Can a Magnetic Resonance Imaging (MRI) scan detect a fracture in the hand?

MRI for Hand Fracture Detection

MRI without IV contrast can effectively detect fractures of the hand that may not be visible on conventional radiographs, making it an excellent secondary imaging option when radiographs are negative but clinical suspicion for fracture remains high. 1, 2

Imaging Algorithm for Suspected Hand Fractures

1. First-line imaging: Radiographs

   • 3-view radiographic examination (posteroanterior, lateral, and 45° semipronated oblique views) is the recommended initial study 2
   • Provides assessment of bone alignment, joint spaces, displacement, and angulation

2. When radiographs are negative but clinical suspicion remains high:

   • MRI without IV contrast is appropriate for detecting:
     • Occult fractures not visible on radiographs
     • Bone marrow edema (the most common MRI finding in occult fractures) 3
     • Concomitant soft tissue injuries (ligaments, tendons, cartilage) 1, 2

Advantages of MRI for Hand Fracture Detection

• MRI can detect fracture lines in approximately 21% of patients with negative radiographs 3
• Bone contusion or bruising can be identified in up to 52% of patients with recent trauma 3
• Superior soft tissue contrast allows evaluation of associated injuries that may contribute to symptoms 1, 4
• Can detect signal changes in bone marrow that indicate acute injury 3, 4

Clinical Applications

• Particularly useful for:
  • Carpal bone fractures (especially scaphoid)
  • Intra-articular fractures
  • Stress fractures
  • Distinguishing between acute and chronic injuries 3

Limitations and Caveats

• Not typically indicated as first-line imaging for metacarpal and digital fractures during acute injury 1
• One study reported that MRI did not predict the need for treatment better than the combination of physical examination and radiography 1
• No evidence supports the use of MRI with IV contrast in acute hand trauma 1
• Some fracture types may not reliably generate marrow edema, potentially leading to false negatives 5
• Availability and cost considerations may limit immediate access

Alternative Advanced Imaging Options

• CT without IV contrast:

  • Alternative for excluding occult fractures
  • Better for complex fractures with intra-articular extension
  • Useful for preoperative planning 1, 2
  • Cannot evaluate concomitant ligamentous injuries 1

• Dual-energy CT (DECT):

  • Emerging alternative to MRI for detecting bone marrow edema in acute wrist fractures 6
  • Can identify bone marrow edema with high sensitivity and specificity 6

In summary, while conventional radiographs remain the first-line imaging modality for suspected hand fractures, MRI provides excellent detection of occult fractures and associated soft tissue injuries when radiographs are negative or inconclusive.