Objectives <p>To evaluate the impact of calcium suppression (CaSupp) imaging of spectral computed tomography (SpCT) on fracture detection in clinical routine in the acute trauma setting of the hand and wrist.</p> Materials and methods <p>Retrospective inclusion of 125 patients who underwent both X-ray and SpCT examinations of the hand and wrist in an acute trauma setting. Two independent readers evaluated fracture presence on X-ray, conventional CT, and conventional CT plus CaSupp images (time interval 4&#xa0;weeks, each). Bone bruise (BBr) presence was evaluated on CaSupp images. Sensitivity and specificity were calculated according to the consensus reading as the reference standard.</p> Results <p>Of the 125 patients (mean age, 55&#xa0;years ± 19.5 [SD]; 67 female), 120 presented with at least one fracture, for a total of 212 fractured bones. Sensitivity was increased significantly for both readers in CT + CaSupp (94.3 and 97.2%) compared to conventional CT (88.2 and 90.1%, <i>p</i> &lt; .01) and X-ray (72.6 and 75.9%, <i>p</i> &lt; .01). Specificity was 99.9 and 100% for CT + CaSupp, 99.8 and 99.9% for conventional CT, and 99.4 and 99.9% for X-ray. Reader 1 detected 13 additional fractures in CT + CaSupp compared to conventional CT alone, while Reader 2 detected 15 additional fractures. BBr was seen in 58% of all fractures, in 76% of multifragmentary fractures, and in 13% of avulsion fractures. Inter-reader <i>κ</i> was almost perfect for X-ray (<i>κ</i> = .85), CT and CT + CaSupp (<i>κ</i> = .95), and substantial for BBr (<i>κ</i> = .61).</p> Conclusion <p>CaSupp images in combination with conventional CT images significantly improved sensitivity for acute trauma fracture detection in the hand and wrist compared to conventional CT images alone and X-ray.</p>