Hand and wrist protocol (CT)
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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:
- complex distal radial fractures and ulnar fractures
- scaphoid fractures or carpal fractures
- carpal instability
- foreign bodies
- inflammatory or infectious processes
- bone and soft tissue tumors (if MRI is contraindicated)
- postoperative follow up, implants and their complications
- ligamentous injury
- triangular fibrocartilage complex injury
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.
- 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
- ≤120 kVp (100 kVp)
- as suggested by the automated current adjustment mode
- whole hand to the distal third of the forearm
- wrist: including radial metaphysis and proximal third of the metacarpal bones
- hand: includes the entire hand to the radial metaphysis
- 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)
- 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%
- patient positioning before scanning might reduce and facilitate multiplanar reconstructions
- reconstructions in both standard kernel and high-resolution kernels
- depending on the exact indication the scan might require an extension of the scan field
- dose optimization 1
- use iterative reconstruction or artificial intelligence-based algorithms if available
- imaging of implants 1
- 1. Welling R, Jacobson J, Jamadar D, Chong S, Caoili E, Jebson P. MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns. AJR Am J Roentgenol. 2008;190(1):10-6. doi:10.2214/ajr.07.2699 - Pubmed
- 2. Ahlawat S, Corl F, Fishman E, Fayad L. MDCT of the Hand and Wrist: Beyond Trauma. Emerg Radiol. 2014;22(3):307-14. doi:10.1007/s10140-014-1274-5 - Pubmed
- 3. Grunz J, Gietzen C, Grunz K, Bley T, Schmitt R. Imaging of Carpal Instabilities. Rofo. 2020;193(02):139-50. doi:10.1055/a-1219-8158 - Pubmed
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- 5. Moser T, Dosch J, Moussaoui A, Buy X, Gangi A, Dietemann J. Multidetector CT Arthrography of the Wrist Joint: How to Do It. Radiographics. 2008;28(3):787-800. doi:10.1148/rg.283075087 - Pubmed
- 6. Lee R, Ng A, Tong C et al. Intrinsic Ligament and Triangular Fibrocartilage Complex Tears of the Wrist: Comparison of MDCT Arthrography, Conventional 3-T MRI, and MR Arthrography. Skeletal Radiol. 2013;42(9):1277-85. doi:10.1007/s00256-013-1666-8 - Pubmed
- 7. Kim S, Lee G, Lee J. Evaluation of the Triangular Fibrocartilage: Comparison of Two-Compartment Wrist CT Arthrography Using the Distal Radioulnar and Radiocarpal Joints and Unicompartment Wrist CT Arthrography Using the Radiocarpal Joint. BJR. 2019;92(1102):20190298. doi:10.1259/bjr.20190298 - Pubmed
- 8. Grunz J, Gietzen C, Luetkens K et al. The Importance of Radial Multiplanar Reconstructions for Assessment of Triangular Fibrocartilage Complex Injury in CT Arthrography of the Wrist. BMC Musculoskelet Disord. 2020;21(1):286. doi:10.1186/s12891-020-03321-2 - Pubmed