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Multidetector CT of Musculoskeletal Disease in the Pediatric Patient: Principles, Techniques, and Clinical Applications¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N Wolfe St, JHOC 3171-C, Baltimore, MD 21287. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received April 23, 2004; revision requested June 8; received and accepted January 24, 2005. All authors have no financial relationships to disclose.

View larger version (142K): [in a new window]   Figure 1a.  DDH in a 5-month-old girl with a history of hemangiomas and with widening of the left hip joint space at radiography. (a) Axial CT image does not clearly show the location of the left femoral head. (b–d) Coronal posterior (b), coronal anterior (c), and axial oblique (d) volume-rendered 3D CT images of the pelvis show superolateral displacement of the left femoral head without evidence of a space-occupying lesion. At the request of the referring physician, the lumbar spine was included in the study because the patient was experiencing hip pain. Hip pain is occasionally referred from the lumbar spine. Typically, a CT examination for DDH does not require imaging of the lumbar spine.

 

View larger version (137K): [in a new window]   Figure 1b.  DDH in a 5-month-old girl with a history of hemangiomas and with widening of the left hip joint space at radiography. (a) Axial CT image does not clearly show the location of the left femoral head. (b–d) Coronal posterior (b), coronal anterior (c), and axial oblique (d) volume-rendered 3D CT images of the pelvis show superolateral displacement of the left femoral head without evidence of a space-occupying lesion. At the request of the referring physician, the lumbar spine was included in the study because the patient was experiencing hip pain. Hip pain is occasionally referred from the lumbar spine. Typically, a CT examination for DDH does not require imaging of the lumbar spine.

 

View larger version (124K): [in a new window]   Figure 1c.  DDH in a 5-month-old girl with a history of hemangiomas and with widening of the left hip joint space at radiography. (a) Axial CT image does not clearly show the location of the left femoral head. (b–d) Coronal posterior (b), coronal anterior (c), and axial oblique (d) volume-rendered 3D CT images of the pelvis show superolateral displacement of the left femoral head without evidence of a space-occupying lesion. At the request of the referring physician, the lumbar spine was included in the study because the patient was experiencing hip pain. Hip pain is occasionally referred from the lumbar spine. Typically, a CT examination for DDH does not require imaging of the lumbar spine.

 

View larger version (111K): [in a new window]   Figure 1d.  DDH in a 5-month-old girl with a history of hemangiomas and with widening of the left hip joint space at radiography. (a) Axial CT image does not clearly show the location of the left femoral head. (b–d) Coronal posterior (b), coronal anterior (c), and axial oblique (d) volume-rendered 3D CT images of the pelvis show superolateral displacement of the left femoral head without evidence of a space-occupying lesion. At the request of the referring physician, the lumbar spine was included in the study because the patient was experiencing hip pain. Hip pain is occasionally referred from the lumbar spine. Typically, a CT examination for DDH does not require imaging of the lumbar spine.

 

View larger version (136K): [in a new window]   Figure 2a.  DDH in a 7-year-old girl. (a, b) Coronal volume-rendered 3D CT images obtained in two slightly oblique orientations show dysplasia of the right hip with a shallow acetabulum and flattening of the right femoral head. (c) Coronal MPR CT image obtained for comparison shows identical findings.

 

View larger version (142K): [in a new window]   Figure 2b.  DDH in a 7-year-old girl. (a, b) Coronal volume-rendered 3D CT images obtained in two slightly oblique orientations show dysplasia of the right hip with a shallow acetabulum and flattening of the right femoral head. (c) Coronal MPR CT image obtained for comparison shows identical findings.

 

View larger version (137K): [in a new window]   Figure 2c.  DDH in a 7-year-old girl. (a, b) Coronal volume-rendered 3D CT images obtained in two slightly oblique orientations show dysplasia of the right hip with a shallow acetabulum and flattening of the right femoral head. (c) Coronal MPR CT image obtained for comparison shows identical findings.

 

View larger version (95K): [in a new window]   Figure 3a.  DDH in a 16-year-old boy with Down syndrome. (a) Axial CT image shows that the femoral heads are uncovered bilaterally. (b) Coronal MPR CT image shows bilateral shallow acetabula and uncovering of the femoral heads. The abnormalities are more severe on the left side than on the right. (c) Coronal volume-rendered 3D CT image shows the deformities and displacement of the femoral heads.

 

View larger version (111K): [in a new window]   Figure 3b.  DDH in a 16-year-old boy with Down syndrome. (a) Axial CT image shows that the femoral heads are uncovered bilaterally. (b) Coronal MPR CT image shows bilateral shallow acetabula and uncovering of the femoral heads. The abnormalities are more severe on the left side than on the right. (c) Coronal volume-rendered 3D CT image shows the deformities and displacement of the femoral heads.

 

View larger version (110K): [in a new window]   Figure 3c.  DDH in a 16-year-old boy with Down syndrome. (a) Axial CT image shows that the femoral heads are uncovered bilaterally. (b) Coronal MPR CT image shows bilateral shallow acetabula and uncovering of the femoral heads. The abnormalities are more severe on the left side than on the right. (c) Coronal volume-rendered 3D CT image shows the deformities and displacement of the femoral heads.

 

View larger version (121K): [in a new window]   Figure 4a.  Evaluation of surgical screws in a 16-year-old girl with a history of hip fixation for bilateral SCFE. (a) Axial CT image shows bilateral intramedullary surgical screws. Note the streak artifacts surrounding the screws (arrows). (b) Coronal volume-rendered 3D CT image shows the bilateral intramedullary screws (arrows). Note that the streak artifacts related to the metal screws are eliminated with the rendering technique. (c) Coronal MPR CT image obtained for comparison shows the intramedullary screws (arrows). The alignment is satisfactory.

 

View larger version (132K): [in a new window]   Figure 4b.  Evaluation of surgical screws in a 16-year-old girl with a history of hip fixation for bilateral SCFE. (a) Axial CT image shows bilateral intramedullary surgical screws. Note the streak artifacts surrounding the screws (arrows). (b) Coronal volume-rendered 3D CT image shows the bilateral intramedullary screws (arrows). Note that the streak artifacts related to the metal screws are eliminated with the rendering technique. (c) Coronal MPR CT image obtained for comparison shows the intramedullary screws (arrows). The alignment is satisfactory.

 

View larger version (112K): [in a new window]   Figure 4c.  Evaluation of surgical screws in a 16-year-old girl with a history of hip fixation for bilateral SCFE. (a) Axial CT image shows bilateral intramedullary surgical screws. Note the streak artifacts surrounding the screws (arrows). (b) Coronal volume-rendered 3D CT image shows the bilateral intramedullary screws (arrows). Note that the streak artifacts related to the metal screws are eliminated with the rendering technique. (c) Coronal MPR CT image obtained for comparison shows the intramedullary screws (arrows). The alignment is satisfactory.

 

View larger version (112K): [in a new window]   Figure 5a.  Legg-Calvé-Perthes disease in a 9-year-old boy with left hip pain. (a) Axial CT image shows remodeling of the left femoral neck. The epiphysis is difficult to evaluate on axial source images. (b) Coronal volume-rendered 3D CT image shows fragmentation of the left femoral epiphysis (thin arrow), a finding compatible with Legg-Calvé-Perthes disease. The patient has already undergone left acetabuloplasty (thick arrow). (c) Coronal MPR CT image shows fragmentation of the epiphysis (thin arrow) and remodeling of the femoral neck (thick arrow).

 

View larger version (133K): [in a new window]   Figure 5b.  Legg-Calvé-Perthes disease in a 9-year-old boy with left hip pain. (a) Axial CT image shows remodeling of the left femoral neck. The epiphysis is difficult to evaluate on axial source images. (b) Coronal volume-rendered 3D CT image shows fragmentation of the left femoral epiphysis (thin arrow), a finding compatible with Legg-Calvé-Perthes disease. The patient has already undergone left acetabuloplasty (thick arrow). (c) Coronal MPR CT image shows fragmentation of the epiphysis (thin arrow) and remodeling of the femoral neck (thick arrow).

 

View larger version (138K): [in a new window]   Figure 5c.  Legg-Calvé-Perthes disease in a 9-year-old boy with left hip pain. (a) Axial CT image shows remodeling of the left femoral neck. The epiphysis is difficult to evaluate on axial source images. (b) Coronal volume-rendered 3D CT image shows fragmentation of the left femoral epiphysis (thin arrow), a finding compatible with Legg-Calvé-Perthes disease. The patient has already undergone left acetabuloplasty (thick arrow). (c) Coronal MPR CT image shows fragmentation of the epiphysis (thin arrow) and remodeling of the femoral neck (thick arrow).

 

View larger version (130K): [in a new window]   Figure 6a.  Pectus excavatum in a 7-year-old boy. (a) Sagittal volume-rendered 3D CT image shows pectus excavatum and narrowing of the anteroposterior diameter of the chest. Arrow = sternum. (b) Sagittal 3D CT image, produced by modifying the volume-rendering parameters to selectively display the skeletal anatomy, shows the deformed sternum (arrowheads).

 

View larger version (118K): [in a new window]   Figure 6b.  Pectus excavatum in a 7-year-old boy. (a) Sagittal volume-rendered 3D CT image shows pectus excavatum and narrowing of the anteroposterior diameter of the chest. Arrow = sternum. (b) Sagittal 3D CT image, produced by modifying the volume-rendering parameters to selectively display the skeletal anatomy, shows the deformed sternum (arrowheads).

 

View larger version (105K): [in a new window]   Figure 7.  Pectus excavatum in a 24-year-old man. Sagittal volume-rendered 3D CT image shows pectus excavatum.

 

View larger version (113K): [in a new window]   Figure 8.  Albright hereditary osteodystrophy in an 11-year-old girl. Sagittal oblique volume-rendered 3D CT image of the ankle shows proximity of the anterior process of the calcaneus to the navicular bone with surrounding sclerosis (arrow), findings indicative of a nonosseous calcaneonavicular coalition. Note the shortened third and fourth metatarsals associated with the syndrome.

 

View larger version (118K): [in a new window]   Figure 9a.  Bilateral talocalcaneal coalitions in a 7-year-old patient with foot pain. Coronal MPR CT images of the right (a) and left (b) ankles show nonosseous talocalcaneal coalitions. The patient was treated with surgery and resection of the coalitions.

 

View larger version (123K): [in a new window]   Figure 9b.  Bilateral talocalcaneal coalitions in a 7-year-old patient with foot pain. Coronal MPR CT images of the right (a) and left (b) ankles show nonosseous talocalcaneal coalitions. The patient was treated with surgery and resection of the coalitions.

 

View larger version (120K): [in a new window]   Figure 10a.  Tibial fracture in a 13-year-old boy who experienced a fall. (a) Axial CT image shows a fracture of the distal tibia. However, the relationship of the fracture to the physis is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image of the ankle shows that the fracture is a Salter type IV injury. (c, d) Coronal MPR CT images (c obtained posterior to d) show the Salter type IV fracture extending into the joint space.

 

View larger version (106K): [in a new window]   Figure 10b.  Tibial fracture in a 13-year-old boy who experienced a fall. (a) Axial CT image shows a fracture of the distal tibia. However, the relationship of the fracture to the physis is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image of the ankle shows that the fracture is a Salter type IV injury. (c, d) Coronal MPR CT images (c obtained posterior to d) show the Salter type IV fracture extending into the joint space.

 

View larger version (109K): [in a new window]   Figure 10c.  Tibial fracture in a 13-year-old boy who experienced a fall. (a) Axial CT image shows a fracture of the distal tibia. However, the relationship of the fracture to the physis is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image of the ankle shows that the fracture is a Salter type IV injury. (c, d) Coronal MPR CT images (c obtained posterior to d) show the Salter type IV fracture extending into the joint space.

 

View larger version (129K): [in a new window]   Figure 10d.  Tibial fracture in a 13-year-old boy who experienced a fall. (a) Axial CT image shows a fracture of the distal tibia. However, the relationship of the fracture to the physis is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image of the ankle shows that the fracture is a Salter type IV injury. (c, d) Coronal MPR CT images (c obtained posterior to d) show the Salter type IV fracture extending into the joint space.

 

View larger version (145K): [in a new window]   Figure 11a.  Elbow fracture in a 7-year-old girl. Multidetector CT was performed for surgical planning and complete evaluation of the fracture, which was diagnosed with radiography. At clinical evaluation, intraarticular displacement of a fracture fragment was suspected. (a) Axial CT image shows a fracture of the right proximal radius. There is posterolateral displacement of a fracture fragment (arrow). (b) Coronal oblique volume-rendered 3D CT image of the elbow shows a fracture dislocation of the radial head. Note the fracture fragment (arrow). (c) Sagittal volume-rendered 3D CT image of the elbow shows posterior displacement of the fracture fragment (thin arrow). Note the remaining preserved epiphysis (thick arrow).

 

View larger version (143K): [in a new window]   Figure 11b.  Elbow fracture in a 7-year-old girl. Multidetector CT was performed for surgical planning and complete evaluation of the fracture, which was diagnosed with radiography. At clinical evaluation, intraarticular displacement of a fracture fragment was suspected. (a) Axial CT image shows a fracture of the right proximal radius. There is posterolateral displacement of a fracture fragment (arrow). (b) Coronal oblique volume-rendered 3D CT image of the elbow shows a fracture dislocation of the radial head. Note the fracture fragment (arrow). (c) Sagittal volume-rendered 3D CT image of the elbow shows posterior displacement of the fracture fragment (thin arrow). Note the remaining preserved epiphysis (thick arrow).

 

View larger version (120K): [in a new window]   Figure 11c.  Elbow fracture in a 7-year-old girl. Multidetector CT was performed for surgical planning and complete evaluation of the fracture, which was diagnosed with radiography. At clinical evaluation, intraarticular displacement of a fracture fragment was suspected. (a) Axial CT image shows a fracture of the right proximal radius. There is posterolateral displacement of a fracture fragment (arrow). (b) Coronal oblique volume-rendered 3D CT image of the elbow shows a fracture dislocation of the radial head. Note the fracture fragment (arrow). (c) Sagittal volume-rendered 3D CT image of the elbow shows posterior displacement of the fracture fragment (thin arrow). Note the remaining preserved epiphysis (thick arrow).

 

View larger version (143K): [in a new window]   Figure 12a.  Acetabular fracture after a motor vehicle accident in a 17-year-old patient. (a) Coronal volume-rendered 3D CT image (anterior projection) shows asymmetry of the acetabula with a possible fracture on the right (arrow). (b) Sagittal volume-rendered 3D CT image clearly shows the fracture of the posterior acetabular wall (arrow).

 

View larger version (123K): [in a new window]   Figure 12b.  Acetabular fracture after a motor vehicle accident in a 17-year-old patient. (a) Coronal volume-rendered 3D CT image (anterior projection) shows asymmetry of the acetabula with a possible fracture on the right (arrow). (b) Sagittal volume-rendered 3D CT image clearly shows the fracture of the posterior acetabular wall (arrow).

 

View larger version (138K): [in a new window]   Figure 13a.  Slipped humeral epiphysis in a 13-year-old boy who was injured while playing football. He presented with right shoulder pain. (a) Axial CT image of the right shoulder does not clearly show a slipped humeral epiphysis. (b, c) Coronal MPR (b) and volume-rendered 3D (c) CT images show the slipped epiphysis.

 

View larger version (141K): [in a new window]   Figure 13b.  Slipped humeral epiphysis in a 13-year-old boy who was injured while playing football. He presented with right shoulder pain. (a) Axial CT image of the right shoulder does not clearly show a slipped humeral epiphysis. (b, c) Coronal MPR (b) and volume-rendered 3D (c) CT images show the slipped epiphysis.

 

View larger version (119K): [in a new window]   Figure 13c.  Slipped humeral epiphysis in a 13-year-old boy who was injured while playing football. He presented with right shoulder pain. (a) Axial CT image of the right shoulder does not clearly show a slipped humeral epiphysis. (b, c) Coronal MPR (b) and volume-rendered 3D (c) CT images show the slipped epiphysis.

 

View larger version (112K): [in a new window]   Figure 14a.  Sacral osteosarcoma in an 11-year-old girl with a history of pelvic osteosarcoma. (a) Axial CT image of the pelvis shows a left-sided sacral lesion (arrow) that contains osteoid matrix and is associated with a soft-tissue mass. The relationship to the posterior sacroiliac joint is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image shows that the sacral lesion abuts the sacroiliac joint and involves the lower sacral foramina. (c) Coronal volume-rendered 3D CT image (posterior perspective) shows the sacral lesion.

 

View larger version (154K): [in a new window]   Figure 14b.  Sacral osteosarcoma in an 11-year-old girl with a history of pelvic osteosarcoma. (a) Axial CT image of the pelvis shows a left-sided sacral lesion (arrow) that contains osteoid matrix and is associated with a soft-tissue mass. The relationship to the posterior sacroiliac joint is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image shows that the sacral lesion abuts the sacroiliac joint and involves the lower sacral foramina. (c) Coronal volume-rendered 3D CT image (posterior perspective) shows the sacral lesion.

 

View larger version (164K): [in a new window]   Figure 14c.  Sacral osteosarcoma in an 11-year-old girl with a history of pelvic osteosarcoma. (a) Axial CT image of the pelvis shows a left-sided sacral lesion (arrow) that contains osteoid matrix and is associated with a soft-tissue mass. The relationship to the posterior sacroiliac joint is not clearly demonstrated. (b) Coronal volume-rendered 3D CT image shows that the sacral lesion abuts the sacroiliac joint and involves the lower sacral foramina. (c) Coronal volume-rendered 3D CT image (posterior perspective) shows the sacral lesion.

 

View larger version (119K): [in a new window]   Figure 15a.  Fibrous cortical defects and nonossifying fibromas in a 13-year-old boy with right knee pain. Multiple lesions were seen at plain radiography. (a) Axial CT image obtained through one of the lesions shows an eccentric lytic lesion involving the cortex with a probable very thin rim of overlying periosteum, findings indicative of a fibrous cortical defect. (b) Coronal MPR CT image shows multiple eccentric, well-defined, lobulated, low-attenuation lesions with sclerotic borders, findings compatible with nonossifying fibromas and fibrous cortical defects.

 

View larger version (127K): [in a new window]   Figure 15b.  Fibrous cortical defects and nonossifying fibromas in a 13-year-old boy with right knee pain. Multiple lesions were seen at plain radiography. (a) Axial CT image obtained through one of the lesions shows an eccentric lytic lesion involving the cortex with a probable very thin rim of overlying periosteum, findings indicative of a fibrous cortical defect. (b) Coronal MPR CT image shows multiple eccentric, well-defined, lobulated, low-attenuation lesions with sclerotic borders, findings compatible with nonossifying fibromas and fibrous cortical defects.

 

View larger version (115K): [in a new window]   Figure 16a.  Orthopedic hardware in a 6-year-old girl with McCune-Albright syndrome (polyostotic fibrous dysplasia). She underwent osteotomy with placement of a dynamic hip screw and a lateral plate. (a) Coronal volume-rendered 3D CT image shows varus deformity of the right hip. Note the orthopedic hardware. (b) Coronal volume-rendered 3D CT image obtained more obliquely shows the metallic hardware. (c) Coronal MPR CT image shows extensive streak artifacts related to the orthopedic hardware. Volume rendering nearly eliminates these artifacts.

 

View larger version (116K): [in a new window]   Figure 16b.  Orthopedic hardware in a 6-year-old girl with McCune-Albright syndrome (polyostotic fibrous dysplasia). She underwent osteotomy with placement of a dynamic hip screw and a lateral plate. (a) Coronal volume-rendered 3D CT image shows varus deformity of the right hip. Note the orthopedic hardware. (b) Coronal volume-rendered 3D CT image obtained more obliquely shows the metallic hardware. (c) Coronal MPR CT image shows extensive streak artifacts related to the orthopedic hardware. Volume rendering nearly eliminates these artifacts.

 

View larger version (116K): [in a new window]   Figure 16c.  Orthopedic hardware in a 6-year-old girl with McCune-Albright syndrome (polyostotic fibrous dysplasia). She underwent osteotomy with placement of a dynamic hip screw and a lateral plate. (a) Coronal volume-rendered 3D CT image shows varus deformity of the right hip. Note the orthopedic hardware. (b) Coronal volume-rendered 3D CT image obtained more obliquely shows the metallic hardware. (c) Coronal MPR CT image shows extensive streak artifacts related to the orthopedic hardware. Volume rendering nearly eliminates these artifacts.

 

View larger version (145K): [in a new window]   Figure 17.  Orthopedic hardware in a 12-year-old girl with Kniest syndrome (a skeletal dysplasia). She was treated with bilateral valgus osteotomy. Coronal volume-rendered 3D CT image of the lower extremities shows orthopedic hardware. Note the dysplastic acetabula and enlarged distal femoral epiphyses.

 

View larger version (174K): [in a new window]   Figure 18.  Orthopedic hardware in a 17-year-old girl with cerebral palsy and scoliosis who underwent corrective surgery. Coronal volume-rendered 3D CT image of the pelvis shows transpedicle screws and vertical rods in the spine. She also underwent a right Chiari osteotomy with internal fixation for a right hip subluxation. Note the absence of metal artifact.

 

View larger version (172K): [in a new window]   Figure 19a.  Orthopedic hardware in a 14-year-old boy with Legg-Calvé-Perthes disease. A left hip osteotomy was performed to increase coverage of the femoral head and reduce subluxation. (a) Coronal volume-rendered 3D CT image of the pelvis shows surgical screws at the osteotomy site. Note the deformed femoral head. (b) Coronal MPR CT image shows streak artifacts related to one of the surgical screws. Note the deformed femoral head and remodeled femoral neck.

 

View larger version (89K): [in a new window]   Figure 19b.  Orthopedic hardware in a 14-year-old boy with Legg-Calvé-Perthes disease. A left hip osteotomy was performed to increase coverage of the femoral head and reduce subluxation. (a) Coronal volume-rendered 3D CT image of the pelvis shows surgical screws at the osteotomy site. Note the deformed femoral head. (b) Coronal MPR CT image shows streak artifacts related to one of the surgical screws. Note the deformed femoral head and remodeled femoral neck.

 

View larger version (128K): [in a new window]   Figure 20.  Orthopedic hardware in a 14-year-old girl who was struck by a bicycle and sustained multiple fractures. Coronal oblique volume-rendered 3D CT image of the pelvis shows a surgical screw traversing a fracture of the anterior column of the acetabulum.

 

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