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 FOV KV mA

0 Large 140 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 1.25 0.625 -Bone

-Soft Tissue
Reformat 2 2 -Axial
-Coronal
-Sagittal
SHOULDER
Relevant Anatomy Scanning Plane (Axial)
•Prescribe plane parallel to humeral shaft.
•Cover from AC joint through proximal humeral diaphysis.

AC joint Clavicle
Acromium

Humeral
Head
s
ysi
ph
Dia
ra l
me
Hu
SHOULDER
Coronal Imaging Plane
Relevant Anatomy Coronal Imaging Plane
•Prescribe coronal plane off of axial images parallel
to supraspinatus muscle.

Su
pr
asp
In ina
fra tus
sp
ina
tus
SHOULDER
Sagittal Imaging Plane
Relevant Anatomy Sagittal Imaging Plane
•Prescribe sagittal plane off axial images with
line parallel to bony glenoid.
•Image from scapular wing through deltoid muscle.

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
Relevant Anatomy
Causes Bicipital groove to lie at
superior aspect of humeral head
Scanning Plane
Scout view in coronal plane.
Axials prescribed oblique along long axis of humerus.

Clavicle

Bicipital groove

Acromion
SHOULDER
CT Arthrography with ABER
Representative Images
Coronal 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 FOV KV mA

0 Small 120 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 0.625 0.3 -Bone

-Soft Tissue
Reformat 0.8 1.5 -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 Lateral Humeral Condyle

Olecranon process
of Ulna

rus
e
um
H

Ulna Radial head

*
ELBOW
Sagittal Imaging Plane
Relevant Anatomy Sagittal Imaging Plane
•Prescribe plane perpendicular to coronal plane.
• Scan through entire elbow.

Medial Humeral Condyle Lateral Humeral Condyle

Olecranon process
of Ulna

rus
e
um
H

Ulna 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)
Š See dedicated Scaphoid protocol for scaphoid fractures
WRIST
WRIST
Gantry Tilt FOV KV mA

0 Small 120 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 0.625 0.3 -Bone

-Soft Tissue
Reformat 0.8 1.5 -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
cap ham
sc
ap
triq

h
lun
Epiphysis
Distal Distal
Metaphysis
radius ulna

Diaphysis
WRIST
Coronal Imaging Plane
Relevant Anatomy Coronal Imaging Plane
•Prescribe plane parallel to line drawn from
ulnar styloid through radial styloid.
•Scan through entire wrist.

Radial
Ulnar Styloid
Styloid
WRIST
Sagittal Imaging Plane
Relevant Anatomy Sagittal Imaging Plane
•Prescribe plane perpendicular to coronal plane.
• Scan through entire wrist.

Radial
Ulnar Styloid
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
ap
ho
id

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
Š 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 Scanning Plane (Axial)
•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.

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 FOV KV mA

0 Large 140 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 1.25 0.625 -Bone

-Soft Tissue
Reformat 2 2 -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 Coronal Imaging Plane
•Prescribe plane parallel to femoral heads.
•Scan from ischium through pubic
symphysis.

Superior Pubic Ramus Pubic Symphysis

Femoral
Head

Femoral
Neck

Greater Trochanter Ischium

HIP
Sagittal Imaging Plane
Relevant Anatomy Sagittal Imaging Plane
•Prescribe plane perpendicular to coronal plane.
•Scan from acetabulum through greater
trochanter.

Superior Pubic Ramus Pubic Symphysis

Femoral
Head

Femoral
Neck

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 FOV KV mA

0 Small 120 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 1.25 0.625 -Bone

-Soft Tissue
Reformat 0.8 1.5 -Axial
-Coronal
-Sagittal
KNEE
Relevant Anatomy Scanning Plane (Axial)
• Prescribe plane parallel to axis of tibial plateau.
• Scan knee from suprapatellar region to proximal tibia.

Suprapatellar
Region

Femur
Patella

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

Patella

Med Lat
Fem Fem
Condyle Condyle
KNEE
Sagittal Imaging
Relevant Anatomy Sagittal Imaging Plane
•Prescribe plane perpendicular to coronal plane.
•Scan from the medial to the lateral femoral condyle.

Patella

Med Lat
Fem Fem
Condyle Condyle
ANKLE
Positioning:
„ Patient supine
„ Center in scanner both feet or foot of interest
Š Use foot holder if available
Š 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 FOV KV mA

0 Small 120 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 0.625 0.3 -Bone

-Soft Tissue
Reformat 0.8 1.5 -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 Coronal Imaging Plane

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

Tibia

Talus

Calcaneus M
E
T
A
Cuboid A
T
R
S
A
L
S
ANKLE
Sagittal Imaging Plane
Relevant Anatomy Sagittal Imaging Plane
•Prescribe plane with line bisecting calcaneus.
• Scan through entire foot.
m

rm
Cuneifor

Cu dle
if o
Medial

ne
d
Mi

rm
ne la
ifo
Cu ter
La

oid
Cub
eus
can
Cal
FOOT
Positioning
„ Patient supine
„ Center in scanner both feet or foot of
interest
Š Use foot holder if available
Š If imaging both feet, bring them together
„ Toes pointing straight up
„ Foot inverted slightly
FOOT
FOOT
Gantry Tilt FOV KV mA

0 Small 120 200

Slice (mm) Interval (mm) Type/Plane

Reconstruct 0.625 0.3 -Bone

-Soft Tissue
Reformat 0.8 1.5 -Axial
-Coronal
-Sagittal
HINDFOOT/FOREFOOT
Indications
„ Trauma
Š 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

Posterior facet
of subtalar joint
Navicular Talus

Calcaneus
Cuboid
Me
ta
ta
rs
als
HINDFOOT/FOREFOOT
Axial Oblique Imaging Plane

Relevant Anatomy Axial Oblique Imaging Plane

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

Tibia

Posterior facet
of subtalar joint
Navicular Talus

Calcaneus
Cuboid
Me
ta
ta
rs
als
HINDFOOT/FOREFOOT
Coronal Oblique Imaging Plane
Relevant Anatomy Coronal Oblique Imaging Plane
Midtarsal joints (talonavicular/calcaneocuboid •Prescribe plane perpendicular to axial oblique plane
joints) = Chopart’s joint (approximately parallel to midtarsal joints)
•Scan from calcaneus through proximal metatarsals.

Tibia

Posterior facet
of subtalar joint
Navicular Talus

Calcaneus
Cuboid
Me
ta
ta
rs
als
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
Š Lisfranc fracture-dislocation
Š Metatarsal fractures
MIDFOOT/FOREFOOT
Relevant Anatomy Scanning Plane (Coronal)
•Prescribe plane parallel to 1st Metatarsal.
•Scan through entire mid/forefoot.

Navicular
Tibia
1st cuneiform

Talus

l
t arsa
ta
st Me Calcaneus
1
MIDFOOT/FOREFOOT
Axial Imaging Plane
Relevant Anatomy Axial Imaging Plane
Lisfranc joint = tarsometatarsal (TMT) articulations, •Prescribe plane perpendicular to coronal plane.
particularly in area between 1st and 2nd TMTs •This will be parallel to 1st TMT joint
•Scan through entire mid/forefoot.

Navicular
Tibia
1st cuneiform

Talus

l
t arsa
ta
st Me Calcaneus
1

1st TMT joint

MIDFOOT/FOREFOOT
Sagittal Imaging Plane

Relevant Anatomy Sagittal Imaging Plane

•Prescribe along plane parallel to 1st metatarsal.

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
Scanning Plane - parallel to
the scapholunate articulation
Relevant Anatomy
tr i
q (SL ligament evaluation)

h
lun ap
Dist sc
ulna
Dist
radius
CT Arthrogram - Wrist
Scanning Plane - parallel to the scapho-
lunate articulation (SL ligament evaluation)

Dorsal Band SL

Volar Band SL
CT Arthrogram - Wrist
Scanning Plane - perpendicular
to lunatotriquetral articulation
Relevant Anatomy
tr i
q (LT ligament evaluation)

h
lun ap
Dist sc
ulna
Dist
radius
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 Interval Pitch kV mA

Thickness (mm)
(mm)
Large 0.5 0.2 0.7 140 max
Joint

Small 2.5 1.3 0.7 140 max

Joint

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