MSK CT Protocols. *Protocols have been adapted from Thomas Jefferson University Musculoskeletal CT Protocols.
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1 MSK CT Protocols Reviewed by: George Wang, MD Last review date: May 2014 Contact: (866) and choose option 1. George Wang: *Protocols have been adapted from Thomas Jefferson University Musculoskeletal CT Protocols. In accordance with the ALARA principle, TRA policies and protocols promote the utilization of radiation dose reduction techniques for all CT examinations. For scanner/protocol combinations that allow for the use of automated exposure control and/or iterative reconstruction algorithms while maintaining diagnostic image quality, those techniques can be employed when appropriate. For examinations that require manual or fixed ma/kv settings as a result of individual patient or scanner/protocol specific factors, technologists are empowered and encouraged to adjust ma, kv or other scan parameters based on patient size (including such variables as height, weight, body mass index and/or lateral width) with the goals of reducing radiation dose and maintaining diagnostic image quality. Sections Routine Shoulder CT... Routine Elbow CT... Routine Wrist/Hand CT... Routine Bone Pelvis CT... Routine Bone Hip CT... Routine Sacroiliac CT... Routine Knee CT... Routine Foot/Ankle/Distal/Tibia... Ankle/hindfoot... Fore/midfoot... MSK Long Bone/Extremity CT...
2 MSK Soft Tissue CT... MSK CT Arthrogram... Metal Protocol...
3 Routine Shoulder CT Positioning Pt supine Affect arm by side with palm up Contralateral arm above head Coverage From above AC joint to the bottom of the scapula. If there is a shoulder prosthesis, scan to include the distal end of the humeral component. Field of view (FOV) just wide enough to include entire scapula and proximal humerus. Collimation mm Reformats Orient coronal reformats using axial image at the mid glenoid level. Adjust coronal reformats plane to be perpendicular to the glenoid articular surface (green line below top left box). Collimation is 2 mm. Orient sagittal reformats using coronal reformat image at the mid glenoid level. Adjust sagittal reformats plane to be parallel to the glenoid articular surface (blue line below bottom left box). Collimation is 2 mm.
4 Send only these images 1. Scout. 2. Source axial images with bone algorithm mm. 3. Source axial images with soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats with bone algorithm 2 mm. Routine Elbow CT Positioning Patient prone Arm of concern above head with elbow extended Palm up
5 Coverage From distal humeral metadiaphysis to the radial tuberosity. Collimation mm Reformats Orient coronal reformats plane using an axial image at the level of the humeral condyles. Adjust coronal reformats plane to parallel the imaginary line (green line below) connecting the medial and lateral margins of the olecranon fossa. Collimation is 2 mm. Orient sagittal reformats plane using the same image, perpendicular to the coronal reformats plane (blue line above). Collimation is 2 mm.
6 Send only these images: 1. Scout. 2. Source axial images with bone algorithm mm. 3. Source axial images with soft tissue algorithms 2.5 mm. 4. Coronal and sagittal reformats with bone algorithm 2 mm. Routine Wrist/Hand CT Positioning Patient prone Arm straight above head, palm down ( Mighty Mouse position) Coverage When scanning the WRIST From the distal radial diaphysis to the third metacarpal base.
7 When scanning the HAND From just proximal to the distal radioulnar joint to include the entire hand. Collimation mm intervals Small Scanning Field of View (SFOV) cm Display Field of View (DFOV) Reformats Orient coronal reformats using axial image at the distal radial epiphysis. Adjust coronal reformats plane to be perpendicular to the radial articular surface of the distal radioulnar joint (green line below top left box). Collimation is 2 mm. Orient sagittal reformats using the same image, perpendicular to the coronal reformats plane (blue line below top left box). Collimation is 2 mm.
8 Send only these images 1. Scout. 2. Source axial images with bone algorithm mm. 3. Source axial images with soft tissue algorithms 2.5 mm. 4. Coronal and sagittal reformats with bone algorithm 2 mm. Routine Bone Pelvis CT Positioning Pt supine, legs flat on table, feet together. No cushions or wedges under feet or legs.
9 Coverage From just above iliac crests to just below lesser trochanters. If hardware is present, cover the inferior most aspect of the hardware and adjacent bone. Collimation mm
10 Reformats Coronal reformats are oriented using an axial image that shows the ischial tuberosities. Adjust coronal plane line (dotted line) to connect the posterior most ischial tuberosities. Cover from front of pubic symphysis to behind gluteal muscles. Collimation is 2 mm. Sagittal reformats are oriented using the same axial image as above, perpendicular to the coronal reformats plane. Cover continuously from right hip to left hip including sacrum. Collimation is 2 mm. Send only these images 1. Scout. 2. Source axial images with bone algorithm mm. 3. Source axial images with soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats of the pelvis with bone algorithm 2 mm.
11 Routine Bone Hip CT Positioning Pt supine, legs flat on table, feet together. No cushions or wedges under feet or legs. Coverage From just above iliac crests to just below lesser trochanters. If hardware is present, cover the inferior most aspect of the hardware and adjacent bone.
12 Collimation mm Reformats Coronal reformats are oriented using an axial image that shows the ischial tuberosities. Adjust coronal plane line (dotted line) to connect the posterior most ischial tuberosities. Cover from front of pubic symphysis to behind gluteal muscles. Collimate images to show only the hemipelvis/hip of interest. Collimation is 2 mm.
13 Sagittal reformats are oriented using the same axial image as above, perpendicular to the coronal reformats plane. Cover from the hip of interest to the mid sacrum. Collimation is 2 mm. Send only these images 1. Scout. 2. Source pelvis axial images with bone algorithm mm. 3. Source pelvis axial images with soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats of the hemipelvis/hip of interest with bone algorithm 2 mm. Routine Sacroiliac CT Positioning Pt supine, legs flat on table, feet together. No cushions or wedges under feet or legs.
14 Coverage From just above iliac crests to just below lesser trochanters. Collimation mm Reformats Sagittal reformats are oriented using an axial image that shows the pubic symphysis. Adjust sagittal reformats plane to be parallel the pubic symphysis and to be perpendicular to the line connecting the ischial tuberosities (blue line below). Collimation is 2 mm.
15 Oblique coronal reformats are oriented using a midline sagittal image through the sacrum. Adjust oblique coronal reformats plane to parallel to the long axis of the sacrum. Cover the sacrum from front to back, including the entire SI joints. Cover SI joint to SI joint. Collimation is 2 mm.
16 Oblique axial reformats are oriented using the same midline sagittal image through the sacrum, perpendicular to the oblique coronal plane. Cover entire sacrum and coccyx. Collimation is 2 mm. Send only these images 1. Scout. 2. Source pelvis axial images with bone algorithm mm. 3. Source pelvis axial images with soft tissue algorithm 2.5 mm. 4. Sagittal, oblique coronal and oblique axial reformats of the sacrum with bone algorithm 2 mm. Routine Knee CT Positioning Pt. supine. Slide patient over so that the knee being imaged is centered in scanner. Taping the feet together helps stabilize knees. In most cases it is fine to leave the other knee straight and within scanning field. If there is metal in the other knee, try to bend other knee so it is not in the scanning field. Plaster casts are not a problem. Scout in 2 planes.
17 Coverage Small FOV. Side of interest only. From the distal femoral metadiaphysis to the proximal tibial metadiaphysis. If scanning a metal prosthesis, cover the entire length of both the femoral and tibial components of the side of interest. Collimation Collimation is mm Reformats Coronal reformats are oriented using axial image at the level of the femoral condyles. Adjust coronal reformats plane to parallel to the line connecting the posterior femoral condyles on the axial reformat (green line below). Collimation is 2 mm. Sagittal reformats are oriented using same axial image at the level of the femoral condyles, perpendicular to the coronal reformats (blue line above). Collimation is 2 mm. Send only these images 1. Scout. 2. Source axial images of the requested side with bone algorithm mm. 3. Source axial images of the requested side with soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats with bone algorithm 2 mm.
18 Routine Foot/Ankle/Distal Tibia CT Positioning Patient Supine. Feet together, centered in scanner. Toes pointing straight up. In most cases we scan both feet together. If feet cannot be brought together or if the contralateral foot/ankle has hardware, position the patient such that the ankle of interest is centered in the scanner and the contralateral knee is bent with foot/ankle out of the way. Coverage: Small FOV. Only side of interest. Distal tibial metadiaphysis to include the whole foot.
19 Collimation mm Ankle/hindfoot: Reformats Orient coronal reformats using axial image at the level of the tibial fibular syndesmosis. Adjust coronal reformats plane to bisect the tibia and fibula (green line below). Collimation 2 mm.
20 Orient the sagittal reformats plane using the same image, peripendicular to the coronal reformats plane (blue line above). Collimation is 2 mm. Send only these images 1. Scout. 2. Source axial images side of interest with bone algorithm mm. 3. Source axial images side of interest with soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats side of interest with bone algorithm 2 mm. Fore/midfoot: Reformats Orient axial reformats using routine reformat sagittal image that shows the entire first metatarsal (may have to oblique this image to see the entire first metatarsal). Adjust axial reformats plane to parallel the long axis of the first metatarsal. Collimation is 2 mm.
21 Orient coronal reformats using the same image, perpendicular to the axial reformats. Collimation is 2 mm. Orient the sagittal reformats plane using the axial reformat image that shows the entire first metatarsal. Adjust the sagittal reformats plane to parallel the long axis of the first metatarsal. Collimation 2 mm.
22 Send only these images 1. Scout. 2. Source axial images side of interest with bone algorithm mm. 3. Axial reformats side of interest with bone and soft tissue algorithms 2.5 mm. 4. Coronal and sagittal reformats side of interest with bone algorithm 2 mm. MSK Long Bone/Extremity CT Positioning Same as the adjacent joint. Coverage Limit scanning field of view. Only do the area and side of interest. Collimation 1.25 mm Reformat Coronal and sagittal reformats of side of interest. If field of view center around a joint, make coronal and sagittal reformats according to orientation parameters of the adjacent joint CT as described above. Otherwise, make routine coronal and sagittal reformats. Collimation is 2 mm. Send only these images 1. Scout.
23 2. Source axial images side of interest in bone algorithm 1.25 mm 3. Source axial images side of interest in soft tissue algorithm 2.5 mm. 4. Coronal and sagittal reformats side of interest in soft tissue algorithm 2 mm. MSK Soft Tissue CT (use IV contrast if possible) (abscess, infection, mass) Positioning Same as the adjacent joint. Coverage Limit scanning field of view. Only do the area and side of interest. Collimation 2.5 mm Scanning Parameters secs delay after intravenous contrast injection. Reformat Coronal and sagittal reformats of side of interest. If field of view center around a joint, make coronal and sagittal reformats according to orientation parameters of the adjacent joint CT as described above. Otherwise, make routine coronal and sagittal reformats. Collimation is 2.5 mm. Send only these images 1. Scout. 2. Source axial images side of interest in bone and soft tissue algorithms 2.5 mm. 3. Coronal and sagittal reformats side of interest in soft tissue algorithm 2.5 mm. MSK CT Arthrogram Perform according to the joint specific protocols above.
24 Metal Protocol General Principle Increasing photon flux will improve the image quality; to accomplish this: o increase mas o increase overlap o use higher kv Avoid accentuation of artifact; to accomplish this: o do not use a "sharpening" or "bone algorithm" o avoid using very thin slices o if possible beam should be directed along length of hardware Body Part Slice Thickness (mm) Interval (mm) kv ma Large Joint max Small Joint max Reformat and Send only these images as per individual joint protocols above.
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