Extent of bone marrow edema on dual-energy CT aids in differentiation of acute from post-acute fractures of lower legs

Objectives: Bone marrow edema (BME) from dual-energy CT is useful to direct attention to radiographically occult fractures. The aim was to characterize utility of BME of lower extremity (LE) fractures with the hypothesis that stabilized and post-acute fractures exhibit decreased extent and frequency of BME than non-stabilized and acute fractures, respectively. Methods: An IRB-approved retrospective review of known LE fractures. A total of 141 cases met inclusion criteria, including 82 fractures without splint/cast stabilization, and 59 cases with stabilization. Two readers independently recorded BME, and its multiplicity and area (mm²). A separate reader assessed fracture location, comminution, and chronicity. Wilcoxon rank sum test, multiple regression, intraclass correlation (ICC), kappa statistics, and chi-square tests were used. Results: BME was significantly larger in non-stabilized (859.3 mm² (420.6–1451.8)) than stabilized fractures (493.5 mm² (288.8–883.2)), p =.011). Comminuted (p = 0.006), non-stabilized (p = 0.0004), and acute fractures (p = 0.036) were all associated with larger BME area. BME presence had excellent results for both stabilized (Cohen’s Kappa = 0.81) and non-stabilized fractures (Cohen’s Kappa = 0.84). ICC for BME area showed excellent correlation for both stabilized (ICC = 0.78) and non-stabilized groups (ICC = 0.86). BME multiplicity showed excellent agreement for stabilized (ICC = 0.81) and good agreement for non-stabilized (ICC = 0.67) fractures. Lastly, stabilized cases showed increased multiplicity of BME compared to non-stabilized fractures (p < 0.001). Conclusions: BME evaluation can assist in differentiation of acute versus post-acute fractures. Extent of BME is reduced with splint/cast stabilization, which may limit its accuracy in detection of lower extremity fractures. Key Points: • Evaluation of bone marrow edema on dual-energy CT aids in differentiation of acute versus post-acute fracture. • Bone marrow edema evaluation is limited in the setting of post-acute or stabilized fractures. • There is decreased frequency and extent of bone marrow edema in post-acute, non-comminuted, and stabilized fractures.