Radiography Area of Interest In patients with clinical suspicion of hand or wrist fracture and negative radiographs, one option is to place the patient in a short arm cast and repeat the radiographs at 10 to 14 days [13]. The downside of this option is that it results in delay of diagnosis, which may lead to functional impairment. CT Area of Interest When the initial radiographs are equivocal, CT without IV contrast is commonly used to exclude or confirm suspected wrist fractures [18]. CT shows intra-articular extension of distal radius fractures more frequently than radiography. Three-dimensional reconstructions can be particularly helpful in preoperative planning for complex articular injuries [7,8]. CT should be used to exclude an occult fracture of the upper extremity. Unlike MRI, CT cannot evaluate for concomitant ligamentous injuries [19-21]. CT is useful in diagnosing injuries that are difficult to recognize on radiographs, such as carpometacarpal joint fracture dislocations. For metacarpal and digital fractures, CT is usually not indicated during acute injury [22]. There is no evidence to support the use of CT with IV contrast in the setting of acute hand and wrist trauma. MRI Area of Interest When initial radiographs are normal but there is high clinical suspicion for fracture, MRI without IV contrast can detect fractures of the distal radius and carpal bones [12,23-25]. One study of patients in which the radiographic findings did not explain the clinical symptoms reported that the MRI led to a change in diagnosis in 55% of patients and a change in patient management in 66% [12]. However, another study of patients with acutely injured wrists reported that the MRI did not predict the need for treatment better than the combination of physical examination and radiography [23]. More importantly, there was no difference in outcomes with MRI compared with radiography [24].
Acute Hand and Wrist Trauma. Radiography Area of Interest In patients with clinical suspicion of hand or wrist fracture and negative radiographs, one option is to place the patient in a short arm cast and repeat the radiographs at 10 to 14 days [13]. The downside of this option is that it results in delay of diagnosis, which may lead to functional impairment. CT Area of Interest When the initial radiographs are equivocal, CT without IV contrast is commonly used to exclude or confirm suspected wrist fractures [18]. CT shows intra-articular extension of distal radius fractures more frequently than radiography. Three-dimensional reconstructions can be particularly helpful in preoperative planning for complex articular injuries [7,8]. CT should be used to exclude an occult fracture of the upper extremity. Unlike MRI, CT cannot evaluate for concomitant ligamentous injuries [19-21]. CT is useful in diagnosing injuries that are difficult to recognize on radiographs, such as carpometacarpal joint fracture dislocations. For metacarpal and digital fractures, CT is usually not indicated during acute injury [22]. There is no evidence to support the use of CT with IV contrast in the setting of acute hand and wrist trauma. MRI Area of Interest When initial radiographs are normal but there is high clinical suspicion for fracture, MRI without IV contrast can detect fractures of the distal radius and carpal bones [12,23-25]. One study of patients in which the radiographic findings did not explain the clinical symptoms reported that the MRI led to a change in diagnosis in 55% of patients and a change in patient management in 66% [12]. However, another study of patients with acutely injured wrists reported that the MRI did not predict the need for treatment better than the combination of physical examination and radiography [23]. More importantly, there was no difference in outcomes with MRI compared with radiography [24].