Blunt nonaortic chest trauma: radiographic and CT findings

Following initial clinical evaluation and stabilization of a patient who has sustained blunt chest trauma, imaging has an important role in the evaluation of thoracic injuries. The initial study is the chest radiograph. However, chest CT is being used with increased frequency in the evaluation of blunt chest trauma. Although CT is used primarily to assess for traumatic aortic injuries, it is also useful in the evaluation of pulmonary and bronchial, airway, skeletal and diaphragmatic injury. The aim of this article is to review the characteristic imaging findings of pulmonary and bronchial, esophageal, thoracic, skeletal and diaphragmatic injuries. Electronic Publication     

Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms

In patients after chest trauma, imaging plays a key role for both, the primary diagnostic work-up, and the secondary assessment of potential treatment. Despite its well-known limitations, the anteroposterior chest radiograph remains the starting point of the imaging work-up. Adjunctive imaging with computed tomography, that recently is increasingly often performed on multidetector computed tomography units, adds essential information not readily available on the conventional radiograph. This allows better definition of trauma-associated thoracic injuries not only in acute traumatic aortic injury, but also in pulmonary, tracheobronchial, cardiac, diaphragmal, and thoracic skeletal injuries. This article reviews common radiographic findings in patients after chest trauma, shows typical imaging features resulting from thoracic injury, presents imaging algorithms, and recalls to the reader less common but clinically relevant entities encountered in patients after thoracic trauma.     

胸腔镜在胸部创伤中应用的研究进展

创伤患者经常出现严重的胸部损伤,如血胸、肋骨骨折、肺损伤,食管、气管及胸导管损伤虽然少见但常常是患者死亡的主要原因,如果上述胸部创伤没有及时的诊断和治疗,会导致高病死率及远期不良预后。视频辅助胸腔镜(VATS)是外科手术中成熟的技术,在胸部损伤中,VATS可以提供胸腔内结构最大可视化,不但可作为胸部损伤的诊断方法而且能同时进行治疗,本文对VATS在胸部各类创伤中的应用及其优缺点进行综述,并讨论在胸部创伤中使用VATS的禁忌证及注意事项。     

Trauma of the chest

Trauma to the chest may cause a wide range of injuries including fractures of the thoracic skeleton, contusion or laceration of pulmonary parenchyma, damage to the tracheobronchial tree, diaphragmatic rupture or cardiac contusion. Conditions affecting primarily extrathoracic sites may have indirect effects on the lungs causing adult respiratory distress syndrome or fat embolism. Laceration of the aorta is the typical and likewise most life threatening complication of massive blunt chest trauma necessitating immediate diagnosis and repair.Conventional radiography rather than cross-sectional imaging is the mainstay in diagnosing thoracic trauma. During the critical phase with often concomitant shock, pelvic and spinal injuries tailored radiographic views or even upright chest radiographs are impractical. The severely traumatized patient is usually radiographed in the supine position and suboptimal roentgenograms may have to be accepted for several reasons. It is well documented that many abnormalities detected on CT were not apparent on conventional radiographs, but CT is reserved for hemodynamical stable patients. Nevertheless certain situations like aortic rupture require further evaluation by CT and aortography.The value of conventional radiography, CT, MRI and aortography in chest trauma is reviewed and typical radiographic findings are presented.     

Chest injury in children with blunt abdominal trauma: evaluation with CT

One or more significant chest injuries were identified in 62 of 512 children (12%) examined with computed tomography (CT) after blunt abdominal trauma. Thirty-eight percent of all abnormalities identified on CT scans were underestimated or missed on the initial chest radiograph. Pleural and parenchymal abnormalities were missed in 50% and 34% of initial chest radiographs, respectively. Chest injuries occurred more frequently in children less than 7 years of age than in older children (62% vs 38%, P less than .02). Children with chest injuries tended to be more physiologically unstable than children without, as determined with lower (worse) mean trauma scores (P less than .001). Both the presence and severity of chest injuries strongly affected outcome. Mortality was 1.3% in children with no chest injury, 10.8% in children with significant unilateral chest injury, and 40% in children with significant bilateral or mediastinal chest injury (P less than .0001). Significant unsuspected or underestimated thoracic injuries are relatively common in children, and CT scans of the chest obtained while examinations of the upper abdomen are being performed can be helpful in the early recognition of such injuries.     

Pediatric thoracic trauma: imaging considerations

Imaging plays an important role in the evaluation of the pediatric thorax following blunt and penetrating trauma. This essay reviews important differences between children and adults with respect to the pattern of thoracic injury. Additionally, the role of various imaging modalities in the assessment is discussed. Finally, the spectrum of pediatric thoracic injury is provided. Electronic Publication     

MR imaging of ligament injuries to the elbow

MR imaging is a highly valuable tool in the evaluation of ligamentous injuries of the elbow. Proper coil selection, patient positioning, and pulse sequence parameters are essential for optimization of image quality. Clinical evaluation of ligamentous injuries is often difficult and visualization at surgery may be limited. MR imaging can demonstrate not only ligamentous pathology but abnormalities in the adjacent osseous and soft tissue structures, making it an important aid to clinical management. In skeletally immature patients, MR imaging can demonstrate injury not only to the ligaments but to the physes and apophyses, making it useful in the evaluation of the pediatric elbow.     

The value of routine cervical spine,chest, and pelvis radiographs in children after trauma

The appropriate use of imaging to screen infants and children for injuries after trauma remains controversial, and routine radiographs of the cervical spine, chest, and pelvis are still obtained at some centers. The purpose of this study was to document the abnormalities encountered on such films obtained in 292 pediatric trauma patients to evaluate the worth of obtaining such studies, particularly in children who are asymptomatic and have no clinical findings referable to these areas.The medical records, radiographs, and other imaging studies of 292 children evaluated in the emergency department after trauma were retrospectively reviewed. Ages ranged from 5 months to 17 years (mean =10 years). The numbers and types of abnormal imaging findings were documented for each patient and were correlated with the type of injury, patient complaints, physical examination findings, level of consciousness, and laboratory abnormalities. Final diagnosis and short-term outcome were also documented.The most common causes of injury were motor vehicle accidents (55.1%), automobile-pedestrian accidents (14.7%), and falls (13.4%). Acute cervical spine injuries were found in 2 patients (0.7%), radiographic abnormalities of the chest were found in 11 patients (3.8%), and pelvic fractures were detected in 6 patients (2.0%). All except 1 of the 19 confirmed injuries were associated with local symptoms and/or signs or were found in patients with altered mental status. A stable cervical fracture was found in one infant who was too young to complain of neck pain or tenderness. Twenty-two patients (7.5%) were asymptomatic with no physical findings, and in none of these children were any imaging abnormalities detected.We conclude that routine posttrauma radiographs of the cervical spine, chest, and pelvis are of limited utility and are not warranted in children and adolescents who are alert and demonstrate no associated symptoms or physical findings. Radiography, particularly of the cervical spine, may be worthwhile in infants and young children, but we advocate selective imaging in such patients.     

Blunt thoracic aortic injury in children

Thoracic aortic injury (TAI) in children secondary to blunt chest trauma is rare and less well documented than TAI in adults. To further establishe the incidence and radiographic manifestations of this severe injury, we reviewed our experimence with TAI in children over an 8-year period. We performed a computer search from the Trauma Registry at our level I trauma center for all cases of TAI among patients 16 years of age or younger who were admitted after sustaining blunt chest trauma between August 1984 and September 1992. We reviewed our records of all thoracic aortograms performed on children for blunt trauma during this same time period. Indication for angiography was determined by review of chest radiographs and medical records of all patients who underwent thoracic aortography. We reviewed medical records and all available chest radiographs, computed tomography (CT) examinations, and thoracic aortograms of children diagnosed with TAI. Of 308 children admitted with blunt chest trauma, 26 (8.4%) underwent angiography to exclude aortic or great vessel injury. Of these 26 patients, three (11.5%) were diagnosed with TAI, and one patient demonstrated a traumatic pseudoaneurysm of the proximal left subclavian artery. The incidence of TAI among children who sustained blunt chest trauma was 1.0% in our series. All three patients with TAI in our series were male, ages 10–12 (mean: 11 years). Chest radiographs on two of the patients with TAI revealed mediastinal widening, ill-defined aortic outline, shift of the trachea and nasogastric tube, and depression of the left main stem bronchus. The chest radiograph in one patient with TAI was technically inadequate. CT demonstrated abnormalities in two patients. Angiographic findings were similar to those seen in adults. TAI in children is rare, occurring in 1% of children sustaining blunt chest trauma in our series. Our findings support previous reports that the plain film, CT, and angiographic findings with this injury resemble those found in adults.     

Abnormalities of the chest wall in pediatric patients

A variety of focal processes and diffuse abnormalities are found predominantly in children. In addition, thoracic manifestations of trauma differ in children because of increased chest wall compliance. Familiarity with both these abnormalities as well as the common normal variations provides optimal imaging evaluation.     

Traumatic aortic injury: an imaging review

Traumatic aortic injury (TAI) is a major cause of fatality in high speed deceleration injuries. It accounts for 10–20% of fatalities in blunt chest trauma. These injuries are usually related to high-speed motor vehicle and motorcycle collisions, pedestrian–motor vehicle collisions, and falls. Only 10–20% of patients who suffer TAI survive the initial injury and reach the emergency department. If left untreated, 30% die within 6 h, 40–50% die within 24 h, and 90% die within 4 months. A chronic pseudoaneurysm will develop in 2–5% of patients whose injury is not diagnosed. It is imperative, therefore, that these injuries are detected promptly and accurately. Symptoms and physical examination findings are nonspecific. External evidence of chest wall injury is present in 7–90% of cases, so that in up to 30% of the cases no apparent chest injury is identified on physical examination. Chest radiographs are very sensitive in detecting mediastinal hemorrhage, but have a low positive predictive value for aortic injury. The positive predictive value for chest radiography ranges between 5% and 20% for TAI. Aortography has been considered the gold standard for many years in the evaluation of TAI, but is time-consuming, labor- and resource-intensive, and invasive. Because of the shortcomings of physical examination and these more traditional imaging examinations, computed tomography (CT) has become increasingly utilized as a screening and diagnostic tool. Recent investigations have documented its high sensitivity and specificity in the detection of TAI. This article reviews the recent investigations of imaging evaluation of TAI, with a focus on helical CT. Electronic Publication     

Traumatic left main coronary artery dissection in a young adult following blunt chest trauma – A case report

Blunt chest trauma may cause variable degrees of thoracic injuries. Most of the patients may remain asymptomatic after sustaining blunt chest trauma. But in rare instances, life-threatening conditions such as coronary artery dissection may occur. The authors present a 29-year-old male adult with persistent chest pain following blunt trauma with a rise in cardiac troponins and elevated ST segment in ECG. Coronary CT and conventional angiography demonstrated dissection of the left main coronary artery. It is deemed necessary to suspect cardiac injury in patients with a history of blunt chest trauma in appropriate clinical settings. Early recognition of coronary artery dissection is vital to reduce morbidity and mortality. ECG combined with cardiac enzymes can be essential tools helping the physicians raise the suspicion towards a cardiac injury followed by cross-sectional and conventional angiographies for confirmation.     

Blunt traumatic injuries of the lung parenchyma,pleura, thoracic wall,and intrathoracic airways: multidetector computer tomography imaging findings

This pictorial review discusses multi-detector computed tomography (MDCT) cases of non-vascular traumatic chest injuries, with a brief clinical and epidemiological background of each of the pathology. The purpose of this review is to familiarize the reader with common and rare imaging patterns of chest trauma and substantiate the advantages of MDCT as a screening and comprehensive technique for the evaluation of these patients. Images from a level 1 trauma center were reviewed to illustrate these pathologies. Pulmonary laceration, pulmonary hernia, and their different degrees of severity are illustrated as examples of parenchymal traumatic lesions. Pleural space abnormalities (pneumothorax and hemothorax) and associated complications are shown. Diaphragmatic rupture, fracture of the sternum, sternoclavicular dislocation, fracture of the scapula, rib fracture, and flail chest are shown as manifestations of blunt trauma to the chest wall. Finally, direct and indirect imaging findings of intrathoracic airway rupture and post-traumatic foreign bodies are depicted. The advantage of high quality reconstructions, volume rendered images, and maximal intensity projection for the detection of severe complex traumatic injuries is stressed. The limitations of the initial chest radiography and the benefits of MDCT authenticate this imaging technique as the best modality in the diagnosis of chest trauma. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Imaging evaluation of children after falls from a height: review of 45 cases

The injury pattern in the child who falls from a height is markedly different from that in the adult, so a different imaging protocol is needed. To help establish such a protocol, the authors reviewed the charts and imaging records of 45 children and infants 12 years of age and younger who had fallen one to six stories. Extremity fractures were the most common injury, occurring in 20 patients. Head injuries (including skull fractures) occurred in 19 patients. Abdominal injuries were present in only one patient. Pneumothoraces were seen in four patients and lung contusions in two patients. Fractures of the pelvis, spine, and os calcis were uncommon. The height of the fall did not enable prediction of either the severity or type of injury. The authors recommend radiography of the cervical spine and chest alone in the initial evaluation of the injured child and greater willingness to obtain computed tomographic (CT) scans of the head in children than in adults. Radiographs of the pelvis, thoracolumbar spine, and lower extremities, as well as CT scans of the head and abdomen, should be obtained on a case-by-case basis, and not according to protocol, as is often the situation in adults.     

Imaging of head trauma in child abuse

This article reviews the imaging modalities used to evaluate head trauma received as a consequence of child abuse, signs most indicative of intentional injury, and methods use to data injury. Knowledge of neuroimaging features of child abuse is useful to radiologists who may encounter these children and may be in a position to raise the question of intentional injuries.     

Magnetic resonance imaging of congenital abnormalities of the thoracic aorta

This article outlines the ability of MR imaging in the detection and presurgical evaluation of congenital abnormalities of the thoracic aorta (CATA). Congenital abnormalities of the thoracic aorta may be found incidentally on chest radiographs in patients without symptoms, or it can be associated with clinical findings which are very variable depending on the association with congenital cardiac malformations or vascular ring. When CATA is suspected as the cause of anomalies in the mediastinum in asymptomatic patients, confirmation of the abnormality should be by MR imaging allowing precise evaluation of the thoracic aorta and origin of the principal arteries. When CATA is considered because clinical findings indicate coarctation of the aorta, vascular ring or associated cardiac disorder, evaluation with ultrasound can be complemented by MR, which in most cases will replace the diagnostic catheterization. Received 2 April 1997; Revision received 14 July 1997; Accepted 12 September 1997     

胸部穿透伤救治中常见失误及预防

目的 探讨和指出胸部穿透伤救治中的失误、难点,危险因素,并发症及防范措施。方法 回顾总结的胸部穿透伤３１８例,重点分析诊治错误和并发症。结果 胸腔伤的物理和Ｘ线漏误诊率为１１．１％（３５／３１６）,但致使误治率仅为４．１％（１３／３１６）,２４例心脏大血管损伤初期漏误诊５例。２８例膈肌损伤早期漏诊９例。２６７例次有腔闭式引流操作失误１１例次（４．１％）。发生需剖胸处理的并发症１７例。全组治愈３０８     

胸部创伤的电视胸腔镜手术

电视胸腔镜手术（VATS）是近年来诊治胸外伤的一项新技术,其创伤小、术后恢复快。目前VATS已广泛应用于创伤性血胸、创伤性气胸、创伤性膈肌破裂、心脏大血管损伤、创伤性乳糜胸、创伤后脓胸和多发性肋骨骨折等胸部创伤。对其适应证的选择、围手术期的处理和手术操作方法等进行规范具有重要意义。     

X-ray computed tomography of thoracic injuries. Apropos of 40 cases]

On chest radiographs, the precise assessment of thoracic injuries consecutive to blunt trauma is often compromised by the nonspecific appearance of many lesions. Furthermore, significant injuries are frequently overlooked. However, the management of the patients with chest trauma is still often based primarily upon clinical and radiographic findings and Computed Tomography (CT) is often performed secondarily on the basis of unexplained clinical signs or suspected radiographic abnormality. Some authors have reported that CT was a highly sensitive method for detecting thoracic lesions frequently not seen or underestimated on conventional supine chest radiographs. However, the value that these new CT findings could have in the therapeutic management of these patients, have not been systematically investigated to our knowledge, except in a limited series suggesting that the course of critically ill patients could be substantially altered after thoracic CT. In order to estimate the role of early CT in the management of patient care, we report the therapeutic consequences of CT findings in forty patients who we report the therapeutic consequences of CT findings in forty patients who had a thoracic CT within few hours following a chest injury. We showed that early thoracic CT scan in patients with blunt trauma detected significantly more lesions than did chest X-Ray and appreciably modified the treatment modalities in 70% of our patients. We then recommend that all the patients admitted in ICU after chest trauma undergo a thoracic CT scan as soon as possible in order to optimize their treatment modalities.     

Unusual radiologic findings in the thorax after radiation therapy.

Radiation therapy is used to treat many intrathoracic and chest wall malignancies. A variety of changes may occur after radiation therapy to the thorax. Radiation therapy produces dramatic effects in the lung. Pulmonary necrosis is an uncommon, severe, late complication of adjuvant postoperative radiation therapy. Bronchiolitis obliterans with organizing pneumonia is a distinct clinicopathologic entity characterized by patchy, migratory, peripheral air-space infiltrates. Radiation therapy can also cause spontaneous pneumothorax, mesothelioma, and lung cancer. In the mediastinum, radiation therapy may cause thymic cysts, calcified lymph nodes, and esophageal injuries. Cardiovascular complications of radiation therapy are often delayed and insidious. Premature coronary artery stenosis occurs after radiation therapy to the mediastinum. Radiation therapy may also give rise to calcifications of the ascending aorta, pericardial disease, valvular injuries, and conduction abnormalities. Women who undergo thoracic irradiation before the age of 30 years have a high risk of developing a second breast cancer. Radiation-induced sarcomas are an infrequent but well-recognized complication of radiation therapy. Other chest wall injuries due to radiation therapy are osteochondroma and rib or clavicle fractures. Knowledge of the imaging features of injuries caused by radiation therapy can prevent misinterpretation as recurrent tumor and may facilitate further treatment.