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

Patient positioning
Topogram
Axial
AP
topogram/
scout
(to include joint
under
investigation)

Axial
AP
topogram/
scout
(to include entire
joint under
investigation)

Examination

axial foot/ankle
coronal foot/ankle

axial wrist
axial elbow
sagittal wrist
coronal wrist
coronal elbow

Patient Positioning
- patient positioned supine, feet first
- arms by patients side or across chest
- use Velcro straps and immobilisation
pads to help the patient keep his/her
feet/ankle still
- if the patient is likely to jump off table
use thick Velcro straps and strap the
patient down to the table
--ensure
patient is
comfortable
patientthat
positioned
prone,
head first
- arm to be investigated is placed above
patients head and rested on scan table
- use Velcro straps and immobilisation
pads to help the patient keep his/her
arm still
- if the patient is likely to jump off table
use thick Velcro straps and strap the
patient down to the table
- ensure that patient is comfortable

Axial
AP
topogram/
scout
(to include entire
shoulder joint)

axial shoulder

Axial
AP
topogram/
scout
(to include joint
under
investigation)

axial knee
axial acetabulum

- patient positioned supine, head first

- endeavour to get the shoulder to be
imaged towards the isocentre of the
gantry
- arms relaxed by patient's side
- if the patient is likely to jump off
table
use thick Velcro straps and strap the
patient down to the table
- ensure that patient is comfortable
- patient positioned supine, feet first
- arms above patients head
- if the patient is likely to jump off
table
use thick Velcro straps and strap the
patient down to the table
- ensure that patient is comfortable
- for knee examinations use sponge
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 imagings 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
criteria

- entire wrist joint

- visually sharp reproduction of all the

bones of the wrist
image
reproductio - visually sharp reproduction of the wrist
joint
n
- visually sharp reproduction of the
criteria
musculature and other soft
tissue structures
anatomy
- distal radius to the proximal metacarpals
covered

Wrist protocol
Acquisiti
on

Slice
Thi
ckn
ess

Table
Mov
eme
nt

range 1
Axial
Spiral 1-2 mm 2-3 mm
pitch
= 1.5

mAs

75-100

kV

algorithm

bone + soft
tissue
120
adult
body

Rotation
Time

0.75-1.5
second

IV
con
tras
t

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 range
1

20003000

200-500

Soft Tissue
150-450
range 1

30-50

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

Acquisition

range 1
Axial Spiral
pitch =
1.5

Slice
Thic
knes
s

1-2 mm

Table
Mov
eme
nt

2-3 mm

mAs

~75-100

kV

algorithm

Rotation
Time

120

bone + soft
tissue
adult
body

0.75-1.5
second

IV
cont
rast

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

Bone range 20001

3000
Soft Tissue
150-450
range 1

Centre
200-500
30-50

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
- entire shoulder joint
imaging criteria

- 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
anatomy covered

- top of acromion to mid scapula or until end of

lesion to be investigated

Shoulder Spiral Protocol

Acquisitio
n

range 1
Axial
Spiral
pitch =
1.5

Slice
Thic
kne
ss

3 mm

Table
Move
ment

4.5 mm

mAs

~200250

kV

algorithm

Rotation
Time

140

bone + soft
tissue
adult
body

0.75-1.5
second

IV
con
tras
t

windowing
Window

Width

Centre

Bone
range 1

20003000

200-500

Soft Tissue
150-450
range 1

30-50

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
criteria

- entire hip joint

- 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

Acquisiti
on

range 1
Axial
Spiral
pitch
= 1.5

Slice
Th
ick
nes
s

3 mm

Table
Mov
eme
nt

4.5 mm

mAs

~200250

kV

algorithm

140

bone +
soft
tissue
adult
body

Rotation
Time

0.75-1.5
second

IV
con
tras
t

windowing
Window

Width

Bone range 20001

3000
Soft Tissue
150-450
range 1

Centre
200-500
30-50

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
criteria

- entire knee joint

- visually sharp reproduction of all the bones of the

knee
image
reproduction - visually sharp reproduction of the knee joint
- 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

Acquisit
ion

range 1
Axial
Spiral
pitch
= 1.5

Slice
Thi
ckn
ess

1-2
m
m

Table
Mo
ve
me
nt

2-3
mm

kV

algorith
m

Rotation
Time

~75120
150

bone +
soft
tissue
adult
body

0.75-1.5
secon
d

mAs

IV
co
ntr
ast

windowing
Window

Width

Bone range 20001

3000
Soft Tissue
150-450
range 1

Centre
200-500
30-50

Foot and ankle imaging

start of range 1

start of range 2

end of range 1

AXIAL FOOT

end of range 2

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
imaging
criteria

- entire foot (calcaneum to proximal metatarsals)

- or specific area determined by request

- visually sharp reproduction of all the bones of the

foot/ankle
image
- visually sharp reproduction of the foot/ankle
reproduction
joints
criteria
- visually sharp reproduction of the musculature
and other soft
- tissue
axial structures
parallel to the Chopart's joint between the

navicular and
anatomy covered medial cuneiform
- perpendicular (as possible) to axial scan plane for
coronal scans

Foot and Ankle Spiral

Protocol
Acquisi
tion

range 1
Axial
Spira
l
pitch
= 1.5

Slice
Th
ick
ne
ss

1-2
m
m

Table
Mo
ve
me
nt

2-3
m
m

kV

algorith
m

Rotatio
n
Time

IV
co
nt
ra
st

~75120
100

bone +
soft
tissue
adult
body

0.75-1.5
secon
d

mAs

windowing
Window

Width

Centre

Bone range 1

2000-3000

200-500

Soft Tissue
range 1

150-450

30-50