X-Ray (Plain Radiography): Indications and Contraindications

Indications

• Suspected fracture or dislocation (trauma, fall, sports injury)
• Follow-up of fracture healing/alignment, and post-reduction or post-operative check (hardware position)
• Suspected bone tumor, lytic/sclerotic lesion, or metabolic bone disease (e.g., osteoporosis, Paget disease)
• Joint pathology - osteoarthritis, rheumatoid arthritis, joint effusion, foreign body localization
• Preoperative evaluation, e.g., standing AP, lateral, and skyline views before total knee arthroplasty (Campbell's Operative Orthopaedics, p. 453-474)

• Suspected pneumonia, pneumothorax, pleural effusion, heart failure/pulmonary edema
• Evaluation of cardiac silhouette, mediastinal widening (e.g., suspected aortic pathology), line/tube placement (ET tube, central line, chest tube)
• Screening/monitoring in known cardiopulmonary disease

• Suspected bowel obstruction or perforation (free air), foreign body ingestion
• Constipation/fecal loading assessment in bowel bladder dysfunction (Smith and Tanagho's General Urology)
• Suspected renal or ureteric calculi (KUB film), abdominal aortic aneurysm calcification screening (though CT is needed for definitive evaluation) - ROSEN's Emergency Medicine, p. 3399

• Retropharyngeal abscess/airway compromise assessment (soft tissue neck film) - Scott-Brown's Otorhinolaryngology
• Localization of radiopaque foreign bodies
• Screening in trauma protocols (C-spine, pelvis, chest as part of primary survey)

Contraindications

1. Pregnancy (relative contraindication) - Ionizing radiation is potentially mutagenic/carcinogenic to the fetus, so radiography should be avoided during pregnancy if possible, and used only when the diagnostic benefit outweighs the risk (Emery's Elements of Medical Genetics and Genomics, p. 137). The American College of Obstetricians and Gynecologists has issued specific guidance on imaging in pregnancy (Roberts and Hedges' Clinical Procedures in Emergency Medicine, Box 71.4):
   • Most diagnostic radiographic studies (including chest X-ray) result in fetal radiation exposure far below the threshold associated with fetal harm, and should not be withheld if clinically indicated.
   • Abdominal and pelvic shielding should be used when feasible without compromising the study.
   • Chest radiography is considered acceptable during pregnancy with appropriate shielding (Creasy & Resnik's Maternal-Fetal Medicine).
   • Alternative non-ionizing modalities (ultrasound, MRI without gadolinium) should be considered first when they can answer the clinical question.
2. Unnecessary/low-yield repeat imaging - Avoid repeated exposure without clear clinical indication, particularly in children and young adults, due to cumulative radiation (ALARA principle - As Low As Reasonably Achievable).
3. Inability to position the patient appropriately (e.g., severe trauma, inability to cooperate) may limit diagnostic quality but is a practical limitation rather than a true contraindication - alternative views or modalities (CT) may be substituted.
4. When a more definitive study is required - plain film is often insufficient alone; for example, a calcified aneurysm seen on plain film still requires CT for definitive characterization (ROSEN's Emergency Medicine, p. 3399), and a plain film showing a soft tissue mass in suspected rhabdomyosarcoma still requires MRI (Miller's Review of Orthopaedics).

1. Religious/devotional - to communicate with God or a deity, whether asking for help, expressing gratitude, seeking forgiveness, or simply reflecting in worship (e.g., "She prays every morning before breakfast").
2. Earnest hope/wish - to hope fervently for something to happen, even without a religious context (e.g., "We can only pray that the weather holds").
3. Archaic/formal request - an old-fashioned way of saying "please" or "I beg you" (e.g., "Pray, be seated").

• Physical nature: Ionizing electromagnetic radiation, same family as gamma rays but produced differently - X-rays originate from electron transitions/deceleration outside the nucleus, while gamma rays are emitted from the atomic nucleus (Bradley and Daroff's Neurology in Clinical Practice; ROSEN's Emergency Medicine, p. 1366-1368).
• Medical use: The most common and oldest form of diagnostic medical imaging, used for chest, bone/joint, and abdominal evaluation, among many other applications.
• Discovery: First described by Wilhelm Röntgen in 1895 (hence the term "roentgenogram" sometimes used interchangeably with X-ray/radiograph).

CT Scan: Indications and Contraindications

Indications

• Acute head trauma, suspected intracranial hemorrhage, stroke (especially to rule out hemorrhage before thrombolysis), altered mental status, new focal neurologic deficit, suspected mass lesion, hydrocephalus (Bradley and Daroff's Neurology in Clinical Practice, "Indications for Computed Tomography or Magnetic Resonance Imaging," p. 544)
• CT is generally preferred over MRI in the acute trauma/emergency setting because of speed and wide availability, especially when the patient is unstable

• Suspected pulmonary embolism (CT pulmonary angiography), lung nodule/mass characterization, staging of lung cancer, aortic dissection/aneurysm, complex pneumonia or empyema

• Acute abdominal pain of unclear cause, suspected appendicitis, diverticulitis, bowel obstruction, abscess or collection requiring drainage guidance (Yamada's Textbook of Gastroenterology, p. 615-629), trauma (solid organ injury), staging of abdominal/pelvic malignancy, suspected abdominal aortic aneurysm or its complications
• Renal/urologic imaging - CT urography for hematuria workup, stone disease, renal masses (Grainger & Allison's Diagnostic Radiology, "Indications and Contraindications for CT Urography," p. 2571)

• Complex fractures (especially intra-articular or spine), preoperative planning, occult fracture not seen on plain film

• Cancer staging/surveillance, guidance for biopsies and percutaneous procedures, presurgical planning, trauma pan-scan in polytrauma patients

Contraindications

• Pregnancy (relative contraindication) - CT delivers a higher radiation dose than plain film; it should be avoided unless the diagnostic benefit clearly outweighs fetal risk, and alternatives (ultrasound, MRI) should be considered first. If CT is necessary, dose-reduction protocols and shielding should be used.
• Pediatric patients - increased lifetime cancer risk from ionizing radiation means CT should be used judiciously, with low-dose protocols and MRI/ultrasound substituted where feasible.

• Contrast allergy - prior moderate-to-severe reaction to iodinated contrast is a relative contraindication; premedication (steroids/antihistamines) or use of a non-iodinated alternative modality may be considered.
• Renal impairment - historically considered a major contraindication due to risk of contrast-induced nephropathy, but current evidence has revised this significantly: "there is no absolute contraindication to iodinated contrast administration, either for CTA or cardiac catheterization, in patients with CKD, including those already on maintenance dialysis," although preservation of residual renal function and use of the lowest effective contrast dose with periprocedural hydration is still recommended in at-risk patients (National Kidney Foundation Primer on Kidney Diseases, p. 1627-1628).
• Metformin use - in patients with reduced renal function receiving contrast, metformin is often temporarily withheld around the time of contrast administration due to a small risk of lactic acidosis if acute kidney injury occurs (a precaution rather than an absolute contraindication).
• Hyperthyroidism/thyroid disease - iodinated contrast can precipitate thyrotoxicosis in patients with untreated Graves disease or toxic nodular goiter; caution advised.

• Inability of the patient to remain still or fit within the scanner (e.g., severe claustrophobia, extreme body habitus) can limit feasibility, though sedation or open-bore scanners may help.
• Inability to lie supine or hold breath as required for certain protocols (e.g., unstable trauma patients) may necessitate a modified approach.

Bottom line

MRI: Indications and Contraindications

Indications

• Suspected stroke (especially posterior fossa/brainstem, where CT is less sensitive), multiple sclerosis and other demyelinating disease, brain tumor characterization, seizure workup, spinal cord compression, and detailed evaluation after an initial CT (Bradley and Daroff's Neurology in Clinical Practice, "Indications for Computed Tomography or Magnetic Resonance Imaging," p. 544)
• MRI of the brain is preferred over CT for lesion characterization, white matter disease, and posterior fossa pathology (Grainger & Allison's Diagnostic Radiology, Table 53.3)

• Soft tissue injury (ligament/tendon/meniscal tears), occult fracture not seen on X-ray, bone marrow edema, osteomyelitis and infection workup, bone tumor characterization and staging (Rockwood and Green's Fractures in Adults, p. 1016-1018)

• Disc herniation, spinal stenosis, cord compression, spinal infection or tumor
• Where MRI is contraindicated, CT myelography can be used as an invasive alternative (Campbell's Operative Orthopaedics, p. 6978-6992; Grainger & Allison's, "Myelography," p. 2495-2498)

• Breast MRI - high-risk screening, further characterization of indeterminate findings, pre-surgical extent of disease assessment (Grainger & Allison's, "Indications for Breast MRI," p. 1544)
• Rectal cancer staging - now largely replaces endorectal ultrasound unless MRI is contraindicated (Current Surgical Therapy, p. 2566-2568)
• Prostate, liver, and pelvic tumor characterization

• Cardiac MRI for structural and functional cardiac assessment, myocardial viability, cardiomyopathy characterization
• MR angiography as a non-ionizing alternative to CT angiography in selected patients

Contraindications

• Non-MRI-compatible cardiac pacemakers or implantable cardioverter-defibrillators (ICDs) - many modern devices are now MRI-conditional/compatible, but if the patient is pacemaker-dependent and the device is non-compatible, scanning is contraindicated (Comprehensive Clinical Nephrology, p. 3550-3552)
• Certain neural stimulator devices
• Cerebral aneurysm clips (non-MRI-safe/ferromagnetic clips) - the magnetic field can cause clip movement and catastrophic hemorrhage
• Ferromagnetic intraocular or intracranial metallic foreign bodies - risk of movement causing tissue damage, especially in the eye or near the spinal cord/brain (Brogdon's Forensic Radiology, p. 4400-4418; Rockwood and Green's, p. 1016-1018)
• Certain older cochlear implants and other implanted electronic devices

• Severe claustrophobia - may require sedation or an open-bore/wide-bore scanner (Grainger & Allison's, p. 2495-2498)
• Inability to remain still for the exam (30-45 minute scan times, motion artifact is a significant limitation) - may require sedation, especially in children
• Recent surgical clips, orthopedic hardware, or other implants of uncertain MRI compatibility - need to verify compatibility before scanning
• Pregnancy - generally considered safe, especially after the first trimester, but used cautiously and per departmental protocol; gadolinium contrast is typically avoided in pregnancy unless essential

• Severe renal impairment (eGFR <30) - risk of nephrogenic systemic fibrosis (NSF), a rare but serious and potentially irreversible fibrosing condition affecting skin and internal organs, occurring weeks to months after gadolinium exposure (Wills Eye Manual, p. 7220-7222; Campbell-Walsh Urology, p. 4100-4102; Fishman's Pulmonary Diseases, p. 3191-3198)
• In these patients, non-contrast MRI, ultrasound, or non-contrast CT is preferred when gadolinium risk outweighs benefit
• History of severe allergic reaction to gadolinium contrast

• The MRI environment itself is hazardous if ferromagnetic objects (oxygen tanks, certain monitoring equipment, jewelry) are brought near the "always-on" magnet - staff and patients must be screened thoroughly before entry (Harrison's Principles of Internal Medicine, "Complications and Contraindications," p. 598-600)
• Limited availability/longer exam times make it less suitable in truly emergent, unstable patients compared to CT

Summary comparison

Yes, MRI is usually possible - but it depends on the implant material

What's safe

• Titanium and titanium alloy implants (plates, screws, rods, artificial joints) - it is safe to perform MRI on patients with these implants. Titanium is non-ferromagnetic, so there is no risk of movement or clinically significant heating (Roberts and Hedges' Clinical Procedures in Emergency Medicine, Box 71.5, p. 3684-3690).
• 316L stainless steel - most fracture fixation hardware (plates, screws, K-wires) is made of this implant-grade stainless steel, which is non-ferromagnetic or only weakly ferromagnetic and is considered MRI conditional in terms of both heating and migration risk (Rockwood and Green's Fractures in Adults, "MRI Safety With Orthopaedic Implants and External Orthopaedic Devices," p. 1083-1085).
• Traction pins made of implant-quality stainless steel have also been shown to be MRI safe, though individual centers may still restrict them in the MRI suite as a precautionary policy (Rockwood and Green's, p. 1086-1088).
• Chrome-cobalt implants (common in joint arthroplasty) also generally do not interfere significantly with MRI safety (ROSEN's Emergency Medicine, p. 100-101).
• External fixators - modern devices are increasingly manufactured with low-ferromagnetic materials specifically so patients can safely undergo MRI when needed (e.g., to evaluate associated soft tissue or spinal injury) (Rockwood and Green's, p. 1083-1085).

What to actually watch for

1. Heating - theoretically metal implants can experience some RF-induced heating in the MRI bore, but for standard orthopedic hardware this effect is negligible (Rockwood and Green's, p. 669-670).
2. Implant motion - a real concern for older, strongly ferromagnetic devices, but modern orthopedic plates/screws/K-wires made of titanium or 316L stainless steel are not strongly ferromagnetic enough to move.
3. Image artifact (not a safety issue, but a diagnostic limitation) - metal hardware, especially bulkier implants, causes local signal distortion/artifact around the implant. The degree depends on implant bulk, orientation, and material (titanium causes less artifact than stainless steel). This can obscure surrounding soft tissue or bone detail, sometimes limiting diagnostic use even though the scan itself is safe (Campbell's Operative Orthopaedics, p. 552-599). If the concern is infection or a lesion near the hardware, CT or nuclear studies (gallium/FDG-PET) may be more useful than MRI because of this artifact (Goldman-Cecil Medicine; Rockwood and Green's, p. 1379-1380).
4. Unknown/unlabeled hardware - if you don't know what an implant is made of (e.g., an old or foreign device, or documentation is unavailable), the standard practice is to check the implant's MRI conditional labeling/manufacturer documentation before scanning, or default to caution. "When in doubt, ask the radiologist to look up the specific device" (Wills Eye Manual, p. 7223-7226).

Bottom line for your question

• Image quality near the hardware may be degraded by metal artifact (not a safety issue, just a diagnostic limitation)
• Some centers have blanket policies requiring confirmation of implant type/MRI-conditional status before scanning, especially for older or unclear hardware
• Radiology should ideally confirm the specific implant type/manufacturer if there is any uncertainty, particularly for external fixators or unusual devices

Secondary Complications of Fracture

A. Local Secondary Complications

• Infection - wound infection, osteomyelitis (especially in compound/open fractures)
• Compartment syndrome - raised pressure within a fascial compartment causing ischemia; if untreated leads to Volkmann's ischemic contracture
• Avascular necrosis (AVN) - loss of blood supply to a fracture fragment (e.g., femoral head, scaphoid, talus)
• Fracture blisters
• Secondary hemorrhage
• Late nerve injury - e.g., "tardy ulnar palsy" following malunited supracondylar fracture with cubitus valgus (S Das, A Manual on Clinical Surgery, p. 178)

• Delayed union
• Non-union (including pseudoarthrosis)
• Malunion
• Joint stiffness/contractures - from prolonged immobilization or intra-articular adhesions
• Myositis ossificans traumatica - heterotopic bone formation in muscle near the fracture
• Complex regional pain syndrome (CRPS) / Sudeck's atrophy - also listed as a recognized complication in ROSEN's Emergency Medicine (Box 4.1.5, p. 1259-1299)
• Post-traumatic osteoarthritis of the adjacent joint
• Growth disturbance in children (physeal injury leading to limb length discrepancy or angular deformity)
• Implant-related complications in operatively treated fractures - hardware loosening/breakage, peri-implant fracture, nonunion (Rockwood and Green's Fractures in Adults, p. 1501-1508)

B. General (Systemic) Secondary Complications

• Fat embolism syndrome - classically after long bone or pelvic fractures
• Deep venous thrombosis (DVT) and pulmonary embolism (PE)
• Shock (hypovolemic, from blood loss)
• "Fracture fever"
• Hypostatic pneumonia
• Tetanus - risk in compound (open) fractures
• Delirium tremens - in patients with underlying alcoholism
• Accident neurosis (psychological/compensation neurosis) (S Das, A Manual on Clinical Surgery, "Complications of Fractures and Dislocations," p. 177-178)

C. Complications of Prolonged Immobility/Hospitalization (also systemic secondary complications)

• Muscle atrophy and contractures
• Decubitus (pressure) ulcers
• Deep venous thrombosis / pulmonary embolism (overlaps with above)
• Catheter-associated urinary tract infection
• Nosocomial/wound infection
• Stress ulcers and GI hemorrhage
• Delirium or psychosis, particularly in elderly patients (ROSEN's Emergency Medicine Concepts and Clinical Practice, Box 4.1.5, p. 1259-1304)

Quick summary table

Late Complications of Fracture (excluding malunion/non-union)

1. Joint stiffness / Contractures

2. Avascular necrosis (AVN)

• Femoral head (femoral neck fracture)
• Scaphoid (especially proximal pole)
• Talus

3. Myositis ossificans traumatica

4. Complex regional pain syndrome (CRPS) / Sudeck's atrophy

5. Post-traumatic osteoarthritis

6. Volkmann's ischemic contracture

7. Tardy nerve palsy

8. Growth disturbance (in children)

9. Chronic osteomyelitis

10. Implant-related late complications

11. Refracture

12. Chronic instability