IMAGING DIAGNOSIS OF NONAORTIC THORACIC INJURY

doi:10.1016/S0033-8389(05)70110-X

Radiologic Clinics of North America

Volume 37, Issue 3, 1 May 1999, Pages 533-551

https://doi.org/10.1016/S0033-8389(05)70110-X Get rights and content

Imaging diagnosis of thoracic trauma is typically based upon assessment of the admission supine chest radiograph. Although this tool appears indispensable for rapid diagnosis of immediate life-threatening traumatic thoracic pathology, such as tension pneumothorax, it is being increasingly shown to be less sensitive than thoracic CT for detection of a broad spectrum of thoracic injuries including pneumothorax, pneumomediastinum, hemidiaphragm injury, and pericardial hemorrhage, among others.⁸⁷ Although chest CT is not mandatory in the evaluation of the blunt thoracic trauma patient, it is becoming increasingly utilized, particularly given the increasing role of CT for demonstration of mediastinal hemorrhage and direct arterial injury.24, 51 This article reviews the major clinical and imaging findings occurring with primarily blunt force injury to the chest excluding mediastinal bleeding and major vascular injury that is dealt with elsewhere in this issue.

Section snippets

THORACIC CAGE INJURY

Isolated fractures of the ribs, scapula, or clavicle are seldom of clinical significance, but serve to reflect the location and magnitude of impact, particularly in adult patients with noncompliant chest walls. In particular, fractures of the first three ribs indicate a significant energy transfer and should increase concern for underlying lung and mediastinal injuries. Fractures involving the thoracic outlet may produce injuries to the brachial plexus or adjacent arteries in 3% to 15% of

Pneumomediastinum

Pneumomediastinum represents extra-alveolar air in the mediastinum, a common sequela of both blunt and penetrating trauma. Rupture of the alveoli, tracheobronchial tree, or the esophagus can result in air leaking into the mediastinum. The rupture occurs in blunt trauma from increased intraluminal airway pressure. Air can also enter the mediastinum from the neck (facial fractures, laryngeal, and cervical tracheal injury); retroperitoneum (perforated duodenum, colon); or chest wall wounds. The

PLEURAL EFFUSION AND HEMOTHORAX

Pleural effusions appearing after acute thoracic trauma usually represent hemothorax and are present in about 50% of major trauma victims.⁸² Isolated hemothorax may be the result of injury to the visceral pleura, or a laceration or contusion of lung parenchyma. A small amount of hemorrhage typically accompanies traumatic pneumothorax and presents as an air–fluid level on erect chest radiography. Bleeding of pulmonary venous origin is typically of low pressure and is likely to be self-limited

Pulmonary Contusion

Pulmonary contusion is the commonest primary lung injury, occurring in approximately 17% to 70% of patients following severe blunt chest trauma.13, 29 The direct transmission of energy through the chest wall to the underlying lung results in injury to the interstitium and alveoli. The site of energy transfer often occurs adjacent to solid structures, such as the ribs, sternum, and vertebral bodies. Disruption of small blood vessels and damage to the alveolar capillary membrane leads to

TRACHEOBRONCHIAL INJURIES

Tracheobronchial injuries (TBI) are relatively uncommon and often go unrecognized as a result of lack of visible external signs of injury. Early symptoms may be nonspecific and minimal. TBI has been reported in 2.8% to 5.4% of autopsy series of trauma victims and in 0.4% to 1.5% of clinical series of patients sustaining major blunt force trauma.4, 21, 30, 33, 43, 80 Following blunt trauma, right-sided bronchial injuries occur more frequently than on the left side.⁸ More than 80% of the injuries

THORACIC ESOPHAGEAL DISRUPTION

Trauma accounts for only 10% of cases of esophageal perforation⁵ and is a very uncommon injury from blunt impact.42, 90 In any case of penetrating trauma that may have traversed the mediastinum it is necessary to exclude esophageal injury. Generally, the likely tract of a bullet can be inferred from entrance and exit wounds combined with posterior and lateral chest radiographs. On occasion, the authors have utilized CT of the chest to attempt to verify the presence or absence of mediastinal

DIAPHRAGMATIC INJURY

Injuries to the diaphragm have always been a diagnostic challenge to both the radiologist and surgeon or traumatologist. Most diaphragmatic injuries are caused by penetrating trauma that is usually found during surgical exploration.9, 11 Diaphragmatic injuries occur in 0.8% to 5.8% of patients following major blunt abdominal trauma and in 3% to 7% of patients undergoing celiotomy secondary to blunt abdominal trauma.6, 36, 46, 54, 73, 91 More than 90% of the blunt traumatic diaphragm ruptures

BLUNT CARDIAC AND PERICARDIAL INJURY

Cardiac injury has been reported in 10% to 16% of patients admitted following blunt thoracic trauma.⁵⁹ Typically, the mechanism of injury is a severe direct blow to the chest from motor vehicle collision or automobile-pedestrian accidents.20, 59, 61 Although cardiac contusion is the most common injury of the heart, a spectrum of injuries may result including pericardial tears; injury to the cardiac conducting system; coronary artery injury; and rupture of the free wall, septum, or heart valves.

CONCLUSION

The supine chest radiograph remains the initial imaging screening tool for rapid assessment of chest trauma victims who are stable enough to undergo diagnostic studies. Most immediate life-threatening thoracic injuries are detected using chest radiographs. CT scanning, particularly with spiral capability, is recognized as being more sensitive for detection of some thoracic pathology, such as pneumothorax, pneumomediastinum, mediastinal hematoma, and pericardial hemorrhage, and may also be

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CT as a first-line modality in elderly patients with stable blunt chest trauma
2021, Chinese Journal of Traumatology - English Edition
Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients.
A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay.
There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18–64 years; group 2: 184 patients were included and aged 65–99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR.
Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.
Pleural tumours and tumour-like lesions
2018, Clinical Radiology
Citation Excerpt :
The former can be seen up to 50% of patients with substantial blunt chest trauma.42 The origin of a bloody effusion may be arterial (intercostal, subclavian or mammary arteries) and less frequently, venous.42,43 Massive haemothorax is considered when more than 1 l of blood has accumulated in the pleural space and this is associated with hypovolaemic shock.42,44
There are various neoplasms and tumour-like conditions of the pleura. Mesothelioma is perhaps the most widely recognised; however, there are many others that are more common and should be considered. Understanding the similarities and differences can be helpful in managing the patient with a newly found pleural lesion. We will discuss clinical symptoms at presentation and describe the imaging findings associated with these tumours, starting with conventional radiology, and correlating with computed tomography and combined positron-emission tomography (PET)/computed tomography (CT). Finally, imaging characteristics that help differentiation between the benign and malignant varieties will be reviewed.
Selective common and uncommon imaging manifestations of blunt nonaortic chest trauma: When time is of the essence
2015, Current Problems in Diagnostic Radiology
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Supine radiographs are insensitive to small hemothoraces, but larger pleural collections can result in opacification of the hemithorax with contralateral shift of the mediastinum (Fig 10). MDCT reveals a pleural collection with increased attenuation (usually 35-70 HU), which will distinguish a hemothorax from other causes of pleural fluid.25 The hematocrit sign refers to dense clot layering in the dependent pleural space.
This is a pictorial essay in which we review and illustrate a variety of thoracic injuries related to blunt trauma. Non-aortic blunt thoracic trauma can be divided anatomically into injuries of the chest wall, lungs, pleura, mediastinum, and diaphragm. Some injuries involve more than one anatomic compartment, and multiple injuries commonly coexist. This article provides common imaging findings and discussion of both common and uncommon but critical thoracic injuries encountered.
Multi-detector computed tomography imaging of blunt chest trauma
2014, Egyptian Journal of Radiology and Nuclear Medicine
Citation Excerpt :
They are commonly associated with other injuries including pneumothorax, hemothorax, pulmonary injuries, and spinal injuries. In the present study, we reported 3 patients (10%) with clavicular fractures and one patient (3.3%) with anterior sterno-clavicular dislocation which were detected on both chest radiography and MDCT scan, these results coincided with Shanmuganathan and Mirvis (19) who reported that clavicular fractures from blunt chest trauma account for 3–11%, with anterior dislocations being the most common and usually without clinical significance. This study included 5 patients (16.7%) with thoracic spine fractures with 100 percent sensitivity by MDCT scan compared to 20% by chest radiography.
Chest trauma is a significant cause of mortality and morbidity, especially in the younger population. The purpose of this study was to evaluate the role of multi-detector computed tomography (MDCT) in the assessment of patients with blunt chest trauma.
A prospective study was conducted on thirty (30) patients with blunt chest trauma (21 males and 9 females, aged from 6 to 62 years) and 29 control patients presented with any trauma other than blunt chest trauma (23 males and 6 females, aged from 10 to 68 years) at the Emergency Department, Tanta University Hospital, from January 2013 to February 2014. Cases were subjected to clinical evaluation and radiological assessment of the chest using conventional chest X-ray (CXR) and multi-detector computed tomography.
The most common mode of injury was motor vehicle accidents (56.7%). On MDCT scan, the frequency of chest injuries were; chest wall injuries (86.7%), pleural injuries (80%), parenchymal injuries (56.7%), mediastinal injuries (30%) and finally the dorsal spine injuries (16.7%). MDCT is more sensitive, specific, and accurate than CXR in the assessment of blunt chest trauma and management of patients.
MDCT is the modality of choice for rapid assessment of emergency chest trauma patients, when chest X-ray was inconclusive.
Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma
2013, Chinese Journal of Traumatology - English Edition
Thoracic injuries are responsible for 25% of deaths of blunt traumas. Chest X-ray (CXR) is the first diagnostic method in patients with blunt trauma. The aim of this study was to detect the accuracy of CXR versus chest computed tomograpgy (CT) in hemodynamically stable patients with blunt chest trauma.
Study was conducted at the emergency department of Sina Hospital from March 2011 to March 2012. Hemodynamically stable patients with at least 16 years of age who had blunt chest trauma were included. All patients underwent the same diagnostic protocol which consisted of physical examination, CXR and CT scan respectively.
Two hundreds patients (84% male and 16% female) were included with a mean age of (37.9±13.7) years.
Rib fracture was the most common finding of CXR (12.5%) and CT scan (25.5%). The sensitivity of CXR for hemothorax, thoracolumbar vertebra fractures and rib fractures were 20%, 49% and 49%, respectively. Pneumothorax, foreign body, emphysema, pulmonary contusion, liver hematoma and sternum fracture were not diagnosed with CXR alone.
Applying CT scan as the first-line diagnostic modality in hemodynamically stable patients with blunt chest trauma can detect pathologies which may change management and outcome.
Hypothermia at admission increases the risk of pulmonary contusion's infection in intubated trauma patients
2012, Annales Francaises d'Anesthesie et de Reanimation
La contusion pulmonaire (CP) est fréquente chez le polytraumatisé. L’objectif de l’étude était de déterminer les facteurs favorisants les surinfections bactériennes de la CP et d’en effectuer une analyse microbiologique.
Étude observationnelle rétrospective.
Les dossiers des patients polytraumatisés présentant une CP admis en réanimation chirurgicale au CHU de Rouen sur une période de quatre ans ont été analysés. Les patients présentant un traumatisme thoracique pénétrant, ou décédés dans les 48 premières heures de leur admission, étaient exclus. Le diagnostic d’infection pulmonaire était posé devant l’association d’une hyperthermie et d’un prélèvement bronchique mettant en évidence au moins un germe à une concentration de 103 UFC/mL. Après analyse univariée, les variables significativement associées avec une valeur de p < 0,05 étaient intégrées dans le modèle de régression logistique afin d’identifier les facteurs de risque indépendant d’infection pulmonaire. Une étude des données microbiologiques a également été réalisée.
Cent dix-sept patients ont été inclus et l’incidence des surinfections bactériennes pulmonaires était de 33,3 % (39 patients). Les germes les plus fréquemment retrouvés étaient par ordre de fréquence Haemophilus sp., Staphylococcus aureus, les entérobactéries, Pseudomonas sp. et les streptocoques. En analyse multivariée, seule la présence d’une hypothermie à l’admission était un facteur de risque indépendant d’infection de la CP (OR = 2,61 ; IC 95 % [4,2–13,3]).
La CP se surinfectait dans 33,3 % des cas et ce risque était augmenté par la présence d’une hypothermie à l’arrivée du patient. Une étude prospective est nécessaire pour valider ces résultats.
Pulmonary contusion (PC) is common in cases of polytrauma. The aim of this study was to perform a multivariate analysis of risk factors associated with the occurrence of infection in PC and analyze the microbiological epidemiology.
All patients with PC admitted to the intensive care unit (ICU) between January 2002 and December 2006 were included in this retrospective observational study. Patients with penetrating thoracic trauma or those who died in the 48 hours following admission to hospital were excluded. Diagnosis of bacterial infection in PC was performed if hyperthermia was associated with a positive quantitative culture (103 colony forming units/mL) on the bronchial sample. Univariate analysis provided statistical difference between variables that were integrated in the multivariate analysis model. Multivariate analysis was then performed to determine the risk factors of bacterial infection in PC.
One hundred and seventeen patients were included. The incidence of bacterial infection in PC was 33.3% (39 patients). The most frequently encountered bacteria were Haemophilus sp., Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Streptococcus sp. According to multivariate analysis, the existence of hypothermia at hospital admission increased the risk of PC infection (OR = 2.61; IC 95% [4.2–13.3]).
In conclusion, PC was infected in 33.3% of cases. The existence of hypothermia was identified as a risk factor. A prospective study is warranted to confirm these results.

View all citing articles on Scopus

: Address reprint requests to Kathirkamanathan Shanmuganathan, MD, Department of Diagnostic Radiology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201

^*: Department of Diagnostic Radiology and the Shock-Trauma Center, University of Maryland Medical Center, Baltimore, Maryland

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IMAGING DIAGNOSIS OF NONAORTIC THORACIC INJURY

Section snippets

THORACIC CAGE INJURY

Pneumomediastinum

PLEURAL EFFUSION AND HEMOTHORAX

Pulmonary Contusion

TRACHEOBRONCHIAL INJURIES

THORACIC ESOPHAGEAL DISRUPTION

DIAPHRAGMATIC INJURY

BLUNT CARDIAC AND PERICARDIAL INJURY

CONCLUSION

Chest

Ann Thorac Surg

Am J Emerg Med

J Thorac Cardivasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clin Imaging

Ann Thorac Surg

Clin Radiol

Ann Thorac Surg

Chest

Am J Emerg Med

Semin Roentgenol

Pneumomediastinum: Old signs and new signs

AJR Am J Roentgenol

Avulsion of the innominate artery associated with fracture of the sternum

AJR Am J Roentgenol

Injuries to the trachea and bronchi

Thorax

A comparison of right and left blunt traumatic diaphragmatic rupture

J Trauma

Diaphragmatic injury in children

J Trauma

Early diagnosis of traumatic rupture of the bronchus

JAMA

Chest trauma approach and management

Clin Chest Med

Aging of the diaphragm: A CT study

Radiology

Diaphragmatic injuries: Recognition and management in sixty-two patents

Am Surg

Radiographic recognition of pneumothorax in the intensive care unit

Crit Care Med

Pulmonary contusion: Review of the clinical entity

J Trauma

MR imaging of delayed presentation of traumatic diaphragmatic hernia

Gastrointest Radiol

Subpleural sparing: A CT finding of lung contusion in children

Radiology

The significance of first and second rib fractures

Aust N Z J Surg

The progressive nature of pulmonary contusion

Surgery

Traumatic pulmonary hernia: Surgical versus conservative management

J Trauma

The inadequacy of peritoneal lavage in diagnosing acute diaphragmatic rupture

J Trauma

Blunt traumatic rupture of the heart and pericardium: A ten-year experience (1979–1989)

J Trauma

Bockdalek hernia: Prevalance and CT characteristics

Radiology

Diaphragmatic rupture due to blunt trauma: Sensitivity of plain chest radiographs

AJR Am J Roentgenol

CT aortography of thoraic aortic rupture

AJR Am J Roentgenol

Diaphragmatic motion: Fast gradient-recall-echo MR imaging in healthy subjects

Radiology

General case of the day

Radiographics

The SICU chest radiograph after massive blunt trauma

Radiol Clin North Am

Deep sulcus sign

Radiology

Lung alterations in thoracic trauma

J Thorac Imaging

Bronchial rupture caused by blunt chest trauma

Scand J Cardiovasc Surg

Thoracic trauma: Radiologic triage of the chest radiography

Am Roentgen Ray Soc Apr