Hand and wrist protocol (CT)

Last revised by Dr Joachim Feger on 14 Jan 2022

The CT hand and wrist protocol serves as an examination for the bony assessment of the wrist and is often performed as a non-contrast study and less often as a contrast-enhanced study. A CT wrist can be also conducted as a CT arthrogram for the evaluation of ligamentous injuries and the triangular fibrocartilage complex

Note: This article aims to frame a general concept of a CT protocol for the assessment of the wrist and hand. Protocol specifics will vary depending on CT scanner type, specific hardware and software, radiologist and perhaps referrer preference, patient factors e.g. implants, specific indications.

Contrast doses apply for CT examinations in adults.

A typical CT of the elbow might look like as follows:

Typical indications include the following 1-8:

The aim of a wrist CT in the setting of traumatic injuries or fractures is their timely diagnosis as well as their classification and characterization 1.

In the setting of inflammatory or neoplastic processes, the purpose of a CT hand or wrist is the localization and characterization of the respective process, its extent and its relation to the adjacent tissues as well as the detection of potential complications 2. If gout is suspected a dual-energy CT can visualize urate crystal deposits 2

In the setting of carpal instability, a non-contrast CT can demonstrate bony morphology and osteoarthrosis of the radiocarpal and midcarpal joint in the late stages of the disease 3.

A CT arthrogram of the wrist is done to demonstrate and localize scapholunate or lunotriquetral ligament tears as well as to detect and classify triangular fibrocartilage complex injuries 4-8.

  • patient position
    • prone position 
    • the hand in question is raised above the head in the center of the scanning table
    • the elbow should be extended palm facing downwards
    • the head can rest on the other arm
  • tube voltage
    • ≤120 kVp (100 kVp)
  • tube current
    • as suggested by the automated current adjustment mode
  • scout
    • whole hand to the distal third of the forearm
  • scan extent
    • wrist: including radial metaphysis and proximal third of the metacarpal bones
    • hand: includes the entire hand to the radial metaphysis 
  • scan direction
    • craniocaudal
  • scan geometry
    • field of view (FOV): ≤150 mm (should be adjusted to increase in-plane resolution)
    • slice thickness: ≤0.625 mm, interval: ≤0.3 mm
    • reconstruction algorithm: bone, soft tissue
  • contrast injection considerations
    • non-contrast (e.g. fractures)
    • single acquisition with monophasic injection
      • contrast volume: 70-100ml (0.1 mL/kg) with 30-40 mL saline chaser at 3-5 mL/s
      • scan delay: 40-60 seconds (venous) or 20-25 seconds (angiogram)
  • multiplanar reconstructions
    • axial images:  perpendicular to the forearm-3rd metacarpal axis and fairly parallel to the radiocarpal joint, dorsum of the wrist oriented upwards
    • coronal images: parallel to the forearm and the metacarpal bones forearm pointing downwards
    • sagittal images: in the axis of the forearm and the 3rd metacarpal bone, perpendicular to the coronal images and the radiocarpal joint, forearm pointing downwards

slice thickness: bone ≤1,5 mm, soft tissue ≤3 mm, overlap 50%

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Cases and figures

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