Symposium on Orthopedic Surgery

Computed Tomography in
Orthopedics

Leonard F. Hubbard, M.D.*

Since the discovery of the x-ray by Rontgen in the last century, a

constant effort has been directed toward improving diagnostic x-ray tech-
niques. This improvement has included use of contrast materials, tomog-
raphy, xeroradiography, and other specialized methods. Not until the
introduction of the CT scanner, however, did a true quantum leap occur.
The first calculations required for the CT scanner were performed by Radon
in 1917. In.1968, Geoffrey Hounsfield applied these theoretical calculations
as a consequence of a project on information retrieval and pattern recog-
nition while he was employed at Electromusical Industries (EMI) in
Britain. 2 To produce the first CT scan, Hounsfield used gamma radiation,
which was eventually replaced with x-ray radiation. The first clinical scan
was performed in 1971.
In 1972, Hounsfield reported a series of 70 cases demonstrating the
usefulness of this technique at the Annual Congress at the Burgess Institute
of Radiology. 2• 27 The extremely favorable reviews he received spurred him
on to further research, resulting in the remarkable development of this
new technique.
In computed axial tomography, or CT scanning, a series of x-ray beams
and detectors are set up in a circle about a patient gantry, and the patient
is placed in the center of this circle. The x-ray beam passes through the
patient, with either the beams or detectors rotating, and a complex series
of images is produced. The mathematical reconstruction of these images by
computer makes the remarkable quality of the CT scan possible. The
information obtained by the detectors is stored on a tape and processed by
computer to produce a cross-sectional image. 13• 14 This method varies
radically from the standard frontal and sagittal planes obtained with the
standard x-ray film in which the beam passes through the patient to a plate
on the opposite side.

*Assistant Professor of Orthopaedics, Rhode Island Hospital, Brown University, Providence,

Rhode Island

Surgical Clinics of North America-Vol. 63, No. 3, June 1983 587

588 LEONARD F. HUBBARD

Each structure in the path of the beam is represented on the scan.

Structures of greater density therefore mask structures of lesser density.
The cross-sectional image produced can be varied in thickness and in
today's modern machines may be as little as 0.5 em thick. This thin "slice"
virtually eliminates this overlap of images, with a clearer representation of
the structures to be defined.
Once the image is obtained, mathematical reconstructions allow for
the density of the image to be changed from computer tape storage. The
operator can then accentuate structures of special interest and exclude
other structures. It is therefore possible to examine soft tissue selectively,
fluid collections, bone, or air densities without further exposure to the
patient. These characteristics are especially valuable in the evaluation of
the musculoskeletal system.
Bony structures are centrally located and are surrounded by soft
tissues. The three-dimensional anatomy of these structures may be ex-
tremely complex, as it is in the pelvis or the spine, a factor that complicates
the evaluation of bone and particularly intraarticular injuries. 11 · 16 Many
musculoskeletal tumors of soft tissues, such as sarcomas, have tissue
densities so similar to surrounding tissues that standard x-ray films cannot
detect them. In these cases, other techniques, such as arteriography and
xeroradiography, have been devised to help define them, though with
limited success. The CT scan overcomes many of these limitations.
As with any technique, there are limitations to CT scanning. First,
current models have less ability to separate two finite points than routine
x-ray films, a property gradually being remedied with further development.
Second, the radiation dose of the CT scan is relatively high, one to two
rads per slice, or eight to ten rads per study. This is a significant radiation
dose and must be considered when the study is ordered. This dose is
higher when fine detail is required, and if image quality can be sacrificed
(as in a study of the bone density), the dose can be considerably lower. 6 • 7
Finally, the studies are usually expensive.
Cost has been of considerable interest in the development of the CT
scanner. Although these machines are expensive, frequently approaching
$750,000, their widespread use in medicine, surgery, neurology, and
neurosurgery has established them as being cost-effective when properly
applied. As the result of their increasing use, the cost per unit study has
dropped considerably over the past several years. Regional use of these
machines has also decreased the cost. 27• 29
Despite these limitations, the CT scanner has come to occupy an
important place in selected situations in orthopedics and deserves consid-
eration in the diagnosis of musculoskeletal disorders. 6 • 8 • 11 · 12

ORTHOPEDIC TRAUMA

Hip and Pelvis

The hip has complex architectural features, with the acetabulum
inclined both in the sagittal and frontal planes. Recently, there has been
COMPUTED TOMOGRAPHY IN ORTHOPEDICS 589

increasing enthusiasm for open reduction and internal fixation techniques

in fractures of the acetabulum and pelvis. (Fractures of the femoral head
have long been approached in this fashion.)
Traction, of course, continues to play a role in the management of
these fractures, particularly where early motion is desired. However, in
the decision of whether to use open reduction and internal fixation methods,
or traction, a precise understanding of the injury must be present. Not
only the method of internal fixation to be used but also the surgical approach
to be employed may be drastically changed according to the features of the
fracture. Among factors to be considered are the degree of comminution
present, the presence or absence of an intact anterior or posterior wall of
the acetabulum, the size of the fracture fragments, medial displacement of
the femoral head, and the presence of loose fragments in the joint. The
articular congruity of the joint, particularly in the superior surface where
weight-bearing occurs, should be restored so that the best functional result
is possible. 5 • 24
Radiographic evaluation of trauma to the femoral head and acetabulum
has included both anteroposterior (AP) and lateral x-ray films, oblique
views, and tomography. However, the multiple structures present anterior
and posterior to the hip introduce considerable overlap in all of these views,
and only by correlating bits of data from each one can a reasonable idea of
the anatomy of the fracture be obtained. Furthermore, as described by
Epstein, loose fragments in the joint may play a part in the eventual
functional result and should be removed if present. 5
The cross-sectional view obtained by CT scanning can be utilized very
effectively in visualizing the important third dimension in trauma to the
hip. The special feature of the CT scan that detects small density changes
makes it possible to detect intraarticular fragments, minor fractures, and
fractures of the dome that are otherwise not seen on routine films or
tomograms.
The view obtained clearly shows that the superior margin of the
acetabulum, the pelvic wall medial to the acetabulum and the femoral
head, and the remainder of the femoral head and neck, since sections are
obtained serially from cranially to caudally. The relationship of these
structures, such as medial migration of the femoral head after fracture of
the central acetabulum, can be accurately assessed.
Since CT scanning is obtained with the patient supine, the patient can
be maintained in traction while the study is performed and the efficacy of
traction methods in reducing the fracture is assessed. Since oblique posi-
tioning is not required, patients are much more comfortable during CT
scanning than during oblique views. Complex fractures of the extraarticular
portion of the osseous pelvis also lend themselves to evaluation by this
method, including disruptions of the sacroiliac joints (Fig. 1). 6 · 7 • 12• 21
Spine
Trauma to the spine is common, and accurate assessment is extremely
important in the selection of treatment. Frequently, the findings in the CT
scan of the injured spine may be considerably more extensive than appre-
ciated on plain x-ray films, particularly in the case of encroachment of the
590 LEONARD F. HUBBARD

Figure 1. A, AP radiograph of a fracture dislocation ·of the right hip. B, CT scan after
reduction shows a large posterior fragment and a significant intraarticular bony fragment.
Open reduction indicated to fix the posterior rim and to remove the intraarticular fragment.
(From Hubbard, L. F., McDermott, J. H., Garrett, G.: Computed axial tomography in
musculoskeletal trauma. J. Trauma, 22:5, 388, 1982, with permission.)

spinal canal by displaced fragments, usually retropulsed from the vertebral

body. This alteration of spinal architecture, although relatively small, can
impinge on nerve roots, cause spinal cord compression, and have late
effects on the stability of the spine. CT scanning is to be considered an
important adjunct to standard x-ray films and tomograms, although it should
not replace them in the evaluation of spine injuries.
Myelography is generally not used for the evaluation of acute spine
injuries, and CT scanning can normally be performed without contrast
material, although it has been suggested that some spine contusions and
hematomas might be better visualized with the use of contrast material. 9
The normal CT scan does not require the difficult positioning of myelog-
raphy and can be performed with the patient supine, which may help
prevent further displacement of fractures and injury to neurologic struc-
tures. As the CT scanners become more closely associated with emergency
rooms, it is more "feasible to scan an injured spine at the same time ·as the
head. This procedure may help alleviate anxiety about the stability of the
spine as patients are moved for the further management of multiple trauma.
Experience has shown that the findings in the CT scan are often easier for
the surgeon to correlate with operative findings than the standard x-ray
films or tomograms. 8 • 12
In the cross-sectional view of the spine, the details of the spinous
process, lamina, pedicles, vertebral body, and spinal canal are outlined,
and any disruptions are immediately apparent (Fig. 2). The newer scanners,
moreover, give additional information by being able to reconstruct mathe-
matically the frontal and sagittal planes from the cross-sectional images.
The upper cervical spine, particularly the atlas, axis, and high thoracic
spine, are notoriously difficult to examine with tomograms. 16 Much clearer
pictures can be obtained with the CT scan, since denser structures that
overlap these vertebrae and obscure subtle findings are eliminated. 3• 19• 26
There are limitations, however, to the use of CT scans in particular
spine injuries. Instability of the spine, particularly in the AP direction, is
COMPUTED TOMOGRAPHY IN ORTHOPEDICS 591

Figure 2. A, CT scan through a lumbar vertebra with normal architecture. The spinal
canal and its boundaries are clearly outlined. B, Fragments of the vertebral body may be
retropulsed posteriorly to encroach on the spinal canal and its contents.

not best appreciated on a cross-section, since the distance between spinous

processes and adjacent vertebral bodies is difficult to evaluate. This difficulty
is also true of fracture subluxations, which may not be obvious unless
sagittal reconstructions are performed. 6 • 26
Musculoskeletal Tumors
Tumors of the musculoskeletal system may arise from cartilage, bone,
or soft tissue and often aggressively involve adjacent structures. Tumors of
bone may be extremely difficult to diagnose specifically before a biopsy,
and as much information as possible must be collected in the preoperative
evaluation of these lesions. Similarly, soft tissue tumors frequently lack
distinguishing clinical or radiographic characteristics to diagnose them
definitively before surgery.
The anatomic location of a given musculoskeletal tumor may have a
great impact on the therapy selected. Many factors must be considered,
including the relationship of the tumor to adjacent vital structures, whether
the tumor is confined to a single anatomic compartment, involvement of
adjacent bone or muscles, encapsulation, the density of the mass, and, of
course, the size in all three dimensions.
Routine x-ray films can be of some benefit, but standard techniques
lack the ability to define subtle differences in tissue density necessary to
define size and extent specifically. Furthermore, an accurate measurement
of tissue density may help diagnose the disease by defining some tissues,
such as fat seen in lipomas. Many adjunctive techniques, such as myelog-
raphy, xeroradiography, and arteriography have been employed, but though
they may add additional information, they are limited in that the important
cross-sectional image cannot be obtained, information so vital for the
assessment of tumor size. The resectability of a tumor often depends on
the involvement of a single anatomic compartment, with sparing of adjacent
vital structures. (Fig. 3).
592 LEONARD F. HUBBARD

Figure 3. A, Lateral view of the femur of

an adolescent boy with an osteosarcoma of the
femur. B, The CT scan shows a dense mass
originating from the femur, with invasion of
soft tissues. This mass crosses compartment
boundaries, and compartment resection will
not adequately exicse the tumor.

Considerable literature has confirmed the efficacy of the CT scanner

in the evaluation of benign and malignant musculoskeletal tumors. 6 • 9 • 10• 15• 30
In a study by Griffiths, in which 35 patients with suspected primary tumors
were studied, the CT scanner provided useful information in 62 per cent. 8
This has been confirmed by deSantos 25 and Levine, who found that a CT
scan influenced tumor management in 66 per cent of the patients studied. 18
These studies found that the information gathered included tissue density,
tumor size, presence of calcifications, and encapsulation.
If sufficient fat is present between muscle planes, each muscle bundle
can be carefully delineated, and the relationship of the tumor to fascial
margins can be obtained. If the tumor is confined to a single anatomic
compartment, a longitudinal resection, with sparing of the limb, may be
appropriate. Whenever possible, however, CT scanning should be obtained
before biopsy. Since this technique depends on these minor changes in
tissue density, hematoma or fluid accumulation after biopsy may make the
interpretation of the distances between planes difficult. 25
CT scanning does not, however, appear to be more useful than routine
x-ray films (and particularly bone scans) when screening for suspected
skeletal metastases. The slice, 0.5 to 1.5 em, is too thin to serve as a useful
screening tool unless a suspected location of a lesion is known. The CT
scan does play a role in screening for pulmonary metastases, since it will
COMPUTED TOMOGRAPHY IN ORTHOPEDICS 593
detect small metastases before they are visible on routine films, and since
other radionuclide methods are not yet available for this.
Other Applications
In addition to trauma to the spine, considerable interest has been
focused recently on the application of CT scanning to the evaluation of disc
disease. Since the disc is radiolucent on standard x-ray films, contrast
material has routinely been used for its evaluation. However, the column
of contrast material depends on a "negative image" to demostrate the disc.
An advantage of routine myelography, however, is that the column of
dye can be allowed to go up and down the spinal canal, as a screening test,
while a lateral x-ray film is taken. If the location of a disc is not known, or
if a block is present due to tumor or other disorders, this allows for accurate
localization. The CT scan must be used in a more localized fashion because
the thin slice does not allow for screening. Once the region is localized,
however, multiple sections can be taken to define the disease further.
Water-soluble contrast material is used with CT scanning, since standard
myelographic dye can induce computer artifacts. This procedure has been
shown to be a very accurate method of assessing disc size, locale and degree
of protrusion. 6
Spinal stenosis is difficult to evaluate with standard radiographic
techniques. The disorder occurs when impingement of bony structures that
surround the spinal canal cause a lessening of spinal canal diameter. CT
scanning allows for accurate measurement of spinal canal diameter, includ-
ing the assessment of osteophytes that may be present on adjacent facets,
without the use of contrast material. This method is clearly superior for
evaluation of this disorder, since it eliminates myelography and is better
tolerated by the patient. 23 • 28 The surgeon can be directed toward the central
canal or toward peripheral osteophytes by the CT scan findings.
Recently it has been shown that the knee can also be examined
successfully with CT scanning. The anterior cruciate ligament, traditionally
examined by arthrography, lends itself well to assessment by this method.
When contrast material is used, the continuity of this ligament can be very
accurately assessed. 1• 22
Although ability of the CT scan to detect minor changes in bone
density should be useful in studying musculoskeletal infections, they have
not in general appeared to contribute much more than standard x-ray films,
at least in the long bones. Pelvic and spine infections, however, are clearly
demonstrated, including soft tissue masses. 8• 17
The sensitivity of the CT scan to changes in bone density can be a
valuable adjunct in diagnosis of avascular necrosis of bone, which occurs
when a bone is deprived of all or a portion of its blood supply. In general,
30 to 50 per cent of the bone substance must be resorbed before lytic
changes are visible on routine x-ray films; CT scan can detect as little as a
5 per cent change. By detecting avascular necrosis of the hip early, the
orthopedist can begin nonweight-bearing therapy for the patient and further
collapse and disintegration of cartilage support might be avoided (Fig. 4).
CT scanning has been shown to be helpful in detecting avascular necrosis
594 LEONARD F. HUBBARD

Figure 4. A, AP radiograph of pelvis with no obvious changes in the hips. B, CT scan

shows dense right femoral head, due to avascular necrosis. (From Hubbard, L. F.: Comput-
erized axial tomography in orthopaedics. Contemp. Orthopaed., 3:1, 1981, with permission.)

of the talus early, in evaluating which portion of the dome of the talus is
involved, and in assessing the benefits of surgical intervention. 11
As an extension of this technique to measure bone density, a small
window can be placed over the area to be measured on the image, and
accurate quantification of x-ray transmission carried out, measured as
"Hounsfield numbers." This method is extremely reproducible and has
great potential benefit in researching the cause of demineralization in the
skeleton, since it offers for the first time an easy reproducible way of
determining how much demineralization has occurred. 20
Pediatric Orthopedics
In pediatric orthopedics, CT scanning has some particular applications
that deserve note. Special attention, however, must be paid to the radiation
COMPUTED TOMOGRAPHY IN ORTHOPEDICS 595
exposure-benefit ratio in children, since the radiation exposure for this
study is relatively high. The CT scan should therefore be observed for
those situations in which the particular attributes of a cross-sectional study
are necessary, in which the CT scan will help to decrease the number of
other adjunctive studies done, or in which diagnostic dilemmas require it.
In congenital spinal disorders in children, including myelodysplasia, dias-
tematomyelia, spinal stenosis, and syringomyelia, the CT scan can be of
enormous benefit. No other technique allows for such accurate assessment
of vertebral anomalies, spinal cord diameters, and, with the use of contrast
material, spinal cord anomalies. The CT scan can detect bony bridges or
vertebral anomalies that may be compressing the spinal cord and nerve
roots and direct the surgeon to accurate intervention. This information can
be extremely helpful in planning surgery, in determining the surgical
approach, and in deciding how wide surgical exposure should be.
Congenital dislocation of the hip continues to be a difficult problem in
orthopedics. The relationship of the hip to the acetabulum must be assessed
accurately and corrected for a good result. The CT scan should not be used
indiscriminately in this disorder, since the radiation exposure, as noted
previously, is relatively high. Nonetheless, if particular difficulties occur
with reduction, it may be extremely useful.
It has also been demonstrated that femoral anteversion can be very
accurately determined with the CT scan. 6 The CT scan in this case may
provide a net reduction in radiation dosage, since a single scan of the knees
(to determine plane of orientation of the femur) and a section or two
through the femoral neck will determine femoral anteversion very accu-
rately. This is in contrast to the multiple x-ray films that may be required
for determination of femoral anteversion with these standard techniques.
Since the anteversion is determined so accurately, the surgeon can measure
directly from the CT scan the amount of femoral derotation necessary to
bring the femur into correct alignment.
Other uses in children parallel those in the adult. Since primary
musculoskeletal tumors do occur in children as well as in adults, the
information derived from the CT scan may help in planning surgery. When
the criteria for restriction of tumor involvement can be met in the
preoperative assessment, saving the limb may be feasible. In pelvic tumors,
assessment of size may dictate whether any surgery is possible and may
help assess the response of tumors to chemotherapy.

SUMMARY

The enormous interest in CT scanning appears fully justified as this

remarkable technique continues its development. In orthopedics, it has a
variety of roles to play: in trauma, tumor management, and developmental
disorders. As experience with the CT scan in musculoskeletal disease is
accumulated, new applications will undoubtedly become apparent, adding
to the already impressive list.
596 LEONARD F. HUBBARD

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Department of Orthopaedics
Rhode Island Hospital
Brown University
Providence, RI 02912