel syndromeDJD: Degenerative joint diseaseDx: DiagnosisGHQ questionnaire: General Health Questionnaire HistoryIAB: Intra-articular osteocartilagenous bodJRA: Juvenile rheumatoid arthritisMC: Most commonMRA: Magnetic resonance arthrographyMRI: Magnetic resonance imagingNM: Nuclear medicine (bone scan)PA: PosteroanteriorROM: Range of motionR/O: Rule outRA: Rheumatoid arthritisSp: SpecificitySn: SensitivitySSS: Symptom Severity ScaleTendinosis: Degeneration of tendons and of tendoTF: Trigger fingerTFCC: Triangular fibrocartilage complexUS: UltrasoundX-ray: Plain film radiographYOA: years of ageN: Greater than≥: Equal or greater thanψ: psychology/psychiatry

158. Souza TA. Differential diagnosis and management for thechiropractor, Third Edition: protocols and algorithms. 3rd ed.Gaitherburg: Aspen; 2005. p. 251.

159. Lichtman DM, Gaenslen ES, Pollock GR. Midcarpal andproximal carpal instabilities. In: Lichtman DM, AlexanderAH, editors. The wrist and its disorders. 2nd ed. Philadelphia,PA: Saunders; 1997. p. 316-28.

160. Breederveld RS, Tuinebreijer WE. Investigation of computedtomographic scan concurrent criterion validity in doubtfulscaphoid fracture of the wrist. J Trauma 2004;57:851-4.

161. Ivers RQ, Cumming RG, Mitchell P, Peduto AJ. The accuracyof self-reported fractures in older people. J Clin Epidemiol2002;55:452-7.

162. Dubert T. Fracture récentes des articulations IPP—Acute PIPjoint fractures. Chirurgie de la Main 2005;24:1-16.

163. Helms CA. Fundamentals of skeletal radiology. 3rd ed.Philadelphia, Pa: Elsevier Saunders; 2004. p. 235.

164. Greenspan A. Orthopedic imaging—a practical approach. 4thed. Philadelphia, Pa: Lippincott, Williams and Wilkins; 2004.p. 209.

PPER EXTREMITY DISORDERS

stal deposition disease

y

n muscle attachments

APPENDIX B. SUMMARY OF RECOMMENDATIONS

Table 1. Summary of recommendations—adult shoulder disorders

Patient presentation Recommendations

Adult patients with full or limited movement andnontraumatic shoulder pain of less than 4-wk duration

Radiographs not initially indicated (B)

Patients unlikely to require initial radiographic examinationif: no precipitating fall, no sudden onset of pain or swelling,no palpable mass or deformity; no pain at rest, and normalROM (adapted from Fraenkel et al43—prospectivevalidation needed)

General indications for radiographs include: If radiographs are indicated (C)• 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 N4 wk• Nonmechanical pain (unrelenting pain at rest, constant

or progressive symptoms and signs, pain not reproducedon assessment)

Additional views: PA chest view, cervical spine AP and lateralviews, Grashey view

• Red flags indicators:Advanced imaging and specialist referral recommended even ifconventional radiographs are unremarkable if there is: (C)

Most patients with chronic shoulder pain can be adequatelyevaluated with a history, physical examination, andplain 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-traumaticacromioclavicular pain

• In presence of a potentially serious pathology as suggested by thepatient history, examination, and/or radiograph

Special investigations (B)MRI, ultrasonography, CT

Glenohumeral joint disordersConsult specific clinical diagnoses and related patient presentations

for additional help in decision making.


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 viewII. 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 andtenderness, 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, passiveexternal rotation. A. Impingement is a dynamic process which may be assessed

by USB. Rotator cuff tear: traumatic in young people and atraumatic

in elderly; there is strong evidence that clinical tests are ableto rule-out full tears but have questionable value for partialtears: 3 positive tests or 2 if N60 YOA is predictive of atear: supraspinatus weakness, external rotation weakness,Hawkins

B. Rotator cuff full and partial thickness tear: MRI, US, MRAimproves diagnostic accuracyC. 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 activitiesSpecial investigations (D)• MRI with direct or indirect arthrogram

• N50% loss of passive abduction and external rotation, usuallyloss 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-scapulaview (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 completeassessment of glenohumeral joint, preferably with intraarticulargadolinium

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-scapulaview (lateral in scapular plane)

Generalized ligamentous laxity (in multidirectional and voluntaryinstability) 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 jointtrauma

Radiographs indicated (B)

Radiographic examination is appropriate if there is trauma sufficientto produce fracture, or dislocation, with accompanying signs/symptoms compatible with fracture or dislocation.

AP neutral view (do not move the shoulder), Y-scapula view (lateralin scapular plane), axillary view (if possible)

• Loss of normal shape, palpable mass or deformityAdditional 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 afternormal initial evaluation or refer for CT scan. Callus formation orabnormal alignment may be present.• MRI

Clinical decision rule in suspected shoulder dislocation mayinclude*:

• US and CT arthrography

• First-time dislocation• Blunt trauma (fall N1 flight of stairs, assault, ormotor vehicle crash)• When the clinician is uncertain of the joint position

Clinical decision rule in suspected fracture-dislocation mayinclude*:

• First-time dislocation• Blunt trauma (fall N1 flight of stairs, a fight/assault episode, or

motor vehicle crash) or a motor vehicle crash• Age N40 y

* Prospective validation needed

Table 1 (continued)


A-C joint disorders Radiographs not initially indicated in non traumatic origin (C)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 viewsremains uncertain.

Special investigations (D)• CT/MRI useful for pathological/surgical cases, especially in

separations of types IV-VI as vascular/neurological complicationscan 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 nontraumaticelbow 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 N4 wk• Non mechanical pain (unrelenting pain at rest, constant orprogressive symptoms and signs, pain not reproduced onassessment)

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 painwith no previous films (tumor?)

Advanced imaging and specialist referral recommended even ifconventional radiographs are unremarkable if there is: (C)

— Red skin, fever, systemically unwell (infection?)

• Pain and significant disability despite attention to occupation andsporting factors

— History of noninvestigated trauma, loss of mobility inundiagnosed condition, loss of normal shape (unreduceddislocation? 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 (neurologicallesion?)

• History of instability, or acute, severe posttraumatic injury• In presence of a potentially serious pathology as suggested by thepatient history, examination and/or radiograph

• High-field-strength MRI provides greater detail than mid-field orlow-field MR systems.

• CT and US may be more optimal than a low-field magnet inevaluation 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 imagingrecommended (C)When the etiology is uncertain and the patient has failed appropriateconservative therapeutic trials (see recommendation above).


1. Lateral epicondylitis (tennis elbow) Radiographs not initially indicated (C)Epicondylar pain AND tenderness at the elbow laterally AND painon 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 elbowmedially AND painon 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 areliable indicator of osseous/joint injury

Table 1 (continued)


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Additional views (C): AP in pronation, tangential view (axial), lateralstress view

Instability tests–lateral pivot-shift apprehension test (most sensitive),lateral pivot-shift test, posterolateral rotary drawer test, and standup test

Special investigations (GPP)• Increasing use of MRI for the determination of associated injuries ofthe 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 painsymptoms

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 N4 wk• Non mechanical pain (unrelenting pain at rest, constant or

progressive symptoms and signs, pain not reproduced onassessment)—eg, Keinbock's disease

Additional views: radial and ulnar deviation views or clenched fistviews 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 noprevious films (tumor?)

Special investigations (D)

○ Red skin, fever, systemically unwell (infection?)

• The combination of standard radiographs and US can diagnose awide variety of disorders.

○ History of noninvestigated trauma, loss of mobility inundiagnosed condition, loss of normal shape (unreduceddislocation? 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, scapholunateadvanced collapse, scapholunate dissociation, ulnar translocationof the wrist—Trauma section

• Possible operative candidate

Consult clinical presentation with related specific clinical diagnosesfor additional help in decision making


1. Tendinopathy of the wrist Radiographs not initially indicated (D)Pain and tenderness over a specific tendon or tendon group are thehallmarks of this condition. Other findings include localizedswelling, impaired function, crepitus, pain with passive stretchingof the tendon, and positive provocative testing. Tendinosis,however, can be asymptomatic.

If radiographs are indicated (D)PA, lateral, and medial oblique views of the wristConsider conventional radiography, in persistent painful “soft tissueinjuries,” not only to exclude bony injury but also to aid Dx of rarecases of acute spontaneous calcific peritendinitis of the hand andwrist

Table 2 (continued)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -


Table 3 (continued)


2. De Quervain's tenosynovitis (stenosing tenosynovitis ortenovaginitis)


Pain over the radial styloid AND tender swelling of first extensorcompartment AND EITHER pain reproduced by resisted thumbextension OR positive Finkelstein's testAssociated 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'sor Phalen's, Thenar atrophy, female gender, obesity (body massindex ≥30), worsening of symptoms at night/awakening, orabnormal nerve conduction time

Clinical prediction rule (level IV): Special investigations (D)1. Age N45 y Advanced imaging reserved for patients with equivocal presentation

or with diabetes and diffuse peripheral neuropathy that confoundselectrodiagnostic 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) N.67

• High-resolution sonography may show median nerve enlargementand increased hypoechogenicity

5. SSS score (Brigham and Women Hospital) N1.9

Likelihood of CTS increase with number of positive tests (18.3 or90% when all 5 tests positive)

4. Osteoarthritis Radiographs not initially indicated (D)It is common to have incomplete concordance between pathologicchanges, radiographic and clinical features in OA.

1. History: age N50 y, morning joint stiffness b30 min2. Physical examination: crepitation, bony tenderness, bony

enlargement, no palpable warmth

Other characteristics include: long standing pain, no extraarticularsymptoms; 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 andphysical examination:

Special investigations (C)

• Unrelenting morning stiffness N30 min• If routine radiographs are normal or nondiagnostic, MRI is thestudy of choice; biopsy/aspiration to R/O infection

• Pain at rest • Gadolinium-enhanced MRI of the hand and wrist is a superiortechnique 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 viewsof the wrists and hands 1(Norgaard's/ball catcher projection)

Symmetrical involvement of wrist, metacarpophalangeal andproximal interphalangeal finger joints Radiographs of the hands, feet, and chest are recommended at the

initial evaluationRA diagnostic criteria (≥4/7 required):

Special investigations (C)• Morning joint stiffness N1 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


Table 3 (continued)

• 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 boneand joint processes that are not depicted or as well characterizedwith other imaging modalities

At least 4 of the following must be present in order for a Dx of CRPSto 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 withcertain 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


Patients typically present with an insidious onset of morning painand snapping, clicking, locking, or stiffness in the affected digit.A painful nodule may be palpable at the distal palmar crease. Thenodule 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 nodeformity is present:Pain on passive and active motion A. Additional views (D) PA ulnar deviation (20°), lateral oblique,

maximal wrist extension and ulnar deviationLocalized tenderness and edemaPain with grip and resisted supination

B. Additional views (D) stress tests (include PA with closed fist tostress scapholunate ligament)


Table 3 (continued)

A. Carpal navicular (scaphoid) fracture: Special investigations (C)Accounts for 70%-80% of all carpal fractures; MC in young

active malesIncreasing 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 movementnoted on Watson test. Specialized testing may be indicatedearlier 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 identifygamekeeper's thumb (possible avulsion fracture of the thumbproximal phalangeal base)

Special investigations (D)• Consider advanced imaging (MRI, US, or arthrography) insuspected Stener lesion (entrapment of the ulnar collateralligament) with gamekeeper's fractures.

APPENDIX C. PERTINENT CLINICAL INFORMATION

Shoulder disordersA. Comprehensive assessment of shoulder outcomesA comprehensive assessment of shoulder outcomes

would include a generic measure of health-related qualityof life, a shoulder-specific measure of function, and ameasure of patient satisfaction. The American Shoulderand Elbow Surgeons (ASES) subjective shoulder scale hasoverall acceptable psychometric performance (Test-RetestReliability, Internal Consistency, Content Validity, Criter-ion Validity, Construct Validity, Responsiveness) for out-come 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-derivedobjective assessment. The subjective patient self-reportsection consists of 2 equally weighted domains, pain andfunction. Pain is recorded on an ordinal scale, ranging from0 to 10, and accounts for 50% of the overall ASES score.Function accounts for the other 50% of the overall scoreand is divided into 10 questions with regard to difficultywith 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, participatingin work, and participating in sports.b

Job related mechanical exposure in both sexes isassociated with heightened risk for neck and shoulderpain. In women, job strain, psychological job demands, andlow job decision latitude correlate with increased risk.c

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

Factors predicting chronic shoulder pain mayinclude the followingd:

• Disability (independent of ROM)• Pain in a more narrowly defined region• Pain on examination• Symptoms lasting N1 year• A high score on the GHQ

Risk factors for long-term employee absenteeismmay includee,f:

• Excessive demands in the job• Repetitive movement• Vibration duration during employment• High psychological demands• Poor control at work• Poor social support• Job dissatisfaction• Non–work-related stress reactions


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

• Proposed personal risk factorsSex, age (N40 years), obesity (body mass indexN30), and poor muscular conditioning. In addi-tion, a complaint of baseline shoulder or neckdiscomfort, a history of carpal tunnel syndrome,and a job with a high shoulder posture rating arerelated to tendinitis

• Proposed psychosocial risk factors:Positive associations with high perceived jobstress, high quantitative job demands, and lowjob control (few good-quality studies)

• Proposed physical risk factors:Tension overload and shear stress are 2 mechan-isms most likely responsible for most upperextremity tendinopathies. Prolonged repetitiveuse (half to most of the time), exposed tostrenuous and/or repetitive work

• Proposed systemic risk factors:Pregnancy, diabetes, rheumatoid arthritis, gout,collagen vascular disease, Dupuytren's disease,thyroid disease, amyloid, and chronic renaldisease.

References

a. Kocher MS, Horan MP, Briggs KK, Richardson TR,O'Holleran J, Hawkins RJ. Reliability, validity, andresponsiveness of the American Shoulder and ElbowSurgeons Subjective Shoulder Scale in patients withshoulder instability, rotator cuff disease, and glenohumeralarthritis. 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, SidlesJA, Zuckerman JD. A standardized method for theassessment of shoulder function. J Shoulder ElbowSurg. 1994;3:347-52.

c. Östergren PO, Hanson BS, Balogh I, Ektor-AndersonJ, IsacssonA, Örbaek P,Winkel J, Isacsson SO. Incidence ofshoulder and neck pain in a working population: effectmodification between mechanical and psychosocial expo-sure at work? Results from a 1-year follow up of the Malmöshoulder and neck study cohort. J Epidemiol Communityhealth 2005;59:721-728.

d. Macfarlane GJ, Hunt IM, Silman AJ. Predictorsof chronic shoulder pain: a population based prospec-tive 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 systematicreview. Occupational and Environmental Med 2000;57:433-42.

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

g. Wainstein JL, Nailor TE. Tendinitis and tendinosis ofthe elbow, wrist, and hands. Clin Occup Environ Med2006; 5 (2) 299-322.

APPENDIX D. GENERAL INDICATIONS FOR ADVANCED

IMAGING IN EXTREMITY DISORDERS

Indications MRI CT NM US

Evaluation of neoplasm detected onconventional radiographs

++ +

Determining skeletal distribution of neoplasmsor 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 softtissue mass

++ ++

Osteonecrosis ++ + +Complicated fractures + ++Suspected stress, occult fracture + + ++Complicated disease processes or findingsunexplained 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 forImaging. 2002 (unpublished)

b Santiago RC, Gimenez CR, McCarthy K. Imaging of osteomyelitisand musculoskeletal soft tissue infec-tions: current concepts. Rheum DisClin North Am. 2003;29(1):89-109.

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


APPENDIX E. TYPICAL EFFECTIVE IONIZED RADIATION

DOSE FOR COMMON IMAGING PROCEDURES*

Class Typical effectivedose (mSv)

Examples

0 0 US, MRII b1 Radiograph: cervical and thoracic

spine, extremities, pelvis, and lungsII 1-5 Lumbar spine radiograph, NM,

cervical spine CTIII 5-10 Chest and abdomen CT

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

APPENDIX F. ADDITIONAL READING RECOMMENDED ON

MRI• 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 condi-tions. Clin Chiropr 2005;9:151-60.

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

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

• Wessely MA, Grenier JM. MR imaging of the wristand hand—A review of the normal imaging appearancewith an illustration of common disorders affecting the wristand hand. Clin Chiropr 2007;10(3):156-64.

APPENDIX G. ACKNOWLEDGMENTS

The authors express their sincere appreciation to allDelphi panelists (phase 5), external reviewers (phases 4 and7), and to the quality of literature assessors (phase 2):Jeffrey Cooley, Jonathon Egan, Michael Morgan, JulieO'Shaughnessy, and Jason Napuli, whose significantcontributions were essential in the completion of thisproject. We are grateful to chiropractic college presidentsfor recommending faculty members for the Delphi panel.We have appreciated the feedback received by colleaguesin the field during and after the worldwide consultation onthe Web (Phase 6). Many thanks to Dr. Andre Cardin ofUniversité du Québec à Trois-Rivières for his significantinput in the initial draft (phase 3), Dr. Michelle Wessely ofthe 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. CarloAmmendolia, DC, PhD, Joe Lemire DC, MSc, John Triano,DC, PhD, and Jacques Duranceau, MD for providingconstructive advice. The authors are indebted to those whoassisted 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, academicand technology support, Computer system developmentdivision at UQTR. Finally, we would like to thank Mrs.Vicki Pennick, RN, BScN, MHSc, Senior ClinicalResearch Project Manager, Managing Editor, CochraneBack Review Group, Institute for Work and Health for hervaluable advice and pertinent comments and suggestions asa public representative. We further apologize, once again,to those who experienced temporary technical difficultieswith the evaluation questionnaires at the onset of Websiteconsultations (Delphi, Public and External review).

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

Allan Adams, DC, MSEdTexas, USA, Texas Chiropractic College (Academic andResearcher)

Peter Aker, DC, MSc, FCCS, FCCRSOntario, CANADA (Clinician and Researcher)

Thomas F. Bergmann, DCMinnesota, USA, Professor, Northwestern Health SciencesUniversity (Academic, Clinician)

Douglas G. Brandvold, DCBritish Columbia, CANADA (Clinician)

Jane Cook, DC, DACBRBournemouth, UK, Anglo European Chiropractic College(Academic)

Jeffrey Cooley, DC, DACBRPerth, West Australia, Senior Lecturer, Murdoch University(Academic)

Vince DeBono, DCIllinois, USA, Dean of Clinics, National University ofHealth Sciences (Academic, Clinician)

Martin Descarreaux, DC, PhDQuebec, Canada, Université du Québec à Trois-Rivières(Researcher, Academic and Clinician)

Renee DeVries, DC, DACBRMinnesota, USA, Associate Professor and ConsultingRadiologist, Northwestern Health Sciences University(Academic)


Shawn Dill, DCCalifornia, USA, Professor, Life College Chiropractic West(Academic and Clinician)

Paul Dougherty, DC, FACONew York, USA, New York Chiropractic College(Academic)

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

Francis Fontaine, DC, MDQuebec, Canada, Lecturer, Université du Québec à Trois-Rivières (Clinician)

Simon Forster, DC, DABCOTexas, USA (Clinician)

Edward Fritsch, DCTexas, USA, Texas Chiropractic College (Academic andClinician)

Bryan Gatterman, DC, DACBRCalifornia, USA, Life West Chiropractic College(Academic and Clinician)

Claude Gauthier, DCQuebec, Canada (Clinician)

Kristin L. Grace, DC, DACBRHastings, New Zealand, Senior lecturerNew Zealand Chriopractic College(Academic and Clinician)

Gary Greenstein, DCConnecticut, USA (Clinician)

Julie-Marthe Grenier, DC, DACBRQuebec, Canada, Université du Québec à Trois-Rivières(Academic, Research)

Mitchell Haas, DC, MAOregon, USA, Dean of Research, Western StatesChiropractic College (Academic and Researcher)

Michael W. Hall, DC, DABCNTexas, USA, Associate Professor, Parker College ofChiropractic (Academic and Clinician)

Jan Hartvigsen, DC, PhDOdense, Denmark, Dean of Research, University ofSouthern Denmark (Academic and Researcher)

William Hsu, DC, DACBROntario, Canada, Associate Professor, Canadian MemorialChiropractic College (Academic)

Eric Jackson, DC, FCCRSOntario, Canada (Clinician)

Amanda Kimpton, BAppSc(Chiro), PhDVictoria, Australia, RMIT University (Academic andClinician)

Dana J. Lawrence, DC, FICCIowa, USA, Associate ProfessorPalmer Chiropractic College (Academic and Researcher)

Douglas Lawson, BA, DCAlberta, Canada (Researcher and Clinician)

Kathleen Linaker, DC, DACBRGeorgia, USA, Assistant ProfessorDirector Clinic Radiology, Life UniversityCollege of Chiropractic (Academic, Clinician)

Tracey Littrell, DC, DACBRIowa, USA, Associate Professor, Diagnosis and Radiology,Palmer-Davenport Chiropractic College (Academic)

Stephan Mayer, BSc, DCCalifornia, USA, Chair of Diagnostic Sciences andAssociate Academic Dean, Cleveland ChiropracticCollege (Academic)Ian D. McLean, DC, DACBR

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

Timothy J. Mick, DC, DACBR, FICCMinnesota, USA (Clinician)

Silvano Mior, DC, FCCSOntario, 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, DCMaryland, USA, Adjunct Professor, New York College ofChiropractic, National University of Health Sciences(Clinician)

Elli Morton, DCBritish Columbia, Canada (Clinician)

Greg Norton, DC, FACO, FIACNIowa, USA (Clinician)

Sandra O’Connor, DC, DACBR, FCCROntario, Canada (Clinician)


Rosemary Pace, RN, DipAppSc(MedRad), MEd (ICT),MBus, GradDipEd, GradDipBusVictoria, Australia, RMIT University (Academic andResearcher)

Joseph Pfeifer, DCNewYork, USA, NewYork Chiropractic College (Academic)

John Pikula, DC, FCCR(C), FCCS(C), FCCO(C)Ontario, Canada (Clinician)

Brock Potter, DCBritish Columbia, Canada (Clinician)

Tania C. Pringle, BPE, BA, DC, DACBR, FCCR(C)Ontario, Canada, Assistant Professor, CanadianMemorial Chiropractic College (Academic)

Serge Roux, DC, DABCOQuebec, Canada (Clinician)

Peter Scordilis, DCNew Jersey, USA (Clinician)

Paul Sherman, DC, Assistant ProfessorConnecticut, USA, University of Bridgeport College ofChiropractic (Academic and Clinician)

Thomas A. Souza, DC, DACBSPCalifornia, USA, Dean of Academic Affairs, PalmerChiropractic College West (Academic and Clinician)

John Stites, DC, DACBRIowa, USA, Palmer Chiropractic College(Academic)

Rand Swenson, DC, MD, PhDNew Hampshire, USA, Associate Professor ofAnatomy and of Medicine, Chairman, Departmentof Anatomy, Dartmouth Medical School(Academic, Clinician)

John Sweaney, AM, DCNew South Wales, Australia, Chiropractic EducationConsultant (Clinician)

Cliff Tao, DC, DACBRCalifornia, USA (Clinician)

Jeffrey Thompson, DC, DACBRTexas, USA (Clinician and Researcher)

Jann Thulien, DC, DACBROntario, Canada (Clinician)

Michelle A. Wessely, BSc, DC, DACBRParis, France, Professor, Head of Radiology and ClinicalResearch, Institut Franco-Europeen de Chiropratique(Academic and Clinician)

Michael Whitehead, BS, DC, DACBRMissouri, USA, Chair of Diagnostic Sciences, ClevelandChiropractic 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 ofChiropractic


diagnostic imaging guideline for musculoskeletal … · 2017. 9. 1. · original articles...

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