Imaging of blunt pediatric thoracic trauma

The imaging evaluation of thoracic trauma is a central feature of the acute assessment and management of injured children. A reliable early clinical diagnosis of chest injury often is difficult. Cardiopulmonary symptoms may not be present in the first 24 hours, and there is no consistent relationship between external chest wall injury and underlying abnormalities. This is particularly evident in children, in whom increased compliance of the bony thorax allows major internal injury to occur without associated skeletal injury. Additionally, unlike the examination of injuries to the head and abdomen, which are often evaluated with computed tomography in the initial posttraumatic period, chest radiography remains the primary method for evaluation of chest injuries, although it may not demonstrate or may underestimate many abnormalities. This essay reviews the imaging appearance of common and uncommon thoracic injury in children.     

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.     

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     

Criteria for the selective use of chest computed tomography in blunt trauma patients

Purpose

The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

Methods

This observational study prospectively included consecutive patients (≥16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

Results

We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age ≥55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <?3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with ≥1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

Conclusion

Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.     

Early detection of thoracic spine fracture in the multiple trauma patient: Role of the initial portable chest radiograph

Early detection of thoracic spine fracture in the often unconscious multiple trauma patient is of utmost importance. Failure to recognize thoracic spine fracture early could result in neurologic injury during certain radiologic and therapeutic procedures that may be indicated for other injuries. In most trauma centers, the initial evaluation of the multiple trauma patient includes a portable chest radiograph, which may show signs of thoracic injury.To determine the value of the initial portable chest radiograph in the detection of thoracic spine fracture, 34 cases of multiple trauma patients with proven thoracic spine fractures were studied. The initial portable chest radiograph was reviewed for signs of thoracic fracture and compared with the findings on plain bone radiographs and computed tomographic scans and with the patient's medical record.Of the 34 cases, radiologic signs of fracture were initially reported in 18 patients (53%). On re-review, positive signs of fracture were seen in 27 patients (79%). The authors conclude that the initial portable chest radiograph in the multiple trauma patient must be carefully studied for subtle signs of thoracic spine fracture. The most frequent chest radiographic findings were paraspinal hematoma, decreased vertebral body height, and lateral translation of vertebral bodies. Apical pleural cap, increased interpediculate distance, increased interspinous distance (empty vertebral body sign), and rib disarticulation were also noted.     

Treatment of acute thoracic aortic injury with commercially available abdominal aortic stent-grafts

Traumatic rupture of the thoracic aorta is a common cause of death after vehicle collisions. Associated injuries are common, and patients with lung injury, cardiac contusion, abdominal bleeding, and head injury comprise a group at high risk for conventional surgical or medical therapy. In this particular population, existing commercially available stent-grafts may provide a life-saving repair option. The Ancure and AneuRx stent-grafts, designed for abdominal aortic aneurysm application, were successfully placed in three patients. Accommodation for the short length of the delivery device was achieved by retroperitoneal iliac artery access. All patients had follow-up computed tomography (CT) without evidence of endoleak and were doing well with respect to their chest trauma after 5-9 months of follow-up.     

Imaging hemidiaphragmatic injury

The supine chest radiograph is the initial and most commonly performed imaging study to evaluate the thorax after trauma. Whenever the chest radiograph is equivocal or suspicious for acute diaphragmatic injury (DI), computed tomography (CT) is usually the next study of choice since it is both generally available and often used to examine other body regions in the patient after trauma. CT is usually diagnostic, particularly if supplemented by multiplanar reformation (MPR) obtained using thin-slice axial scanning and overlapping images for reformations. Magnetic resonance imaging (MRI) is potentially useful to assess the diaphragm if CT findings are indeterminate and the patient is stable enough to have the procedure. Simple T1-weighted spin-echo images in the sagittal and coronal orientation are usually sufficient to establish or exclude DI. This article reviews imaging modalities and strategies for diagnosing DI from blunt trauma.     

An unusual case of bronchial rupture—pneumomediastinum appearing 7 days after blunt chest trauma

We present a case of bronchial disruption after blunt chest trauma, which is unusual because the pneumomediastinum on the chest radiograph was detected 7 days after the injury. The first day imaging methods of the thorax showed only the fractures of the first and third left rib without any complications. A computed tomography (CT) scan was done following control chest radiograph and it revealed a rupture of the left main bronchus with pleural effusion, subcutaneous emphysema and pneumomediastinum. This case shows that a finding of pneumomediastinum after blunt chest trauma should always merit further investigation of its cause, even in cases of postponed detection of pneumomediastinum and regardless of the absence of other indicators of tracheobronchial disruption. Although fiber-optic tracheobronchoscopy is considered a diagnostic golden standard, in this case, diagnosis was clearly confirmed by spiral CT scan, due to thin slices and continuous data acquisition.     

Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications

PURPOSE: To evaluate the role of chest radiography, single-slice CT and 16-row MDCT in the direct evidence of tracheobronchial injuries. METHODS: Patients with acute tracheobronchial injury were identified from the registry of our level 1 trauma center during a 5-year period ending July 2005. Findings at chest radiograph and CT were compared to those shown at bronchoscopy. RESULTS: Eighteen patients with tracheobronchial injury - three patients with cervical trachea injury, eight with thoracic trachea injury and seven with bronchial injury - were identified. Twelve patients had a blunt trauma (67%), six patients had a penetrating (iatrogenic) injury (33%). Chest radiograph directly identified the site of tracheal injury in four cases, showing overdistension of the endotracheal cuff in three cases and displacement of the endotracheal tube in one case. At the level of the bronchi, chest radiograph demonstrated only one injury. CT directly identified the site of tracheal injury in all the cases showing the overdistension of the endotracheal cuff at the level of the thoracic trachea (three cases), posterior herniation of the endotracheal cuff at the thoracic trachea (three cases), lateral endotracheal cuff herniation at the thoracic trachea (one case), tracheal wall discontinuity at the cervical (one case) and at the thoracic trachea (one case) and displacement of endotracheal tube at the cervical trachea (two cases). At the level of the bronchi, CT correctly showed the site of injury in six case including: discontinuity of the left main bronchial wall (two cases), the "fallen lung" sign (one case), right main bronchial wall enlargement (one case), discontinuity of the right middle bronchial wall (two cases). In one case, CT showed just direct "air leak" at the level of the carina suggesting main bronchus injury. This finding was confirmed by bronchoscopy. CONCLUSION: Chest radiograph was helpful for the assessment of iatrogenic tracheal injuries. CT detected the site of blunt tracheobronchial injuries in 94% of the cases. Multiplanar 16-row MDCT reconstructions, were essential for the optimal surgical approach.     

Computed tomography whole body imaging in multi-trauma: 7 years experience

AIM: To assess the impact of the introduction of a computed tomography (CT) imaging protocol for multi-trauma patients on the workload, overall diagnostic yield, and effect on detection of cervical spine injury and pneumothorax. METHOD: Between February 1997 and April 2004, all patients presenting acutely to the Emergency Department (ED) with haemodynamically stable trauma (Abbreviated Injury Scale 3 or more) involving more than two body systems were imaged with a comprehensive pre-set helical CT protocol (including non-contrast head, cervical spine: cranio-cervical and cervico-thoracic junctions; and oral and intravenous contrast-enhanced thoracic, abdomen and pelvis) after initial triage and a standard trauma series of radiographs (chest, lateral C-spine and pelvis). Diagnosis of cervical spine fracture and pneumothorax was noted before and after the CT protocol was carried out and findings from all studies were recorded prospectively. RESULTS: Over the 7-year period 296 multi-trauma CT studies were completed of which 41 (13.8%) were negative. Of the positive cases there were 127 (43%) head injuries; 25 cervical spine fractures (8%); 66 pelvic fractures (22%);48 thoracic or lumbar spine fractures (16%); 97 pneumothoraces (33%); 22 mediastinal injuries (7%) and 49 intra-abdominal injuries (17%) with 19 (6%) splenic tears/ruptures. Positive findings included many unsuspected injuries, including 19 cervical spine fractures which were not demonstrated on the standard lateral radiograph from the resuscitation room. Of the 97 CT detected pneumothoraces, 12 were bilateral, 52 already had a chest drain in situ and 36 were not detected on initial supine chest radiography in the resuscitation room. One undetected case had bilateral tension pneumothoraces that were promptly drained on the CT table. Only three patients did not complete their multi-trauma examination because of deterioration in clinical condition and these were all immediately returned to the resuscitation room. CONCLUSION: Over the 7-year period in a large acute National Health Service (NHS) hospital trust currently averaging 85,000 ED attendances per year only 296 patients fulfilled the stated criteria for an immediate multi-trauma CT study. Although disruptive in the short-term, the overall impact on workload was small. A wide range of significant injuries were demonstrated rapidly, accurately and safely, including 19 cervical spine fractures and 26 pneumothoraces not detected on plain radiographs.     

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.     

Lung parenchymal injury and its frequency in blunt thoracic trauma: the diagnostic value of chest radiography and thoracic CT

PURPOSE: The aims of this study were to determine the value of chest radiography in diagnosing lung parenchymal injury in patients with thoracic trauma, and to evaluate the frequency of lung parenchymal injury by using thoracic computed tomography (CT). MATERIALS AND METHODS: Between January 2005 and June 2006, we retrospectively evaluated the anteroposterior chest radiographs and thoracic CTs of 60 patients that presented to our emergency department and were hospitalized due to multi-organ trauma. RESULTS: Chest radiography revealed parenchymal injury in 32 of the patients, while thoracic CT confirmed parenchymal injury in only 27 of these 32 patients. Chest radiographs did not reveal any parenchymal injury in 28 of the patients, whereas thoracic CT detected parenchymal injury in 12 of these 28 patients. Thoracic CT results were accepted as the gold standard in the evaluation of patients with chest trauma and showed that the sensitivity, specificity, positive predictive value, and negative predictive value of chest radiography in determining parenchymal injury were 69%, 76%, 84%, and 57%, respectively. In addition, thoracic CT revealed that 65% of the patients with blunt thoracic trauma suffered parenchymal injury. CONCLUSION: The sensitivity of anteroposterior chest radiography in identifying lung parenchymal injury was low, with a high false negative rate; therefore, we think that early evaluation with thoracic CT is extremely helpful in the diagnosis and treatment of patients with thoracic trauma, adding to the cooperative work that exists between radiologists and emergency physicians.     

Multi-detector computed tomography imaging of blunt chest trauma

Background and purpose

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.

Patients and methods

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.

Results

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.

Conclusion

MDCT is the modality of choice for rapid assessment of emergency chest trauma patients, when chest X-ray was inconclusive.     

Thoracic foreign bodies in adults.

AIM: The aim of this pictorial essay is to illustrate a range of imaging manifestations of thoracic foreign bodies. METHODS AND RESULTS: The essay includes documented intrathoracic foreign bodies introduced by inhalation, aspiration, penetrating trauma or ingestion. Imaging modalities include chest radiography and computed tomography (CT). CONCLUSIONS: The majority of foreign bodies are seen on the plain chest radiograph. CT is helpful in demonstrating the presence of radiolucent foreign bodies and determining the exact location of the foreign bodies within the airways or lung parenchyma.     

Diaphragmatic injuries after blunt trauma: are they still a challenge?

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.     

Spinal trauma

Spinal trauma is classified according to the mechanism of injury and the presence or absence of stability. A variety of imaging modalities, including radiography, conventional tomography, computed tomography, and magnetic resonance imaging are available for assessment of the injured spine. This article discusses the role of these various methods in evaluating osseous, ligamentous, and neural damage. Common injuries are described at the upper and lower cervical, thoracic, and thoracolumbar regions.     

Imaging the neonatal heart--essentials for the radiologist

Modern radiological imaging provides precise diagnosis in congenital heart disease (CHD). The most important and readily available radiological examination is still chest radiography. The diagnostically most important imaging method is echocardiography. Magnetic resonance imaging and computed tomography have gained much ground over the more invasive cardiac catheter angiography, which is still needed in more complex conditions and for interventional procedures, which are performed more frequently. This article is focused on imaging of the neonatal heart. Basically, characteristics of the chest radiograph in CHD are illustrated. To establish an understanding of CHD haemodynamics are reviewed. It is not the role of the radiologist to make a detailed anatomic or physiologic diagnosis on the basis of a plain film, but the radiologist should be aware of changes in a neonatal chest X-ray that CHD can cause and should point out that the child might have CHD thus initiating further work-up.     

Diagnosis of blunt traumatic aortic injury 2007: still a nemesis

In recent years, the use of multidetector computed tomography (MDCT) for the diagnosis of acute thoracic injury in blunt trauma has expanded. MDCT has shown high accuracy for the diagnosis or exclusion of injury to the aorta and its primary branches, decreasing the need for thoracic angiography and allowing earlier treatment of this often rapidly fatal lesion. With increasing use of MDCT, more subtle injuries and variants of vascular anatomy are being recognized that create pitfalls in the diagnosis. Of perhaps more concern is the recognition that aortic injury can occur with little or no associated mediastinal hematoma, the principle chest radiographic finding indicating a need for further imaging. The importance of recognizing unusual sites of aortic injury, congenital variants of mediastinal anatomy, the precise extent of injury, and the anatomic pathology present as key factors in deciding among treatment options is emphasized.     

Should an MR scan be performed routinely after a normal clearance CT scan in the trauma patient? Experience with 59 cases

Magnetic resonance (MR) imaging is not routinely used to exclude ligamentous and other soft tissue injury in the unconscious trauma patient. In order to determine the frequency and types of soft tissue injuries detected by MR imaging but not by computed tomography (CT), we performed a retrospective investigation comparing the MR findings in 59 trauma patients, either alert or unconscious, who previously had undergone a negative clearance multislice CT study of the cervical spine. Six patients had abnormalities not identified on the CT studies, including four cases of ligamentous injury.     

Esophageal injuries: spectrum of multidetector row CT findings

BACKGROUND: Aim of this study is to illustrate the multidetector row computed tomographic findings related to oesophageal injuries and their significance for therapeutic decisions. METHOD: From April 2002 to April 2005 we studied 16 patients with suspected oesophageal injury. Ten patients underwent standard chest radiograph, while five patients with suspected foreign body ingestion were submitted to cervical plain film and gastrografin swallow study. All 16 patients underwent multidetector row CT examination. RESULTS: In six patients with cervical, thoracic and abdominal trauma, CT showed the presence of thoracic traumatic lesions and findings suggestive of perforation of the oesophagus. In five patients with foreign body ingestion cervical radiography was positive in only one case, while CT showed the presence of a foreign body in all cases. In three patients with post-intubation complications, CT showed the presence of perioesophageal fluid collection containing small gas bubbles in two cases and an oesophageal-aortic fistula in one case. In the remaining two patients with suspected spontaneous oesophageal perforation, CT demonstrated an oesophageal wall oedema and thickening in one case, and oesophageal fluid distension with perioesophageal small bubbles gas and fluid in the second case. CONCLUSION: Oesophageal injuries, when complicated with perforation, constitute a life-threatening condition. Knowledge of the CT signs of oesophageal injuries has important implications for the role of imaging at the time of initial diagnosis.