Introduction to

Musculosceletal CT:
overview and general positioning

Oleh: Jeffri Ardiyanto

General Indication:

CT scan extremitas utamanya

dipergunakan untuk mendemonstrasikan
fraktur yang kompleks, tetapi juga untuk
kasus lain seperti tumor. IV contrast
media hanya diperlukan untuk kasus
neoplastic. Reconstruksi gambar
menggunakan tulang and soft tissue
algorithma.
 Continued……
As with plain film radiography projections
need to be obtained in two planes
perpendicular to each other. If two planes
cannot be obtained then very fine slice
collimation needs to be used and MPR
(multi planar reformations) reconstructions
created.
INDICATIONS
- fracture
- dislocation
- post-operative evaluation
- osteosarcoma
- chondrosarcoma
- fibrosarcoma
- giant cell tumour
- osteomyelitis
- liposarcoma
- degenerative changes
- infections
- arthritis
- osteonecrotic changes
 Patient positioning
Topogram Examination Patient Positioning
- patient positioned supine, feet first
Axial - arms by patient’s side or across chest
AP - use Velcro straps and immobilisation
topogram/ pads to help the patient keep his/her
axial foot/ankle
scout feet/ankle still
coronal foot/ankle
(to include joint - if the patient is likely to jump off table
under use thick Velcro straps and strap the
investigation) patient down to the table
- ensure that patient is comfortable

- patient positioned prone, head first

- arm to be investigated is placed above
Axial
patients head and rested on scan table
AP axial wrist
- use Velcro straps and immobilisation
topogram/ axial elbow
pads to help the patient keep his/her
scout sagittal wrist
arm still
(to include entire coronal wrist
- if the patient is likely to jump off table
joint under coronal elbow
use thick Velcro straps and strap the
investigation)
patient down to the table
- ensure that patient is comfortable
 - patient positioned supine, head first
- endeavour to get the shoulder to be
Axial imaged towards the isocentre of the
AP gantry
topogram/ - arms relaxed by patient's side
axial shoulder
scout - if the patient is likely to jump off
(to include entire table
shoulder joint) use thick Velcro straps and strap the
patient down to the table
- ensure that patient is comfortable

- patient positioned supine, feet first

- arms above patient’s head
Axial
- if the patient is likely to jump off
AP
table
topogram/
axial knee use thick Velcro straps and strap the
scout
axial acetabulum patient down to the table
(to include joint
- ensure that patient is comfortable
under
- for knee examinations use sponge
investigation)
pads
to keep the knee immobilised
Positioning for axial foot/ankle
examinations
 Positioning for coronal
foot/ankle examinations
Positioning for axial wrist/elbow
examinations
 Positioning for coronal
wrist/elbow examinations
Positioning for sagittal wrist
examinations
Positioning for axial shoulder
examinations
Positioning for axial acetabulum
examinations
Positioning for axial knee
examinations
 Important
 Movement is CT extremity imaging’s greatest
problem. Patients must be told the importance
of staying still during the examination. Slight
movement of the area under investigation can
lead to a non-diagnostic scan which needs to be
repeated. Proper immobilisation with Velcro
straps and sponges will help minimise patient
movement. Field of view (FOV) used for
extremity imaging should not be too small
Continued…

• When two different imaging planes are

used for the investigation of an extremity,
care must be taken to image
perpendicular (as possible) to each other.
Mistakes are often made when the patient
is re-positioned for scans and the same
scan plane is repeated (i.e. two scans
through the same plane).
Wrist Imaging
 Quality criteria for wrist
examinations
visualisation
imaging - entire wrist joint
criteria
- visually sharp reproduction of all the
bones of the wrist
image
- visually sharp reproduction of the wrist
reproductio
joint
n
- visually sharp reproduction of the
criteria
musculature and other soft
tissue structures
anatomy
- distal radius to the proximal metacarpals
covered
 Wrist protocol

Slice Table IV
Acquisiti Thi Mov Rotation con
mAs kV algorithm
on ckn eme Time tras
ess nt t

range 1
bone + soft
Axial
tissue 0.75-1.5
Spiral 1-2 mm 2-3 mm 75-100 120 ?
adult second
pitch =
body
1.5
difficulty
 Wrist imaging can be a difficult examination
if the patient does not keep still. Movement
will ensure that the scan will have to be
repeated. Before a wrist scan is
commenced the radiologist must be
consulted to determine which planes
through the wrist are to be imaged. Fine
slices must be used to get adequate image
quality.
 Windowing

Window Width Centre

Bone 2000-
200-500
range 1 3000

Soft Tissue
150-450 30-50
range 1
Elbow imaging
 Quality criteria for elbow
examinations
visualisation
- entire elbow joint
imaging criteria

- visually sharp reproduction of all the bones of the

elbow
image reproduction - visually sharp reproduction of the elbow joint
criteria - visually sharp reproduction of the musculature and
other soft
tissue structures

anatomy covered - distal humerus to proximal radius and ulna

 Elbow Spiral Protocol

Slice Table
IV
Thic Mov Rotation
Acquisition mAs kV algorithm cont
knes eme Time
rast
s nt

range 1 bone + soft

Axial Spiral tissue 0.75-1.5
1-2 mm 2-3 mm ~75-100 120 ?
pitch = adult second
1.5 body
difficulty
 Elbow imaging is another difficult
examination. It is an uncomfortable
position for the patient. The scans
must be completed as quickly as
possible. Fine slices must be used and
the entire joint included.
 WINDOWING

Window Width Centre

Bone range 2000-

200-500
1 3000
Soft Tissue
150-450 30-50
range 1
Shoulder imaging
GENERAL TECHNIQUE

 Shoulder scanning can produce poor

image quality due to the physical width
and high bone density of the shoulder
area. High mA and kV must be used to
achieve adequate image quality. The
scan range starts at the superior border
on the acromion and ends at the inferior
border of the scapula.
CONTINUED……
 Slice collimation is increased compared
to small part CT imaging. This increase
in slice collimation in conjunction with a
high mA helps achieve good image
quality without getting into tube cooling
problems. Rotation time can be
increased to help increase examination
mAs and therefore obtain better image
quality.
 Quality criteria for shoulder
examinations
visualisation
imaging criteria
- entire shoulder joint

- visually sharp reproduction of all the bones of the

shoulder
image reproduction
- visually sharp reproduction of the shoulder joint
criteria
- visually sharp reproduction of the musculature
and other soft tissue structures

- top of acromion to mid scapula or until end of

anatomy covered
lesion to be investigated
 Shoulder Spiral Protocol

Slice IV
Table
Acquisitio Thic Rotation con
Move mAs kV algorithm
n kne Time tras
ment
ss t

range 1
bone + soft
Axial
~200- tissue 0.75-1.5
Spiral 3 mm 4.5 mm 140 ?
250 adult second
pitch =
body
1.5
 windowing

Window Width Centre

Bone 2000-
200-500
range 1 3000

Soft Tissue
150-450 30-50
range 1
Acetabulum imaging
start of range 1

end of range 1

AXIAL ACETABULUM
 General technique
 Acetabulum scanning can also produce
poor image quality due to the physical
width and high bone density of the pelvic
girdle. High mA and kV must be used to
achieve adequate image quality. The scan
range starts approximately 3 cm (or above
demonstrated fracture line) above the
acetabulum roof and ends at the inferior
border of the pubic ramus.
 Continued…
 Slice collimation is increased compared to
small part CT imaging This increase in
slice collimation in conjunction with a high
mA helps achieve good image quality
without getting into tube cooling
problems.
 Quality criteria for acetabulum
examinations
visualisation
imaging - entire hip joint
criteria

- visually sharp reproduction of all the bones of the

acetabulum
image - visually sharp reproduction of the acetabulum
reproduction joint
criteria - visually sharp reproduction of the musculature
and other soft
tissue structures

anatomy covered - mid pelvis to end of symphysis pubis

 Acetabulum Spiral Protocol

Slice
Table IV
Th
Acquisiti Mov Rotation con
ick mAs kV algorithm
on eme Time tras
nes
nt t
s

range 1
bone + soft
Axial
~200- tissue 0.75-1.5
Spiral 3 mm 4.5 mm 140 ?
250 adult second
pitch =
body
1.5
 windowing

Window Width Centre

Bone range 2000-

200-500
1 3000
Soft Tissue
150-450 30-50
range 1
Knee imaging
 General technique
 Knee CT scanning is usually performed for
the investigation of tibial plateau fractures
to demonstrate the amount of articular
involvement. To obtain this fine detail
very thin slice collimation must be used.
As the knee joint can only really be
scanned in the axial plane, sagittal and
coronal reformations must be
reconstructed.
 Continued….
 The scan must start at the distal femur
and continue until the end of the tibial
fracture. It is very important to scan to
the end of the fracture.
 Quality criteria for knee
examinations
visualisation
imaging - entire knee joint
criteria
- visually sharp reproduction of all the bones of the
knee
image
- visually sharp reproduction of the knee joint
reproduction
- visually sharp reproduction of the musculature
criteria
and other soft
tissue structures
- distal femur to proximal tibia or end of
anatomy covered demonstrated fracture
 Knee Spiral Protocol

Table
Slice IV
Mo
Acquisit Thi algorith Rotation co
ve mAs kV
ion ckn m Time ntr
me
ess ast
nt

range 1 bone +
Axial 1-2 soft 0.75-1.5
2-3 ~75-
Spiral m 120 tissue secon ?
mm 150
pitch m adult d
= 1.5 body
windowing

Window Width Centre

Bone range 2000-

200-500
1 3000
Soft Tissue
150-450 30-50
range 1
 Foot and ankle imaging

start of range 1

start of range 2

end of range 1 end of range 2

AXIAL FOOT CORONAL FOOT

 General technique
 Foot imaging is the extremity where
most people make mistakes when
scanning. It is very important to
concentrate and use bony landmarks
to determine the scan planes. Scans
must be completed perpendicular to
each other. The joints of the tarsals
are a good reference point for these
planes.
 Continued…
• In one plane you scan parallel to the joints
and in the other plane you scan
perpendicular to the joints. Scanning
planes should be set up so that the gantry
tilts away and not towards the patient. If
the other foot does not need to be
included in the study then it can be
removed from the scan plane. Scan range
must include all tarsal bones and articular
surfaces.
Quality criteria for
foot/ankle examinations
visualisation
- entire foot (calcaneum to proximal metatarsals)
imaging
- or specific area determined by request
criteria
- visually sharp reproduction of all the bones of the
foot/ankle
image
- visually sharp reproduction of the foot/ankle joints
reproduction
- visually sharp reproduction of the musculature
criteria
and other soft
tissue structures
- axial parallel to the Chopart's joint between the
navicular and
medial cuneiform
anatomy covered
- perpendicular (as possible) to axial scan plane for
coronal scans
Foot and Ankle Spiral Protocol
Slice Table IV
Th Mo Rotatio co
Acquisi algorith
ick ve mAs kV n nt
tion m
ne me Time ra
ss nt st

range 1
bone +
Axial
1-2 2-3 soft 0.75-1.5
Spira ~75-
m m 120 tissue secon ?
l 100
m m adult d
pitch
body
= 1.5
 windowing

Window Width Centre

Bone range 1 2000-3000 200-500

Soft Tissue
150-450 30-50
range 1