Photon-counting CT of elbow joint fractures: image quality in a simulated post-trauma setting with off-center positioning

BACKGROUND: Photon-counting detector computed tomography (PCD-CT) has the potential to provide superior image quality compared to energy-integrating detector computed tomography (EID-CT). We compared the two systems for elbow imaging in off-center arm positioning, 90° flexion, and cast fixation in a simulated post-trauma setting. METHODS: The institutional review board approved the study protocol. In a cadaver study, an olecranon fracture was artificially created in ten whole arm specimens. Two different scanning positions were evaluated: (a) arm overhead; and (b) arm on top of the abdomen of a whole-body phantom. The ultra-high resolution mode with three dose protocols and two reconstruction kernels was applied. Two blinded radiologists independently evaluated fracture and trabecular bone delineation. Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and cortical sharpness measurements were performed. Cohen κ correlations, Mann-Whitney U and Wilcoxon signed rank tests were used. A p value lower than 0.05 was considered statistically significant. RESULTS: Dose-equivalent PCD-CT scans were rated better for fracture and trabecular bone evaluation (p < 0.001). SNR, CNR, and cortical sharpness were higher for all diagnostic (Br76) PCD-CT images (p < 0.001). The arm position had less effect on image quality in the PCD-CT compared to the EID-CT. The use of a sharp bone kernel (Br89) improved image quality ratings for PCD-CT. In the low-dose scan mode, PCD-CT resulted in more diagnostic scans (75%) compared to EID-CT (19%). CONCLUSIONS: PCD-CT provided superior objective and subjective image quality for fracture and trabecular bone structures delineation of the elbow compared to EID-CT in a typical post-trauma setting. KEY POINTS: • Photon-counting detector computed tomography (PCD-CT) preserved high image quality in elbow imaging with off-center positions. • PCD-CT was advantageous for bone evaluation in trauma elbows. • PCD-CT ultra-high-resolution mode and very sharp reconstruction kernels facilitated higher image quality.