Role Of Imaging Role Of Imaging In In

Thoracic TraumaThoracic Trauma

BYBY

Dr. Wassim M El Gendy, MD Dr. Wassim M El Gendy, MD Consultant RadiologistConsultant Radiologist

Military Medical AcademyMilitary Medical Academy

Chest TraumaChest Trauma Blunt TraumaBlunt Trauma

accounts for 20% of trauma related deaths.accounts for 20% of trauma related deaths.

MVA accounts for 75% of blunt chest trauma.MVA accounts for 75% of blunt chest trauma.

Most serious is acute traumatic aortic injury.Most serious is acute traumatic aortic injury.

Most common injury is Rib #s followed by Pulmonary contusions.Most common injury is Rib #s followed by Pulmonary contusions.

Penetrating Chest InjuuriesPenetrating Chest Injuuries

Modality Based Imaging issuesModality Based Imaging issues• Chest Radiograph: screening sensitive but not specific.Chest Radiograph: screening sensitive but not specific.

• MDCT: replaces X Ray and is 95% sensitive for all life MDCT: replaces X Ray and is 95% sensitive for all life

threatening chest injuries.threatening chest injuries. Anatomy Based Imaging IssuesAnatomy Based Imaging Issues

Starts with most life threatening injuries like acute Starts with most life threatening injuries like acute traumatic aortic injury.traumatic aortic injury.

• Patient stabilization is of utmost importance.Patient stabilization is of utmost importance.

Delayed diagnosis Delayed diagnosis • More than 30 days reveals: More than 30 days reveals:

• 5% aortic transection.5% aortic transection.

• 40% bronchial tears.40% bronchial tears.

• 60% diaphragmatic tears.60% diaphragmatic tears.

Of patients dying within the first 24hours:Of patients dying within the first 24hours:

30% of the radiographs are mis-30% of the radiographs are mis-interpreted: interpreted:

Missed injuries like aortic transection.Missed injuries like aortic transection.

Diaphragmatic herniation.Diaphragmatic herniation.

Flial ChestFlial Chest

Chest Injuries Include:Chest Injuries Include:AA: : AAortic Transection.ortic Transection.

BB: : BBronchial tear.ronchial tear.

CC: : CCord Injury.ord Injury.

DD: : DDiaphragmatic tear.iaphragmatic tear.

EE: : EEsophageal tear.sophageal tear.

FF: : FFlial Chest and Fractured Ribs.lial Chest and Fractured Ribs.

GG: : GGas Collection.as Collection.

HH: : HHeart (Cardiac) Injury.eart (Cardiac) Injury.

II: : IIatrogenic.atrogenic.

Aortic Transection:Aortic Transection: Most common location at aortic isthmus.Most common location at aortic isthmus.

Radiograph will not show transection Rather Radiograph will not show transection Rather displays leakage of blood leading to mediastinal displays leakage of blood leading to mediastinal widening.widening.

If suspected:….. MD CTAngiography or If suspected:….. MD CTAngiography or Aortography Aortography

Bronchial Tear:Bronchial Tear:– Most common location 2.5 cm off the carina.Most common location 2.5 cm off the carina.– Radiograph does not show tear rather Radiograph does not show tear rather

displays air leakage leading to the “displays air leakage leading to the “PP” sign ie: ” sign ie: PPersistent ersistent PProgressive rogressive PPneumothorax.neumothorax.

– If suspected:…. CT or Bronchoscopy for If suspected:…. CT or Bronchoscopy for diagnosis.diagnosis.

Cord Injury:Cord Injury:– Most common location at Functional Thoraco-Most common location at Functional Thoraco-

lumbar junction which is the transition zone lumbar junction which is the transition zone between thoracic facet and lambar facet between thoracic facet and lambar facet orientation (D 9-11).orientation (D 9-11).

– Radiographs may not show the spinal #, Radiographs may not show the spinal #, rather shows paraspinal mass / collection, rather shows paraspinal mass / collection, mal-alignment of spinous processes and mal-alignment of spinous processes and pedicles.pedicles.

– If suspected CT and / or MRI for diagnosis. If suspected CT and / or MRI for diagnosis.

Diaphragmatic Tear:Diaphragmatic Tear:– Most common location through the poster-Most common location through the poster-

lateral central tendon of the left hemi-lateral central tendon of the left hemi-diaphragm.diaphragm.

– Herniation may be delayed due to Positive Herniation may be delayed due to Positive Pressure Ventillation that hinder the Pressure Ventillation that hinder the abdominal contenets from intrathoracic abdominal contenets from intrathoracic herniation.herniation.

– If suspected: Barium studies but less utilized; If suspected: Barium studies but less utilized; – However CT / MRI is diagnostic in Coronal However CT / MRI is diagnostic in Coronal

and Sagittal images rather than axial images and Sagittal images rather than axial images which are less sensitive (90%). which are less sensitive (90%).

Esophageal Tear:Esophageal Tear:– Left postero-lateral wall of the esophago-Left postero-lateral wall of the esophago-

gastric junction is the most common location.gastric junction is the most common location.– Radiograph will not show tears but gas and Radiograph will not show tears but gas and

irritant fluid leakage at left costo-veretbral irritant fluid leakage at left costo-veretbral junction.junction.

– If suspected esophagogram with Non ionic If suspected esophagogram with Non ionic contrast media.contrast media.

Flail Chest:Flail Chest:– Chest radiograph will not show paradoxical Chest radiograph will not show paradoxical

motion of the chest wall.motion of the chest wall.– Radiograph is sensitive for acute rib fractures.Radiograph is sensitive for acute rib fractures.– Suspected flail chest if more than 5 contiguos Suspected flail chest if more than 5 contiguos

rib fractures or more than 3 contiguois rib fractures or more than 3 contiguois segmental rib fractures (2 or more #s in each segmental rib fractures (2 or more #s in each rib).rib).

– 11stst rib fracture signifies sevre trauma. rib fracture signifies sevre trauma.

Gas Collection:Gas Collection:– Supine portable CXR is less sensitive than Supine portable CXR is less sensitive than

Upright CXR for pneumothorax.Upright CXR for pneumothorax.– Air collects in non dependant location, in Air collects in non dependant location, in

supine position in inferior lateral hemithorax supine position in inferior lateral hemithorax (deep sulcus).(deep sulcus).

– Subtle air collection is the first hint for Subtle air collection is the first hint for esophageal, bronchial and diaphragmatic tearesophageal, bronchial and diaphragmatic tear

– Simple pneumothorax may convert to tension Simple pneumothorax may convert to tension pneumothorax when patients ventillated.pneumothorax when patients ventillated.

– if suspected CT or Upright XR.if suspected CT or Upright XR.

Heart (Cardiac) Injury:Heart (Cardiac) Injury:– CXR will not show heart injury but guides to CXR will not show heart injury but guides to

signs of cardiac dysfunction.signs of cardiac dysfunction.– Suspected especially with sudden Suspected especially with sudden

development of pulmonary edema especially development of pulmonary edema especially in young.in young.

– If susepcted Echocardiography is best, CT If susepcted Echocardiography is best, CT and MRI less useful.and MRI less useful.

Iatrogenic (Misplaced Tubesand Iatrogenic (Misplaced Tubesand Catheters):Catheters):– Hurried and hectic environment of trauma Hurried and hectic environment of trauma

may lead to misplaced tubes.may lead to misplaced tubes.– All lines and tubes must be accounted for.All lines and tubes must be accounted for.– NG tube course is often a guide for aortic NG tube course is often a guide for aortic

transection in CXR (displaced from aortic transection in CXR (displaced from aortic arch), or diaphragmatic tear (courses into the arch), or diaphragmatic tear (courses into the abdomen or herniated stomach). abdomen or herniated stomach).

Case presentationCase presentation

Healed Rib Fractures (old)Healed Rib Fractures (old)

Healed lateral ribs fracturesHealed lateral ribs fractures

Lateral dislocation of D12 over L1Lateral dislocation of D12 over L1

Intramural hematoma obstructing Intramural hematoma obstructing 22ndnd portion of Du portion of Du

Subdiaphragmatic air Subdiaphragmatic air (ruptured stomach)(ruptured stomach)

Incomplete filling of 3Incomplete filling of 3rdrd DU from DU from mural hematoma on Ba meal and mural hematoma on Ba meal and

CT AbdCT Abd..

Penetrating bullet injury courses Penetrating bullet injury courses top to bottomtop to bottom

Subcutaneous Bullet shotsSubcutaneous Bullet shots

Bullet course left postero-Bullet course left postero-antero-lateral through post antero-lateral through post

stomach and liverstomach and liver

Bomb blast contusionBomb blast contusion

Bomb blast contusion with air Bomb blast contusion with air under diaphragmunder diaphragm