CT Without Contrast is the Recommended Imaging for Fracture Evaluation
CT scans for fracture evaluation should be performed without contrast, as contrast does not provide additional diagnostic value for fracture detection and characterization.
Initial Imaging Approach
- Radiographs should be the first imaging modality used for suspected fractures due to their availability, low cost, and ability to provide adequate screening information 1
- If radiographs are negative or indeterminate but clinical suspicion for fracture remains high, further imaging is warranted 1
CT Without Contrast for Fracture Evaluation
- CT without IV contrast is the appropriate next imaging study for suspected fractures when radiographs are negative or indeterminate 1
- CT without contrast provides superior visualization of fracture morphology, including size of fragments, displacement, and angulation, which may affect surgical treatment options 1
- For suspected occult fractures, CT without contrast can detect radiographically occult fractures with high specificity (reported as 88-98%) 1
- CT is particularly valuable for complex anatomical areas such as the ankle, where it can identify talar fractures (lateral process or comminuted talar body/dome fractures) and fractures associated with the subtalar joint that may be difficult to detect on radiographs 1
Why Contrast is Not Recommended for Fracture Evaluation
- There is no evidence to support the use of CT with IV contrast for fracture evaluation, as it does not provide additional diagnostic information over non-contrast imaging 1
- ACR Appropriateness Criteria explicitly state that "CT with IV contrast is not indicated in this scenario because soft-tissue abnormalities and fluid collections can be identified on noncontrast high-resolution CT studies" 1
- Multiple guidelines specifically note that there is "no relevant literature to support the use of CT area of interest with IV contrast because it does not provide added information over noncontrast imaging with regard to stress injury" 1
Special Considerations
- For suspected stress fractures, MRI without contrast is more sensitive than CT and should be considered when radiographs are negative but clinical suspicion remains high 1
- In pregnant patients with suspected fractures, MRI without contrast is preferred over CT to avoid radiation exposure, particularly for pelvic or hip fractures 1
- For hip fractures with negative radiographs, CT without contrast can detect radiographically occult fractures with high sensitivity (79-94%) and specificity (up to 100%) 1
Common Pitfalls to Avoid
- Relying solely on radiographs when clinical suspicion for fracture remains high despite negative initial imaging 1
- Using contrast-enhanced CT for fracture evaluation, which adds unnecessary risk of contrast reactions without providing additional diagnostic value 1
- Failing to consider MRI for suspected stress fractures or in cases where CT results are equivocal 1
- Not obtaining adequate radiographic views before proceeding to advanced imaging (minimum of 3 views is necessary for most extremity fractures) 2, 3
By following these evidence-based recommendations, clinicians can optimize fracture detection while avoiding unnecessary contrast administration, which carries risks without providing additional diagnostic benefit for fracture evaluation.