Musculoskeletal CT Protocols

Peter R. Bolos, MD, MPH Ketan Naran, MD W. James Malone, DO Angela Gopez, MD

UPPER EXTREMITY

SHOULDER
Positioning
Patient supine Affected arm by side of body Contralateral arm raised above head

Indications
Trauma GH joint arthropathy and intra-articular bodies Rotator Cuff (CT arthography)

SHOULDER

SHOULDER
Gantry Tilt 0 FOV Large KV 140 mA 200

Slice (mm) Reconstruct Reformat 1.25 2

Interval (mm) 0.625 2

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

SHOULDER
Relevant Anatomy
Prescribe plane parallel to humeral shaft. Cover from AC joint through proximal humeral diaphysis.

Scanning Plane (Axial)

AC joint Acromium

Clavicle

Humeral Head
ysi s Hu me ra l Dia ph

SHOULDER Coronal Imaging Plane

Relevant Anatomy
Prescribe coronal plane off of axial images parallel to supraspinatus muscle.

Coronal Imaging Plane

ina In fra tus sp ina tus

Su pr asp

SHOULDER Sagittal Imaging Plane

Relevant Anatomy
Prescribe sagittal plane off axial images with line parallel to bony glenoid. Image from scapular wing through deltoid muscle.

Sagittal Imaging Plane

Deltoid Muscle

Humeral Head

Scapula

Bony Glenoid

SHOULDER CT Arthrography with ABER

ABER = Abduction External Rotation
Arm abducted greater than 90, with elbow flexed Hand placed over head

Indications

Anterior/inferior labral pathology Inferior glenohumeral ligament pathology

Pitfalls

May be painful for patient to hold position

SHOULDER CT Arthrography with ABER

SHOULDER

CT Arthrography with ABER

Causes Bicipital groove to lie at superior aspect of humeral head

Relevant Anatomy

Scout view in coronal plane. Axials prescribed oblique along long axis of humerus.

Scanning Plane

Clavicle

Bicipital groove Acromion

SHOULDER
Coronal

CT Arthrography with ABER

Representative Images Axial Sagittal

ELBOW
Positioning
Patient supine Arm by side or raised above head Palm up

Indications
Trauma (e.g. radial head fractures) Degenerative arthropathy, intra-articular bodies

ELBOW

Elbow of concern is above the head

ELBOW
Gantry Tilt 0 FOV Small KV 120 mA 200

Slice (mm) Reconstruct Reformat 0.625 0.8

Interval (mm) 0.3 1.5

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

ELBOW
Relevant Anatomy Scanning Plane (Axial)
Prescribe plane perpendicular to coronal localizer plane. Scan from distal humeral shaft to just past radial tuberosity. Lateral & Medial Humeral Condyles

Radial head

Ulna

Radial tuberosity

ELBOW Coronal Imaging Plane

Relevant Anatomy Coronal Imaging Plane
Prescribe plane parallel to anterior humerus at condyles. Scan through entire elbow. Medial Humeral Condyle Olecranon process of Ulna Lateral Humeral Condyle

um H
Ulna

us er

Radial head
*

ELBOW Sagittal Imaging Plane

Relevant Anatomy
Prescribe plane perpendicular to coronal plane. Scan through entire elbow.

Sagittal Imaging Plane

Medial Humeral Condyle Olecranon process of Ulna

Lateral Humeral Condyle

um H
Ulna

us er

Radial head
*

WRIST
Positioning
Patient prone Arm over head (Mighty Mouse Position) Arm as straight as possible Wrist centered in gantry

Indications
Distal radial/ulnar fractures, carpal bone fractures (other than scaphoid)
See dedicated Scaphoid protocol for scaphoid fractures

WRIST

WRIST
Gantry Tilt 0 FOV Small KV 120 mA 200

Slice (mm) Reconstruct Reformat 0.625 0.8

Interval (mm) 0.3 1.5

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

WRIST
Relevant Anatomy Scanning Plane (Axial)
Prescribe plane parallel to distal radius. Scan from proximal metacarpals through distal radial/ulnar metaphysis.

metacarpals
trapz trapm

Epiphysis Metaphysis

cap ham sc ap h lun Distal radius

Diaphysis

triq
Distal ulna

WRIST Coronal Imaging Plane

Relevant Anatomy
Prescribe plane parallel to line drawn from ulnar styloid through radial styloid. Scan through entire wrist.

Coronal Imaging Plane

Ulnar Styloid

Radial Styloid

WRIST Sagittal Imaging Plane

Relevant Anatomy
Prescribe plane perpendicular to coronal plane. Scan through entire wrist.

Sagittal Imaging Plane

Ulnar Styloid

Radial Styloid

WRIST Scaphoid Fracture Evaluation

Hand in radial deviation

WRIST Scaphoid Fracture Evaluation

Relevant Anatomy Oblique Sagittal Imaging Plane
Prescribe plane along long axis of scaphoid. Scan from distal carpal row to distal radius.

Sc id ho ap
Image from University of Wisconsin
http://radiology.wisc.edu/divisions/msk/protocols/CT_wrist.pdf

WRIST DRUJ Instability Evaluation

DRUJ = Distal Radioulnar Joint Positioning
Neutral, supine, and prone imaging Arm above head as straight as possible Scanning both sides at same time
Make sure both sides are aligned with each other

WRIST DRUJ Instability Evaluation

Pronated (Palm Down) Supinated (Palm Up)

Neutral

WRIST DRUJ Instability Evaluation

Relevant Anatomy
Prescribe plane parallel to distal radius. (BOTH wrists). Scan TWICE from proximal metacarpals through distal radial/ulnar metaphysis, ONCE WITH PALM UP AND AGAIN WITH PALM DOWN.

Scanning Plane (Axial)

DRUJ

LOWER EXTREMITY

HIP
Positioning
Patient Supine Legs flat on table

Indications
Trauma (acetabular and femoral head/neck fractures) Degenerative arthropathy, intra-articular bodies

HIPS

HIP
Gantry Tilt 0 FOV Large KV 140 mA 200

Slice (mm) Reconstruct Reformat 1.25 2

Interval (mm) 0.625 2

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

HIP
Relevant Anatomy Scanning Plane (Axial)
Prescribe plane parallel to acetabular roof. Scan from acetabular roof through lesser trochanter.

Acetabular Roof

Greater Trochanter

Lesser Trochanter

HIP Coronal Imaging Plane

Relevant Anatomy
Prescribe plane parallel to femoral heads. Scan from ischium through pubic symphysis.

Coronal Imaging Plane

Superior Pubic Ramus Femoral Head Femoral Neck

Pubic Symphysis

Greater Trochanter

Ischium

HIP Sagittal Imaging Plane

Relevant Anatomy
Prescribe plane perpendicular to coronal plane. Scan from acetabulum through greater trochanter.

Sagittal Imaging Plane

Superior Pubic Ramus Femoral Head Femoral Neck

Pubic Symphysis

Greater Trochanter

Ischium

KNEE
Positioning:
Patient supine with feet first into scanner Keeps knees extended, side-by-side Tape feet together with toes pointing up to help keep knees from moving Slide patient so that knee being scanned is in center of table

Indications
Trauma (e.g. tibial plateau fractures)

KNEE

KNEE
Gantry Tilt 0 FOV Small KV 120 mA 200

Slice (mm) Reconstruct Reformat 1.25 0.8

Interval (mm) 0.625 1.5

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

KNEE
Relevant Anatomy
Prescribe plane parallel to axis of tibial plateau. Scan knee from suprapatellar region to proximal tibia.

Scanning Plane (Axial)

Suprapatellar Region

Patella

Femur

Tibial Plateau

Tibia

KNEE Coronal Imaging

Relevant Anatomy Coronal Imaging Plane
Prescribe plane with line parallel to femoral condyles. Image entire knee.

Patella

Med Fem Condyle

Lat Fem Condyle

KNEE Sagittal Imaging

Relevant Anatomy
Prescribe plane perpendicular to coronal plane. Scan from the medial to the lateral femoral condyle.

Sagittal Imaging Plane

Patella

Med Fem Condyle

Lat Fem Condyle

ANKLE
Positioning:
Patient supine Center in scanner both feet or foot of interest
Use foot holder if available If imaging both feet, bring them together

Toes pointing straight up Foot inverted slightly

Indications
Trauma (e.g. Distal tibial fracture) Talar dome osteochondral lesions

ANKLE

ANKLE
Gantry Tilt 0 FOV Small KV 120 mA 200

Slice (mm) Reconstruct Reformat 0.625 0.8

Interval (mm) 0.3 1.5

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

ANKLE
Relevant Anatomy Scanning Plane (Axial)
Prescribe plane parallel to axis of calcaneus. Scan ankle from distal tibia through beyond the inferior calcaneus.

Tibia Talus Calcaneus

ANKLE Coronal Imaging Plane

Relevant Anatomy
Prescribe plane perpendicular to axial imaging plane. Scan ankle from calcaneus through metatarsal bases.

Coronal Imaging Plane

Tibia

Talus

Calcaneus Cuboid
S L A S R A T A T E

ANKLE Sagittal Imaging Plane

Relevant Anatomy
Prescribe plane with line bisecting calcaneus. Scan through entire foot.

Sagittal Imaging Plane

Cal can eus

Medial Cuneifor m Mi d Cu dle ne if o La rm Cu ter ne al ifo rm

oid Cub

FOOT
Positioning
Patient supine Center in scanner both feet or foot of interest
Use foot holder if available If imaging both feet, bring them together

Toes pointing straight up Foot inverted slightly

FOOT

FOOT
Gantry Tilt 0 FOV Small KV 120 mA 200

Slice (mm) Reconstruct Reformat 0.625 0.8

Interval (mm) 0.3 1.5

Type/Plane

-Bone -Soft Tissue -Axial -Coronal -Sagittal

HINDFOOT/FOREFOOT
Indications
Trauma
Calcaneal and talar fractures

Evaluation for tarsal coalition

HINDFOOT/FOREFOOT
Relevant Anatomy Scanning Plane (Axial)
Prescribe plane parallel to tibiotalar joint. Scan from distal tibia through beyond calcaneus.

Tibia Talus
Posterior facet of subtalar joint

Navicular

Calcaneus
Cuboid
als rs ta ta Me

HINDFOOT/FOREFOOT Axial Oblique Imaging Plane

Relevant Anatomy
Prescribe plane parallel to subtalar joint (posterior facet) Scan from distal tibia through beyond calcaneus.

Axial Oblique Imaging Plane

Tibia Talus
Posterior facet of subtalar joint

Navicular

Calcaneus
Cuboid
als rs ta ta Me

HINDFOOT/FOREFOOT Coronal Oblique Imaging Plane

Midtarsal joints (talonavicular/calcaneocuboid joints) = Choparts joint

Relevant Anatomy

Coronal Oblique Imaging Plane

Prescribe plane perpendicular to axial oblique plane (approximately parallel to midtarsal joints) Scan from calcaneus through proximal metatarsals.

Tibia Talus
Posterior facet of subtalar joint

Navicular

Calcaneus
Cuboid
als rs ta ta Me

HINDFOOT/FOREFOOT Sagittal Imaging Plane

Relevant Anatomy Sagittal Imaging Plane
Prescribe plane off axial plane. Cover entire foot in this plane.

Navicular

Talus

Calcaneus

MIDFOOT/FOREFOOT
Indications
Trauma
Lisfranc fracture-dislocation Metatarsal fractures

MIDFOOT/FOREFOOT
Relevant Anatomy Scanning Plane (Coronal)
Prescribe plane parallel to 1st Metatarsal. Scan through entire mid/forefoot.

Navicular 1st cuneiform Talus

sal tar ta Me

Tibia

st

Calcaneus

MIDFOOT/FOREFOOT Axial Imaging Plane

Lisfranc joint = tarsometatarsal (TMT) articulations, particularly in area between 1st and 2nd TMTs

Relevant Anatomy

Prescribe plane perpendicular to coronal plane. This will be parallel to 1st TMT joint Scan through entire mid/forefoot.

Axial Imaging Plane

Navicular 1st cuneiform Talus

sal tar ta Me

Tibia

st

Calcaneus 1st TMT joint

MIDFOOT/FOREFOOT Sagittal Imaging Plane

Relevant Anatomy
Prescribe along plane parallel to 1st metatarsal.

Sagittal Imaging Plane

1st and 2nd Metatarsals

Lisfranc joint

Cuneiforms Navicular Talus

Image from University of Wisconsin
http://radiology.wisc.edu/divisions/msk/protocols/CT_ankle.pdf

CT Arthrography
Injectate
Nonionic contrast, full strength (with MDCT, no need to dilute) Can also inject lidocaine or long-acting anesthetic for diagnostic exam

Joints-Upper Extremity
Injection volumes Shoulder~12-15 cc Elbow 7-10 cc Wrist
Radiocarpal Joint~3-4 cc Midcarpal Joint~3-4 cc Distal Radial Ulnar Joint~1-2 cc

Joints-Lower Extremity
Injection Volumes Hip~10-12 cc Knee~20-30 cc Ankle~7-12 cc

Example: CT Arthrogram Wrist

Technique: Intra-articular injection into 3 compartments Inject into radiocarpal joint first
radiocarpal joint (RCJ) 3-4 cc

midcarpal joints (MCJ) 3-4 cc

distal radial ulnar joint (DRUJ) 1-2 cc

CT Arthrogram - Wrist
Same positioning as regular wrist
Patient prone Arm over head (Mighty Mouse Position) Arm as straight as possible Wrist centered in gantry

CT Arthrogram - Wrist
Scan as regular wrist with 0.5-0.6 mm/0.2 mm axial, coronal and sagittal reformats In additonal, use the coronal images to obtain reconstructed images:
Parallel to the scapholunate articulation and lunotriquetral articulation at mm intervals May wish to obtain second scan in ulnar deviation to evaluate SL ligament and radial deviation for LT ligament

CT Arthrogram - Wrist
Relevant Anatomy
Scanning Plane - parallel to the scapholunate articulation (SL ligament evaluation)

q tr i

Dist ulna

lun Dist radius

ap sc

CT Arthrogram - Wrist
Scanning Plane - parallel to the scapholunate articulation (SL ligament evaluation)

Dorsal Band SL

Volar Band SL

CT Arthrogram - Wrist
Relevant Anatomy
Scanning Plane - perpendicular to lunatotriquetral articulation (LT ligament evaluation)

q tr i

Dist ulna

lun Dist radius

ap sc

CT Arthrogram - Wrist
Scanning Plane - perpendicular to lunotriquetral articulation (LT ligament evaluation)

Volar Band LT

Dorsal Band LT

Metal Protocol
General principles:
Increasing photon flux will improve the image quality; to accomplish this: -increase mAs -increase overlap (pitch less than 1) -use higher kV Avoid accentuation of artifact; to accomplish this: -do not use a sharpening or bone algorithm -avoid using very thin slices -if possible beam should be directed along length of hardware

Body Part

Slice Thickness (mm) 0.5 2.5

Interval (mm) 0.2 1.3

Pitch

kV

mA

Large Joint Small Joint

0.7 0.7

140 140

max max

Use scanning plans and three plane reconstructions as indicated for routine joint.

Acknowledgements
Special thanks to Michelle Braum and Jessica Bower References:
University of Wisconsin Imaging Protocols http://www.radiology.wisc.edu/divisions/msk/protocols/ Monash Medical Center Protocols http://www.monashmedicalcentre.com.au/imaging/protocols /ct_protocols_2005.pdf Indiana University Orthopedics Protocols http://www.indyrad.iupui.edu/public/ct/Disclaimer.htm American Roentgen Ray Society Musculoskeletal Imaging with Multislice CT AJR 2001; 176:979-986 Kenneth A. Buckwalter, et al. Department of Radiology, Indiana University School of Medicine