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Imaging the chest in trauma Imaging the chest in trauma

Imaging in chest trauma

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Page 1: Imaging in chest trauma

Imaging the chest in traumaImaging the chest in trauma

Page 2: Imaging in chest trauma

Chest traumaChest traumaBlunt

Penetrating

Page 3: Imaging in chest trauma

Trauma Chest RadiographTrauma Chest Radiograph

Usually AP, often supine, frequently in poor inspiration.

Page 4: Imaging in chest trauma

CT ChestCT Chest

Page 5: Imaging in chest trauma

Fractures and DislocationsFractures and DislocationsSpineRibsClaviclesSternumShoulders

Page 6: Imaging in chest trauma

Spine InjuriesSpine Injuries

Loss of alignment, fractures and paraspinal hematoma.

Page 7: Imaging in chest trauma

Rib FracturesRib Fractures

Indicator of underlying pleura, lung, liver, spleen, kidney injuries.

Page 8: Imaging in chest trauma

Flail ChestFlail Chest

Multiple rib fractures, especially if individual ribs fractured more than once, may cause paradoxical motion.

Associated pulmonary contusion.

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Clavicle InjuriesClavicle Injuries

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Sterno-clavicle joint dislocationSterno-clavicle joint dislocation

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Sterno-clavicle dislocation: CTSterno-clavicle dislocation: CT

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Shoulder InjuriesShoulder Injuries

dislocations and scapula fractures

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CT Needed if Scapula Fracture SeenCT Needed if Scapula Fracture Seen

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AIR where it shouldnAIR where it shouldn’’t bet bePneumothoraxPneumomediastinumSubcutaneous emphysemaSystemic venous air embolismPneumopericardiumPneumoperitoneum/retroperitoneum

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pnxpnx

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PNEUMOTHORAX: CTPNEUMOTHORAX: CTMuch more sensitive

Even a small traumatic pneumothorax is important, especially if patient mechanically ventilated or going to OR: A simple pneumothorax can be converted into a life- threatening tension pneumothorax.

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PNEUMOTHORAX: CTPNEUMOTHORAX: CT

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Pneumothorax: SimplePneumothorax: SimpleErect AP/PA view bestVisceral pleural lineNo vessels or markingsVariable degree of lung collapseNo shift

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PNEUMOTHORAX: SimplePNEUMOTHORAX: Simple

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PNEUMOTHORAX: TensionPNEUMOTHORAX: TensionErect AP/PA view bestShift of mediastinum/heart/trachea away

from PTX sideDepressed hemidiaphragmDegree of lung collapse is variable

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PNEUMOTHORAX: TensionPNEUMOTHORAX: Tension

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PNEUMOTHORAX: SupinePNEUMOTHORAX: SupineSupine AP view has limited sensitivity: 50%Deep sulcus signToo sharp heart border/hemidiaphragm signIncreased lucency over lower chest

Cant see vessels

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PNEUMOTHORAX: OpenPNEUMOTHORAX: Open- Gunshot or other wound (hole > 2/3 tracheal diameter) +/-

exit wound

- Air enters the wound rather than trachea and leads to hypoxia.

- Unequal breath sounds

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PNEUMOMEDIASTIUMPNEUMOMEDIASTIUMUsually from ruptured alveoli.Can also be from trachea, bronchi,

esophagus, bowel and neck injuries.

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Air forms linear / curvilinear lucencies outlining mediastinal contours :Air anterior to pericardium: pneumopericardiumAir around pulmonary artery and main branches: ring around artery signAir outlining major aortic branches: tubular artery signAir outlining bronchial wall: double bronchial wall signContinuous diaphragm sign: due to air trapped posterior to pericardiumV sign of Naclerios: “V” sign at aortic-diaphragm junction

Paediatric pneumomediastinum: may have slightly different appearances:elevated thymus: thymic wing signair crossing the superior mediastinum: haystack sign 

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Ring around the artery signRing around the artery sign

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Page 31: Imaging in chest trauma

V sign of nacleriosV sign of naclerios

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PneumopericardiumPneumopericardium

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Spinnaker / angel wing signSpinnaker / angel wing sign

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Haystack sign Haystack sign air around heart makes it look like a Monet paintingair around heart makes it look like a Monet painting

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PNEUMOMEDIASTINUM: CTPNEUMOMEDIASTINUM: CT

Page 36: Imaging in chest trauma

Tracheal / bronchial tearsTracheal / bronchial tears

• Most common site - near the carina, because the airway is fixed and subject to shear injury.

• Tears within the mediastinal pleura – pneumomediastinum

• Tears beyond the mediastinal pleura - pneumothorax.

• Left main bronchus : has a longer mediastinal course than the right main bronchus & so injury - more likely to cause a pneumomediastinum & vice versa.

• Severe injuries, both a pneumomediastinum and a pneumothorax may be present.

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Fallen Lung signFallen Lung signWith complete laceration of the main bronchus, the bronchus may become partially or completely detached, allowing the lung to fall into a dependent lateral position

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PneumoperitoneumPneumoperitoneum

.

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PneumoretroperitoneumPneumoretroperitoneum

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HEMOTHORAXHEMOTHORAXVenous or arterial bleedingCan miss hundreds of cc’s on supine film

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HEMOTHORAXHEMOTHORAX

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CT: HEMOTHORAXCT: HEMOTHORAX

35-70 HU

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Page 46: Imaging in chest trauma

PULMONARY CONTUSION and PULMONARY CONTUSION and LACERATIONLACERATION

Contusion: Blood in intact lung parenchyma. Non-penetrating.

Laceration: Blood in torn lung parenchyma

Can’t tell difference on chest film. Contusions peak in 2-3 days, begin to resolve in a week; lacerations take much longer to resolve and may leave scars

Page 47: Imaging in chest trauma

ContusionContusion• Manifest at the time of the initial examination• Little tendency to increase in severity with subsequent

examinations. • Radiographic clearing within 48 hours. • Features are often not localised in a lobar or segmental

pattern.

Plain film Not sensitive. • Faint patchy consolidative following history of blunt trauma. • CT – focal, non segmental parenchymal opacification. • Can have sub-pleural sparing with smaller contusions• Commoner posteriorly and in lower lobes.

Page 48: Imaging in chest trauma
Page 49: Imaging in chest trauma

LacerationsLacerations• Almost always have concurrent contusion

• PathologyClassification:

Type I - compression rupture: most common type of laceration that usually occurs as a 2-8 cm lesion in the central lung

Type II - compression shear: occurs after sudden compression of the lower chest when the lung suffers from a shear injury to the spine

Type III - direct puncture / rib penetration: occur with a penetrating fractured rib; these lesions are commonly multiple

Type IV - adhesion tears: occurs in sudden injuries of the chest wall where prior pleuropulmonary adhesions had been created

Page 50: Imaging in chest trauma

•Pattern can be similar to contusion•Often have added rib fractures & pneumothorax

CT •Regions of pulmonary contusion with added blebs (pneumatoceles) with air fluid levels.

•Due to normal pulmonary elastic recoil, lung tissues surrounding a laceration often pull back from the laceration which manifesting at CT as a round or oval cavity, instead of having the linear appearance in other solid organs.

•Severe laceration have gross disruption of lung parenchymal architecture.

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DIAPHRAGM InjuriesDIAPHRAGM Injuries5% of major blunt

trauma, also thoraco-abdominal penetrating trauma

Left clinically injured more than right 60/40

Sensitivity of Chest film 40%. CT better, but still misses some

Hard signs: NGT through g.e. junction then up into chest, and hollow viscus above diaphragm

Soft signs: Indistinct diaphragm, effusion, atelectasis

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Position of NG TubePosition of NG Tube

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Gut in ChestGut in Chest

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Vascular InjuryVascular Injury

Signs of mediastinal haematoma:widened mediastinumindistinct or abnormal aortic contourdeviation of trachea or NGT to the rightdepression of left main bronchuswidened paraspinal stripe

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CTCTIndirect signs of aortic injury:mediastinal haematomaperiaortic fat stranding

CTA : sensitivity 100%; specificity 100%.Signs of mediastinal haematoma:abnormal soft tissue density around mediastinal structuresLocation – periaortic haematoma than isolated mediastinal haematoma remote from the aorta.

Signs of aortic injury:intraluminal filling defect (intimal flap or clot)abnormal aortic contour (mural haematoma)Pseudoaneurysm & extravasation of contrast

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