Principles of ankle and foot CT 05/12/2017

Part 1: Basic principles of CT

CT imaging chain
System components
Acquisition techniques
Image quality and artifacts

Part 2:
Applications

CT=computed tomography
CAT=computed axial tomography
X-rays discovered by Roentgen in 1895
2D images-summation of shadows
CT founded by Hounsfield in 1970
Cross-sectional imaging eliminates summation and allows multiplanar and 3D visualization

Notes: Same physics as x-ray, but used in a different way. Advantage of CT = eliminates superimposition

Ionizing radiation
Scientific unit of measurement for radiation dose (effective dose) is the millisievert (mSv)
Other radiation dose units: rad, rem, roentgen, sievert, gray
Tissues have varying sensitivity to radiation exposure
Effective dose refers to radiation risk averaged over entire body
Effective dose accounts for relative sensitivities of tissues exposed

Effective radiation doses in adults

Notes: Gantry contains x-ray source that produces a fan shaped x-ray beam. Other side of gantry is the rotating
x-ray detector array. As it rotates around the pt, x-ray source & detector also rotate. The table will slide.
Images are acquired in a spiral fashion.

Notes: Control console located outside. Post-processing using acquired raw data.
Notes: Scan parameters higher kVp = lower contrast = more current means more will go to the tissue.
Differentiation between the tissues will be lower. mA @left bottom corner it says the parameters. kVp 120,
milliamps 143. Time is 1000 s. Can calculate milliamps.

Notes: Dense tissue looks white on CT. Depends on attenuation coefficient = the higher, the whiter.
X ray source from one source diverges onto the detector.
For X-rays, the image comes from any point of the line, then they all end up on the same plane on the detector.
For CT, you acquire images from the same point of the line on any location.

Notes: Pixels = picture elements. Each = voxel/volume element. 2D image of tissue. Filtered back projection =
converts space/time domain to frequency domain and recreate image from the detector to the image you see )
inversely transform using the convolution integral) to filter out certain frequencies. Only certain # of pixels you

can get in an image.

Notes: Images from different directions where theres nothing in the field, you get a flat line. Take each of the
curve and along that curve, you put a line on the image summation will give you a point on the image.

Notes: Hounsfield = creator of CT

Notes: Air & fat = low, water is 0 (everything is centered around the water). Compact bone/cortical bone is
1000+.
Notes:
Parameters @ corner - W:350 width. 50 = level L.
L (level) = where you center your image.
W (width) = in Hounsfield unit of your image.
Window level and width control.
Left side = bone window. Wide window at high level. Level centered around the bone.
Right side = Density lower level and window values for soft tissues.
Notes: Bone window - take a window from 150~850 from the original scan and expand it to fit your entire scale
for your bone picture.
Center it around water density (-160~240) if you want soft tissue.
 Notes: Reconstruction kernel in addition to changing the window, you can change the level of detail.
1st pic = soft tissue WL. Take the same image and put it into bone WL (picture to the right) not a good
bone detail pic.
But if you use bone reconstruction, you get more detail (4th pic/bottom right) and if you turn that into
ST (3rd pic/bottom left) you get a noisy image. Use the algorithm thats appropriate for your picture.
Notes: You can use any plane (via technologist)
You can tilt your plane of reconstruction in whichever direction.
Bottom 1st pic depicts the talonavicular joint

Notes: Plane of section shown.

Bottom oblique plane so you get talus and calcanueus (STJ)
Notes: You can do 3D rendering. (bones & ST) Fracture can be visualized also.

Notes: Slice thickness: same kilovoltage, same current, same bone reconstruction algorithm, same W & L. The
only difference is slice thickness thinner on the left = more detail.
Right = thicker more blurry but less noise. Trade off btwn spatial resolution and noise.

Cartoon skipped
Notes: digital projection as shown in the pic (scout topogram) but you can use it to determine leg legnths in pts
who cant stand.
Conventional = original method. But now we use volumetric.
 Single slice vs. multi-slice. Single slice has an x-ray projecting from a single detector.
Multi-slice has multidetector that detects multiple points simultaneously.
Bottom pic shows multiple detectors.
Speed has improved.

MDCT = shorter time means less pt motion/artifact. Shows how images are acquired at the same
time. Data acquired in a spiral fashion. Slices are acquired at the same time.
Isotropic imaging images can be reformatted into any plane you want.
 Dual energy acrquires images in diferent kVp.
Cone beam CT WB designed for ankle & foot

Dual CT by using different energies you can differentiate one tissue from another. Used for:
Gout = distinguish uric acid crystal from calcium this way.
 WB pedCAT/Cone beam. Pt stands in the scanner and the detector rotates and acquires the image.
Low energy, low radiation dose sounds nice but the image is noisy.
Pt has to be able to stand otherwise you cant get the WB image. Takes longer.

Pic - you can put pt in a high heel and measure it.

Pes planus in pts w/ PTTD. Or 3D models of TMT joint, etc.
 Last type of PET CT inject radioactive isotope thats specific for tumor. Fuse the images of CT &
PET. Shows tumor localization in specific tissues.
 Can suppress the artifact using mathematical equations/changes in the instruments.

Common artifacts are beam hardening (as the beam passes the tissue, the x-ray has photons of
lower images pass first. Higher energy photons will stay in the beam longer = harder beam
creates streaks and dark bnads operator can tilt gantry/obtain images at different direction)
partial volume ICU pts with different tubes & wires. Use thin acquisition width
 Beam hardening wont see much @ foot & ankle. D
The dark band you see is not real. Just happens when the beam passes through a dense bone.

Pt based artifacts:
Metallic materials (implants, etc.) causes streaking
Motion pt moves
incomplete projection - larger pts
 Metal artifact behind the screw you see a dark band = beam hardening effect of the metal.
MAR used to reduce that (reduced version on the right)
 sagittal view shows which levels the images are taken at.
Top to bottom = distal tib fib & down to get axial images.
 back to front

Coronal/frontal plane picture on the top left corner shows which sections are taken (Medial to
lateral).
 Trimalleolar fx subluxation post reduction shows minimally displaced fibular fx.
 Posterior malleolar fx visible on CT that was not detected on the radiograph. You can use CT to
visualize CT entrapment as well here you can see peroneus brevis and longus (not entrapped in
this case)
 Pylon fx - talus impacts on distal tibia and causes it to shatter. Comminuted fx w/ multiple
fragments. This is an open fracture soft tissue gas visible and medial mal protrudes the skin.
Get a CT to see where the fragments are for the surgical plan

Soft tissue image @ level of distal tib-fib. Posterior tibialis tendon is entrapped btwn fx fragments.
(1st pic) bone image
(2nd pic) shows comminuted fx black dot = air (common in open fx).
Coronal images below show how far the fx was displaced posteriorly.
 Navicular fx fixed w/ a screw presented to surgeon w/ concern for non-union.
Difficult to see if the fx healed or not. (CT confirms the fx hasnt healed).
Sclerosis of the lateral fragment of the navicular could be AVN.
Coronal shows comminuted fx of the navicular.
 Took a chunk off distal tibia and graft it on to navicular (with the vessels) and the graft begins to get
incorporated into the bone. graft is nicely incorporated.

OCD osteochondral defect of talar dome. Radiographs show lucency @ medial talar dome.
CT shows a more accurate size measurement/visualize articular surface shape.
 OCD dots/litte pieces of bone @ the dome. Displaced fragment suspected CT shows the
fragment (loose) better
Calcaneal fx. Radiolucency @ calcaneus.
 CT not necessary to dx fracture but is still used for surgical planning. Helps you guide screw
placement.
 Talar neck fx lucency shows fx. CT shows comminuted fx of the talar neck.

Midfoot pain bases of MT fx. White dots are pain markers put by the technologist
 CT shows LisFranc joint injury, cuneiform fx in addition to bases of MT fx. always get CT for lisfranc
joint injury

Charcot arthropathy primarily involves the ankle. Entire foot is dislocated medially. Navicular is
extruded medially and midfoot is deformed. Distal tibia is articulating with calcaneus (no talus btwn
the two)
 Fluid density = abscess (1st pic) Complete destruction of all of the articulating surfaces. OM
 CT scanagram example
 This pt had distal spiral fibular fx. Couldnt tell if it was healing or not so got CT

CT shows additional info.

 Pt who had hallux valgus sx. 5th MT osteo. Implant on 2nd toe to fix hammertoe. They werent
healing properly so CT was obtained.
Axial images on top left
1st pic shows non-healing 5th MT osteotomy. Osteotomy margins are hypertrophied & sclerotic =
hypertrophic nonunion synostosis.
2nd pic implant on 2nd toe for hammertoe correction.
3rd pic Hypertrophic margin for the hallux = no healing.
Sagittal views on right
1st pic - 1st MT screw radiolucency around the screw, not healing.
2nd pic 2nd toe. Lucency around the screw = hardware is moving within. Not healing.
3rd pic 5th MT lucency = not healing.
 Pt who came with triple arthrodesis that was revised. Piece of bone was grafted to promote
healing. Doc wanted to see if there was solid bony fusion CT shows solid bony fusions.

Next pt also had triple arthrodesis with a bone graft. but here, you can see the screw (top 2 nd) is
coming out. CT shows lucency and sagittal view shows plate retracting/moving posteriorly. Pieces of
graft separating from the bone.
 Pt who had ankle arthritis. Joint space is narrow, osteophytes visible. Prosthesis visible in the 2 nd pic.
Pt has pain in 2014 bubbly lucency @ tibia around the prosthesis.
Cortical disease/osteolysis causes bone resorption around prostheses.

CT shows big lucent lesion @ distal tibia w/ sclerotic border.

 Lesion ws packed w/ graft material to correc the lucency. Follow up CT shows good incorporation of
the graft into the bone.
 Pt w/ comminuted calcaneal fx. Lipohemarthrosis happens with intraarticular fx fat leaks out.
Peroneus longus is entrapped.
 Pt w/ heel pain ossification @ calf visible @ Achilles tendon. Thickened Achilles. Tendinopathy w/
ossification. ST swelling around it.

Tarsal coalitions. TC & CN coalitions are most common.

 C sign visible. Normally theres a gap btwn talus & calc. asymmetric narrowing laterally @ STJ

Solid osseous fusion of STJ @ pic 1.

 C sign with talar beak = tarsal coalition

Radiographs show fibrous coalition. Articular margins of middle facet are expanded. Fibrous tissue
is @ a joint.
 Another pt w/ heel pain. Anterior process of talus is wider than normal it articulates w/ navicular
(wider articulating surface)

Sagittal view picture on bottom left shows broader articulation between the calcaneus and
navicular than normal.
 Ant eater sign CN coalition. (anterior process of calc is large and protrudes)
Edema @ articulation between the calcaneus and navicular.
 IV contrast used for CT angiography or infection when you cant get MRI to see abscess.
 Diabetic pt w/ large foot ulcer on plantar side. Charcot arthropathy of midfoot shown

CT shows vessels are bright (intravenous contrast) and shows dense phlegm surrounding the ulcer
but theres no abscess.

White substance = contrast injected into the joint (fluoroscopic or u/s guidance) shows cartilage
defect @ talar dome. Black line = cartilage.
 Dual energy CT for gout. Typical marginal erosions visible.
Dense material = tophi.
Uric acid and Calcium have different attenuation numbers at 80 kVp - this diferntiates the two.
(color coded map shows it)
 Very few contraindications to CT (relative, not absolute) inonizing radiation (pregnancy, kids under
2), CECT (contrast enhanced CT), weight, girth, medical necessity.