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Role Of Imaging In Thoracic Trauma

Role Of Imaging In Thoracic Trauma. BY Dr. Wassim M El Gendy , MD Consultant Radiologist Military Medical Academy. Chest Trauma. Blunt Trauma accounts for 20% of trauma related deaths. MVA accounts for 75% of blunt chest trauma. Most serious is acute traumatic aortic injury.

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Role Of Imaging In Thoracic Trauma

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  1. Role Of Imaging In Thoracic Trauma BY Dr. Wassim M El Gendy, MD Consultant Radiologist Military Medical Academy

  2. Chest Trauma • Blunt Trauma accounts for 20% of trauma related deaths. MVA accounts for 75% of blunt chest trauma. Most serious is acute traumatic aortic injury. Most common injury is Rib #s followed by Pulmonary contusions. • Penetrating Chest Injuuries

  3. Modality Based Imaging issues • Chest Radiograph: screening sensitive but not specific. • MDCT: replaces X Ray and is 95% sensitive for all life threatening chest injuries. • Anatomy Based Imaging IssuesStarts with most life threatening injuries like acute traumatic aortic injury. • Patient stabilization is of utmost importance. • Delayed diagnosis • More than 30 days reveals: • 5% aortic transection. • 40% bronchial tears. • 60% diaphragmatic tears.

  4. Of patients dying within the first 24hours: • 30% of the radiographs are mis-interpreted: • Missed injuries like aortic transection. • Diaphragmatic herniation. • Flial Chest

  5. Chest Injuries Include: • A: Aortic Transection. • B: Bronchial tear. • C: Cord Injury. • D: Diaphragmatic tear. • E: Esophageal tear. • F: Flial Chest and Fractured Ribs. • G: Gas Collection. • H: Heart (Cardiac) Injury. • I: Iatrogenic.

  6. Aortic Transection: • Most common location at aortic isthmus. • Radiograph will not show transection Rather displays leakage of blood leading to mediastinal widening. • If suspected:….. MD CTAngiography or Aortography

  7. Bronchial Tear: • Most common location 2.5 cm off the carina. • Radiograph does not show tear rather displays air leakage leading to the “P” sign ie: Persistent Progressive Pneumothorax. • If suspected:…. CT or Bronchoscopy for diagnosis.

  8. Cord Injury: • Most common location at Functional Thoraco-lumbar junction which is the transition zone between thoracic facet and lambar facet orientation (D 9-11). • Radiographs may not show the spinal #, rather shows paraspinal mass / collection, mal-alignment of spinous processes and pedicles. • If suspected CT and / or MRI for diagnosis.

  9. Diaphragmatic Tear: • Most common location through the poster-lateral central tendon of the left hemi-diaphragm. • Herniation may be delayed due to Positive Pressure Ventillation that hinder the abdominal contenets from intrathoracic herniation. • If suspected: Barium studies but less utilized; • However CT / MRI is diagnostic in Coronal and Sagittal images rather than axial images which are less sensitive (90%).

  10. Esophageal Tear: • Left postero-lateral wall of the esophago-gastric junction is the most common location. • Radiograph will not show tears but gas and irritant fluid leakage at left costo-veretbral junction. • If suspected esophagogram with Non ionic contrast media.

  11. Flail Chest: • Chest radiograph will not show paradoxical motion of the chest wall. • Radiograph is sensitive for acute rib fractures. • Suspected flail chest if more than 5 contiguos rib fractures or more than 3 contiguois segmental rib fractures (2 or more #s in each rib). • 1st rib fracture signifies sevre trauma.

  12. Gas Collection: • Supine portable CXR is less sensitive than Upright CXR for pneumothorax. • Air collects in non dependant location, in supine position in inferior lateral hemithorax (deep sulcus). • Subtle air collection is the first hint for esophageal, bronchial and diaphragmatic tear • Simple pneumothorax may convert to tension pneumothorax when patients ventillated. • if suspected CT or Upright XR.

  13. Heart (Cardiac) Injury: • CXR will not show heart injury but guides to signs of cardiac dysfunction. • Suspected especially with sudden development of pulmonary edema especially in young. • If susepcted Echocardiography is best, CT and MRI less useful.

  14. Iatrogenic (Misplaced Tubesand Catheters): • Hurried and hectic environment of trauma may lead to misplaced tubes. • All lines and tubes must be accounted for. • NG tube course is often a guide for aortic transection in CXR (displaced from aortic arch), or diaphragmatic tear (courses into the abdomen or herniated stomach).

  15. Case presentation

  16. Healed Rib Fractures (old)

  17. Healed lateral ribs fractures

  18. Lateral dislocation of D12 over L1

  19. Intramural hematoma obstructing 2nd portion of Du

  20. Subdiaphragmatic air (ruptured stomach)

  21. Incomplete filling of 3rd DU from mural hematoma on Ba meal and CT Abd.

  22. Penetrating bullet injury courses top to bottom

  23. Subcutaneous Bullet shots

  24. Bullet course left postero-antero-lateral through post stomach and liver

  25. Bomb blast contusion

  26. Bomb blast contusion with air under diaphragm

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