Imaging Recommendations for Fracture Evaluation

Initial Imaging Approach

The American College of Radiology recommends radiographs as the first imaging modality for suspected fractures due to their availability, low cost, and ability to provide adequate screening information 1, 2, 3
If radiographs are negative or indeterminate but clinical suspicion for fracture remains high, further imaging is warranted, with the American College of Radiology suggesting CT without contrast as the next step 1, 4, 5

The American College of Radiology recommends CT without IV contrast for suspected fractures when radiographs are negative or indeterminate, as it provides superior visualization of fracture morphology 1, 4, 5
CT without contrast can detect radiographically occult fractures with high specificity (reported as 88-98%) and is particularly valuable for complex anatomical areas such as the ankle 2, 3, 5
The American College of Radiology notes that CT without contrast can identify talar fractures and fractures associated with the subtalar joint that may be difficult to detect on radiographs 1

For suspected stress fractures, the American College of Radiology recommends MRI without contrast, as it is more sensitive than CT 2, 6, 3
In pregnant patients with suspected fractures, the American College of Radiology prefers MRI without contrast over CT to avoid radiation exposure 7
For hip fractures with negative radiographs, CT without contrast can detect radiographically occult fractures with high sensitivity (79-94%) and specificity (up to 100%) 5

The American College of Radiology advises against relying solely on radiographs when clinical suspicion for fracture remains high despite negative initial imaging 1, 4, 5
The American College of Radiology recommends avoiding the use of contrast-enhanced CT for fracture evaluation, as it adds unnecessary risk of contrast reactions without providing additional diagnostic value 2, 6, 3