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Everything you need to know about Computed Tomography (CT) & CT Scanning

Musculoskeletal: 3D Imaging Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Musculoskeletal ❯ 3D Imaging

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  • ”In the following pictorial essay, we provide a number of clinical examples of the use of CR in musculoskeletal imaging, including the evaluation of complex fractures, the delineation of the relationship of fractures to adjacent vasculature and overlying soft tissues, and the visualization of vascular and soft tissue injuries.”
CT evaluation of musculoskeletal trauma: initial experience with cinematic rendering.
Rowe SP, Fritz J , Fishman EK
Emerg Radiol. 2017 Sep 12. [Epub ahead of print]
  • BACKGROUND: Surgical stabilization of flail chest is increasingly recognized as a valid approach to improve pulmonary mechanics in selected trauma patients. The use of two-dimensional (2D) computed tomography (CT) has become almost universal in the assessment of blunt chest trauma and multiple rib fractures. We hypothesized that three-dimensional (3D) CT adds valuable information to the preoperative plan for fixation of rib fractures.

    RESULTS: Intraobserver and interobserver reliability was excellent for both 2D CT and 3D CT and was the highest for 2D CT. Overall, 2D CT had the highest diagnostic accuracy for detecting rib fractures as compared with plain radiographs and 3D CT. However, 3D CT changed the surgical tactic in 65.7% of the cases.

    CONCLUSION: We conclude that 3D CT is not as accurate as 2D CT for rib fracture diagnostic purposes; it seems to be an important tool for the preoperative planning of rib fracture fixation.


    Utility of three-dimensional computed tomography for the surgical management of rib fractures.
Pulley BR et al.
J Trauma Acute Care Surg. 2015 Mar;78(3):530-4
  • “We conclude that 3D CT is not as accurate as 2D CT for rib fracture diagnostic purposes; it seems to be an important tool for the preoperative planning of rib fracture fixation.”


    Utility of three-dimensional computed tomography for the surgical management of rib fractures.
Pulley BR et al.
J Trauma Acute Care Surg. 2015 Mar;78(3):530-4
  • “We propose that 3DV images should be part of routine head trauma imaging, especially in the pediatric age group. It requires minimal post-processing time and no additional radiation. Furthermore, 3DV images help in reducing the interpretation time and also enhance the ability of the radiologist to characterize the calvarial fractures.”


    Skull fractures in pediatric patients on computerized tomogram: comparison between routing bone window images and 3D volume-rendered images.
Dundamadappa SK et al.
Emerg Radiol. 2015 Aug;22(4):367-72.
  • “Skull fracture is a common finding following head trauma. It has a prognostic significance and its presence points to severe trauma. Additionally, there is a greater possibility of detecting associated small underlying extra-axial hematomas and subtle injuries to the brain parenchyma. In pediatric patients, the presence of multiple open sutures often makes fracture evaluation challenging. In our experience, 3D volume (3DV)-rendered CT images complement routine axial bone window (RBW) images in detection and characterization of fractures.”


    Skull fractures in pediatric patients on computerized tomogram: comparison between routing bone window images and 3D volume-rendered images.
Dundamadappa SK et al.
Emerg Radiol. 2015 Aug;22(4):367-72.
  • “Perilunate dislocations, perilunate fracture-dislocations (PLFDs), and lunate dislocations are high-energy wrist injuries that can and should be recognized on radiographs. These injuries are a result of important sequential osseous and ligamentous injuries or failures. Prompt and accurate radiographic diagnosis aids in the management of patients with perilunate dislocations, PLFDs, and lunate dislocations while assisting orthopedic surgeons with subsequent surgical planning. CT may better show the extent of the injury and help in treatment planning particularly in cases of delayed treatment or chronic perilunate dislocation. A CT examination with coronal, sagittal, and 3D reformatted images is ordered at our institution in cases in which the extent of the carpal injuries is poorly shown on radiographic examination.”


    Spectrum of carpal dislocations and fracture-dislocations: imaging and management.
Scalcione LR et al.
AJR Am J Roentgenol. 2014 Sep;203(3):541-50.
  • “Prompt and accurate radiographic diagnosis aids in the management of patients with perilunate dislocations, PLFDs, and lunate dislocations while assisting orthopedic surgeons with subsequent surgical planning. CT may better show the extent of the injury and help in treatment planning particularly in cases of delayed treatment or chronic perilunate dislocation. A CT examination with coronal, sagittal, and 3D reformatted images is ordered at our institution in cases in which the extent of the carpal injuries is poorly shown on radiographic examination.”


    Spectrum of carpal dislocations and fracture-dislocations: imaging and management.
Scalcione LR et al.
AJR Am J Roentgenol. 2014 Sep;203(3):541-50.
  • BACKGROUND: Distal humerus fractures are difficult to characterise and to classify according to the AO system. In this multicentre study, our objectives were to assess the usefulness of computed tomography (CT) and to measure intra-observer and inter-observer reliability according to observer experience.

    CONCLUSION: CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation.


    Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures.
Jacquot A et al.
Orthop Traumatol Surg Res. 2014 May;100(3):275-80
  • “CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation.”


    Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures.
Jacquot A et al.
Orthop Traumatol Surg Res. 2014 May;100(3):275-80
  • “The addition of three-dimensional CT imaging did not increase inter- and intraobserver reliability for the classification of calcaneal fractures. Authors commented they experienced no additional benefit from 3D-CT imaging for the assessment of calcaneal fractures.”


    Three-dimensional computed tomography is not indicated for the classification and characterization of calcaneal fractures.
Veltman ES et al.
Injury. 2014 Jul;45(7):1117-20.
  • PURPOSE: Three-dimensional (3D) reformatted images provide a more inclusive representation of abnormalities than transverse images in cranial computed tomography (CT). The purpose of this study was to assess the value of 3D reformations for radiology residents in the interpretation of emergency cranial CTs.

    MATERIALS AND METHODS: In total, 218 consecutive patients who underwent emergency cranial CT scans with 3D reformation were included in this retrospective study. Four blinded readers (three radiology residents and a neuroradiologist) interpreted the transverse and 3D images in two separate sessions. Each reader assessed 1) abnormal finding(s) and the confidence score(s) (5-point scale) for transverse and 3D images, 2) added value score of 3D images (5-point scale), and 3) interpretation time for both transverse and 3D images. We analyzed discordance between each radiology resident and the neuroradiologist on a lesion-by-lesion basis.
  • RESULTS: In total, 509 lesions were detected in 218 patients. Discordance rates between the three residents and the neuroradiologist were 11.4%-20.2% (mean, 15.0%) and 8.8%-16.9% (mean, 12.1%) in the interpretation of transverse and 3D images, respectively. Confidence scores were higher for 3D images than for transverse images for all readers. The added value scores for the 3D images were relatively higher for the inexperienced residents. Interpretation times for 3D images were significantly higher than for transverse images for all readers.

    CONCLUSION: The 3D reformations assist radiology residents in the interpretation of emergency cranial CT examinations
Comparison of emergency cranial CT interpretation between radiology residents and neuroradiologists: transverse versus three-dimensional images.


    Kim ES et al.
Diagn Interv Radiol. 2014 May-Jun;20(3):277-84
  • PURPOSE: Three-dimensional (3D) reformatted images provide a more inclusive representation of abnormalities than transverse images in cranial computed tomography (CT). The purpose of this study was to assess the value of 3D reformations for radiology residents in the interpretation of emergency cranial CTs..

    RESULTS: In total, 509 lesions were detected in 218 patients. Discordance rates between the three residents and the neuroradiologist were 11.4%-20.2% (mean, 15.0%) and 8.8%-16.9% (mean, 12.1%) in the interpretation of transverse and 3D images, respectively. Confidence scores were higher for 3D images than for transverse images for all readers. The added value scores for the 3D images were relatively higher for the inexperienced residents. Interpretation times for 3D images were significantly higher than for transverse images for all readers.

    CONCLUSION: The 3D reformations assist radiology residents in the interpretation of emergency cranial CT examinations
Comparison of emergency cranial CT interpretation between radiology residents and neuroradiologists: transverse versus three-dimensional images.


    Kim ES et al.
Diagn Interv Radiol. 2014 May-Jun;20(3):277-84
  • “The 3D reformations assist radiology residents in the interpretation of emergency cranial CT examinations.”


    Comparison of emergency cranial CT interpretation between radiology residents and neuroradiologists: transverse versus three-dimensional images.
Kim ES et al.
Diagn Interv Radiol. 2014 May-Jun;20(3):277-84
  • What does 3D CT add to 2D CT based on the literature?
    - High impact on surgical planning and decision making
    - Increased concensus on decision making
    - Roadmaps for pre-operative planning with CT
    I- mproved lesion detection with increased accuracy
  • Does the use of 3D differ depending on imaging experience?
    - Resident vs. faculty
    - Experience of the faculty
    - “hands on” vs select images
  • INTRODUCTION: The insertion of thoracic pedicle screws (T1-T10) is subject to a relevant rate of malplacement. The optimum implantation procedure is still a topic of controversial debate. Currently, a postoperative computed tomography is required to evaluate the screw positions. The present study was undertaken to clarify whether intraoperative 3D imaging is a reliable method of determining the position of thoracic pedicle screws.

    CONCLUSIONS: Performing an intraoperative 3D scan enables the position of thoracic pedicle screws to be determined with sufficient accuracy. The rate of revision surgery was reduced to 0 %.
Reliability and consequences of intraoperative 3D imaging to control positions of thoracic pedicle screws.
Beck M et al.
Arch Orthop Trauma Surg. 2012 Oct;132(10):1371-7
  • “For the post-operative patient, conventional axial computed tomography (CT) imaging and 2D multiplanar reconstruction are of limited value because of the beam-hardening artifact. However, three-dimensional (3D) CT imaging is an effective means of detecting subtle fracture healing, or confirming non-union, and for evaluating the integrity of metal hardware. In this article we emphasize the advantages of 3D CT imaging in the assessment and preoperative planning of non-union for patients who have been surgically treated for fractures.”


    Recognition, assessment, and treatment of non-union after surgical fixation of fractures: emphasis on 3D CT.
Calisir C, Fayad LM, Carrino JA, Fishman EK
Jpn J Radiol. 2012 Jan;30(1):1-9.
  • “Pediatric trauma is a significant source of morbidity and mortality in pediatric patients. Prompt and accurate assessment of injuries is necessary for the best outcome. Computed tomography (CT) has become a well-accepted, rapid, relatively noninvasive way to assess the trauma patient. In certain cases of pelvic trauma, two- and three-dimensional CT (2D/3D CT) adds detail not otherwise obtainable or appreciated. Although the benefits must be balanced against the slight increase in delivered radiation dose, we believe that 2D/3D CT is often an important part of patient management.”


    Acetabular and pelvic fractures in the pediatric patient: value of two- and three-dimensional imaging.
Magid D, Fishman EK, Ney DR, Kuhlman JE, Frantz KM, Sponseller PD.
J Pediatr Orthop. 1992 Sep-Oct;12(5):621-5.
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