Can You See a Fracture Without Contrast?
Yes, fractures are readily visible without contrast agents on imaging studies—contrast is not needed and is usually not appropriate for fracture detection. 1, 2
Initial Imaging Approach
- Radiographs (plain X-rays) are the first-line imaging modality for all suspected fractures, providing adequate screening information at low cost and with minimal radiation exposure 2
- Standard radiographs detect approximately 90% of fractures without requiring any contrast administration 1
- Contrast agents (intravenous or oral) add no diagnostic value for fracture detection and are therefore not indicated 1, 2
When Radiographs Are Negative But Fracture Is Still Suspected
CT Without Contrast
- CT without IV contrast is the preferred next imaging study when radiographs are negative or indeterminate but clinical suspicion remains high 2
- CT provides superior visualization of fracture morphology with high specificity (88-98%) for detecting radiographically occult fractures 2
- CT is particularly valuable for complex anatomical areas like the ankle, wrist (hook of hamate), and spine where fractures may be difficult to see on plain films 1, 2
- IV contrast does not add to the examination and is usually not appropriate for fracture evaluation 1, 2
MRI Without Contrast
- MRI without IV contrast is the most sensitive modality for detecting occult fractures, particularly stress fractures and bone bruises 1
- MRI shows near 100% sensitivity for proximal femoral fractures and has excellent negative predictive value 1
- MRI is superior to CT for detecting bone marrow edema, stress reactions, and soft tissue injuries associated with fractures 1
- Contrast-enhanced MRI provides no additional benefit for fracture detection itself—it may only be considered in specific scenarios like assessing osteonecrosis of fracture fragments or soft tissue complications 1, 3
Special Clinical Scenarios
Stress Fractures
- MRI without contrast is the imaging study of choice when radiographs are negative 1
- Bone scintigraphy (nuclear medicine scan) is an alternative but less specific than MRI and has been largely superseded 1
- CT without contrast has limited sensitivity for early stress fractures but can be useful when MRI is equivocal 1
Pregnant Patients
- MRI without contrast is strongly recommended over CT to avoid radiation exposure when evaluating suspected fractures of the pelvis, hip, or sacrum 1
- For extremity fractures in pregnancy, radiographs remain first-line, with MRI as the complementary study if needed 1
Hip Fractures
- MRI without IV contrast is reserved for second-line imaging after negative radiographs with continued clinical suspicion 1
- CT without contrast is a reasonable alternative when MRI is contraindicated or unavailable, with sensitivity of 79-94% and specificity up to 100% 2
- Contrast-enhanced imaging plays no role in initial hip fracture assessment 1
Common Pitfalls to Avoid
- Do not rely solely on negative radiographs when clinical suspicion for fracture remains high—proceed to CT or MRI without contrast 2
- Avoid ordering contrast-enhanced CT or MRI for fracture evaluation—it adds unnecessary risk (contrast reactions, nephrotoxicity) without diagnostic benefit 1, 2, 4
- Do not delay advanced imaging in high-risk scenarios (e.g., suspected hip fracture in elderly, stress fractures in athletes at risk for completion) where early diagnosis changes management 1
- Be aware that some fractures (particularly stress fractures and subchondral insufficiency fractures) may not show radiographic changes for 10-14 days, making early cross-sectional imaging critical 1