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Anatomy of the Lower Extremity in Computed Tomography Michael C. Ficorelli, RT Lesson Description To explain the various exams pertaining to the lower extremity using computed tomography, incorporating cross sectional anatomy from images Lesson Description • To be able to identify anatomy of the lower extremity. Understand the clinical indications for exams of the abdomen. To understand the methods of patient scanning, positioning, and protocols. To understand indications for contrast. CT of the Lower Extremity (Hip, Knee, Ankle, Foot) Ankle and Foot Bony Anatomy • 7 Tarsal Bones – Talus – responsible with the calcaneus for bearing weight; wedge shaped body with upper surface (trochlea) which articulates with Tibia and Fibula – Calcaneus – Largest tarsal, prominence of the heel, tuberosity which is insertion for ligaments and tendons (Achilles) • Sustentaculum Tali – medial surface which supports the talus • Sinus Tarsi – canal from articulation between talus and calcaneous – Navicular, Cuboid, Lateral Cuneiform, Intermediate Cuneiform, Medial Cuneiform • • • • 5 Metatarsals 14 phalanges – 3 for each toe except hallux (2) Distal Tibia – Medial malleoli Distal Fibula – Lateral malleoli Ankle and Foot Anatomy • Arches: – Longitudinal arch: Two parts – lateral and medial – Provides firm base for support – Transverse arch: Distal row of tarsals (Cuboid, 3 cuneiforms) and bases of metatarsals creating dome – major weight bearing arch • Important: – Retinacula – sheaths of tendons around the ankle – Fascia – thickened area on plantar surface Foot Anatomy Foot Anatomy Ankle Joint Knee Bony Anatomy • Made up of: – Distal Femur – lateral and medial condyle and epicondyle • Smooth anterior surface for articulation with the patella • Posterior - intercondylar fossa • Adductor tubercle – above medial epicondyle attachment for adductor magnus – Tibia – widened proximal end with medial and lateral condyles • Tibial Plateau – widened medial and lateral surfaces for articulation with femur • Intercondylar eminence (Tibial Spine) – between the plateaus with two peaks (tubercles) • Tibial Tuberosity – site of attachment of patellar ligament anteriorly – Fibula – long thin bone • Head – apex, sharp and superior with surface that articulates with the lateral condyle of the tibia Knee Anatomy • Patella – Largest sesamoid in the body – Flat triangular bone with base proximal and apex distal • Joint – 2 separate articulations – Femorotibia and Patellofemoral – Capsule – strong, fibrous membrane reinforced by extracapsular ligaments • Anteriorly blends with quadriceps tendon – Synovial membrane is largest synovial cavity of the body – Menisci – (2) found between femoral condyles, connective tissue • Medial – attached to MCL, less mobile • Lateral – closed ring – Ligaments – External and Internal • External – MCL, Lateral Collateral, Patellar • Internal – ACL, PCL GROSS KNEE ANATOMY KNEE ANATOMY KNEE ANATOMY KNEE ANATOMY KNEE ANATOMY KNEE ANATOMY Ankle / Foot Protocol Parameters Single Slice 4 SLICE 16 SLICE FEET FIRST. SUPINE SAME SAME • Lung nodules DEPENDS ON WHAT SAME SAME SCANNING AREA • CancerPART 100ML AT 1-2ML/SEC SAME SAME CONTRAST • Vascular disease 0.5MM 16X0.75 DETECTOR COLLI NA 14-18 SAME SAME DFOV • Effusion and infiltration SAME SAME SLICE THICKNESS 16-20 MM • TraumaNONE SAME SAME ANGLE 3MM VARIES VARIES TABLE • FEED/ROT Pulmonary Parenchymal diseases 1 VARIES VARIES PITCH • Hilar Masses 1 -2 SEC 0.75 SEC 1.5SEC ROT TIME PATIENT RECON STANDARD/BONE SAME SAME WINDOW 450W/30L— 2000W/200L SAME SAME Coronal Foot 1 – Calcanous 2 – Talus 3 – Navicular 4 – Medial Cuneiform 5 – Base of 1st MT 6 – 2nd MT 7 – 2nd Prox Phalanx 8 – 2nd Middle Phalanx 9 – 2nd Distal Phalanx 10 – 5th MTP Joint 11- Navicular Coronal Foot 1 – Base of 5th MT 2 – Cuboid 3 – Calcaneus 4 – Navicular 5 – Medial Cuneiform 6 – 1st MT 7 – 1st Prox Phalanyx 8 – 1st Distal Phalanyx 9 – 2nd Middle Phalanyx 10 – 4th MT Head AXIAL ANKLE 2 1 1- Fibula 2- Tibia AXIAL 1- Lateral malleolus 2 1 3 2- Tallus 3- Medical malleolus AXIAL 1- Talus 2- CALCANUS 1 3- NAVICULAR 3 2 AXIAL 1- CUNEIFORM BONES 2- CUBOID BONE 1 2 SAGITAL MPR 1- TALUS 1 2- SINUS TARUS 2 6 3 3- CALCANEUS 4- CUBOID 5 5- CUNEIFORM 6- NAVICULAR 4 CORONAL MPR 1- LATERAL MALLEOLUS 2 3 2- TALAR JOINT 1 4 3- MEDICAL MALLEOLUS 4- TALLUS 5- CALCANEOUS 5 CORONAL MPR 1- Calcaneous 1 BONE VS SOFT TISSUE BONE SOFT TISSUE KNEE 1- FEMUR 1 KNEE 1- Medial condyle 2- Patella 2 3 1 3- Lateral condyle 4- intercondylar fossa 4 KNEE 1- Tibial Plataeu 1 KNEE 1-Tibia 1 2- Head of fibula 2 CORONAL KNEE 1- Intercondylar fossa 3 1 2 2- Tibial plateau 3- Condyle of femur PROTOCOL FOR HIP AND BONY PELVIS Parameters Single Slice 4 SLICE PATIENT • Lung FEET FIRST. SUPINE SAME nodules CREST TO PUBIS SAME SCANNING AREA ABOVE JOINT TO BELOW • Cancer LESSER TUBEROSITY • Vascular disease 100ML AT 2ML/SEC @ 30 SAME CONTRAST SECOND DELAY • Effusion 4 X 1MM DETECTOR COLLI andNAinfiltration DEPENDS ON PATIENT FOR SAME DFOV • Trauma PELVIS/ 20 CM FOR HIP 5 MM SAME SLICE THICKNESS • Pulmonary Parenchymal diseases NONE SAME ANGLE • Hilar Masses 16 SLICE SAME SAME SAME 16 X 0.75 SAME SAME SAME TABLE FEED/ROT 3-5 MM VARIES VARIES PITCH 1 OR 1.6 VARIES VARIES ROT TIME 1- 2SEC 0.75 SEC 1 SEC RECON STANDARD/BONE SAME SAME WINDOW 450W/30L—1600W/600L SAME SAME HIPS 1- Head of Femur 4 1 2- Acetabulum 3- Fovea Capitis 3 4- Pubic Bone 2 5 5- Ischium HIPS 1 1- Pubic Ramus 2 2- Femoral Neck 3- Ischial Tuberosity 4- Greater Trochanter 3 4 HIPS 1- Symphysis Pubis 2 1 2- Lesser Trochanter HIPS 1- Pubic Bone 1 HIP CORONAL MPR 1- SYMPHYSIS PUBIS 1 2- PUBIC BONE 2 HIP CORONAL MPR 1- Greater Trochanter 1 2 2- Acetabulum 3- Femoral Neck 3 4 4- Lesser Trochanter BONY PELVIS 1- Sacrum 2- Ilium 1 3- S.I. Joint 3 2