Abdominal aortic injury associated with “seat belt syndrome”

Flexion–distraction spinal injuries and intra-abdominal visceral injuries have a well-recognized association with the use of passive restraints during motor vehicle collisions. Abdominal aortic injury due to blunt trauma is rare. However, there is a reported association of this injury with seat belt use. We report a case of a restrained passenger in a motor vehicle collision who sustained this triad of injuries, with the abdominal aortic injury not initially suspected.     

Triple blowout fracture of the orbit

We describe a case of traumatic orbital fracture involving the superior, medial, and inferior walls with preserved orbital rim. This “triple blowout” fracture has not been previously reported. There was no damage to the globe or the optic nerve and the patient had an excellent recovery with minimal residual diplopia.     

Aortic injury with chance fracture in a child

To present the findings in a 10-year-old male with a Chance fracture and associated aortic vascular injury and review of the literature on the subject. We reviewed the clinical and imaging findings in a patient who was in a serious motor vehicle accident, sustaining a Chance fracture of the lumbar spine and associated aortic and common iliac vessel injury. We also accomplished a literature review. Evidence of an associated aortic injury was available on the initial computed tomography (CT) study, but the findings were more exquisitely demonstrated on reconstructed studies of the lumbar spine. Our literature review indicated that aortic injury associated with Chance fracture is relatively rare and often overlooked. Abdominal aortic injury although rare, can occur with Chance fractures. With the now present sophisticated CT imaging in most Emergency Rooms it is possible to obtain exquisite reconstructed images of all organ systems including the vascular tree. The images may provide enough details so that further delineation of any given problem may not be necessary.     

Odontoid fractures following blunt trauma

Fractures of the odontoid process typically result from forceful blunt trauma. They often produce instability of the cervical spine, and may be associated with neurologic impairment. This study was designed to examine the epidemiology and demographics of odontoid injuries, including their incidence and prevalence relative to other spine injuries, the prevalence of associated injuries, and the likelihood of neurologic impairment. Of 34,069 enrolled blunt trauma victims, 818 (2.4 %) sustained a cervical spine injury, 94 of whom had a fracture of the odontoid. The relative prevalence of odontoid fractures varied by age, ranging from less than 3 % among individuals under age 20 years, to greater than 20 % in patients over 80 years old. Classification by Anderson–D'Alonzo criteria revealed 6 type I injuries, 60 type II injuries, and 27 type III injuries; one vertical injury could not be categorized. Over half of the odontoid fracture victims sustained additional cervical spine injuries, with 90 % of these injuries involving the atlanto-axial complex. In addition, non-spine-related injuries were found in 52 % of odontoid injury victims, over one-third (34 %) presented with an altered level of alertness, and almost one-quarter (23 %) exhibited some form of focal neurologic deficit associated with their injury. Fractures of the odontoid are among the most frequently encountered cervical spine injuries, and increase in prevalence with increasing patient age. Odontoid fracture victims often have other spine injuries, particularly to the atlanto-axial complex, and may harbor other non-spine-related injuries and neurologic pathology.     

Syphilitic aneurysm of descending thoracic aorta causing vertebral body erosion and spastic paraparesis

Bone erosion from a syphilitic aortic aneurysm is uncommon, having been reported in only a few cases. Vertebral body erosion by a syphilitic aortic aneurysm is rarely associated with neurological deficits. We report a case of a syphilitic aneurysm of the descending thoracic aorta with associated vertebral body erosion and spinal cord compression causing spastic paraparesis.     

Thoracic computed tomography in victims of blunt trauma: changes in utilization after the introduction of helical technology

Purpose: In blunt trauma, CT of the thorax is often performed because of the limitations of plain film chest radiography in accurately depicting injuries to the thoracic aorta. The advent of helical CT has allowed the entire chest to be imaged more expeditiously. We will evaluate the extent to which this ability to rapidly obtain additional images of the thorax has increased the utilization of chest CT in blunt trauma. Methods: The radiologic records of all victims of blunt trauma who underwent total body CT (TBCT), which included abdomen, pelvis, and chest images, in the 10 months before and 10 months after our institution acquired helical CT (HCT), were retrospectively evaluated. Results: In the 10 months before we obtained HCT, 520 conventional CT of the abdomen and pelvis were completed, of which only 11 (2.1 %) included images of the full thorax. After HCT was instituted, 684 abdomen and pelvis CT were performed, of which 59 (8.6 %) were ordered with the entire chest. Of the 11 conventional TBCT, 6 (55 %) showed findings in the chest; in 2 of these cases (18 %) the abnormalities were confined exclusively to the thorax. Similarly, of the 59 helical TBCT, 31 (53 %) depicted traumatic abnormalities in the thorax, and in 23 of these cases (39 %) injuries were only within the chest. In 4 of the latter the injuries were mediastinal hematomas, 1 of which (25 %) was confirmed angiographically to represent an aortic laceration. Conclusion: The speed and ease with which additional images can be obtained by HCT has greatly increased utilization of cross-sectional imaging of the thorax after blunt trauma (approximately four-fold). Over half of these depict traumatic injuries.     

Woman with intertrochanteric femur fracture diagnosed by MR

We present the case of an elderly woman who sustained an intertrochanteric hip fracture from a fall, with negative findings on plain film. The fracture was subsequently diagnosed using MRI and surgically fixed. MRI continues to be the gold standard for diagnosing occult hip fractures in the acute setting. Any elderly patient presenting with hip pain following a fall or other trauma must be regarded as having a fracture until proven otherwise, even if plain films are normal.     

Chronic nontraumatic spinal epidural hematoma of the lumbar spine: MRI diagnosis

An uncommon case of chronic nontraumatic spinal epidural hematoma of the lumbar spine in a 75-year-old woman is reported. The patient presented with a 7-month history of low back pain and bilateral sciatica. Magnetic resonance imaging enabled a correct preoperative diagnosis revealing a nodular, well-circumscribed epidural mass with peripheral enhancement and signal intensities consistent with chronic hematoma, which extended from L2 to L3. Laminectomy of L2–L3 was performed and the hematoma was totally resected. Histological examination of the surgical specimen demonstrated a chronic encapsulated hematoma. No evidence of vascular malformation was found. The patient recovered fully after surgical treatment. Received: 23 August 1999; Revised: 13 January 2000; Accepted: 4 February 2000     

Rotational injuries of the cervical spine

Injuries which are caused in part by a rotational mechanism include atlantoaxial rotatory fixation (AARF), traumatic isolation of the articular pillar (TIAP), and unilateral interfacetal dislocation (UID). The anatomy, classification, radiographic findings, and frequency of neurological signs are reviewed. Key points include: AARF: (1) Mild injury is not diagnosed radiographically since the appearance is the same as for physiologic rotation. More significant injuries demonstrate widening of the atlanto-dens interval ( > 3 mm in adults) and/or abnormal rotation ( > 45 °) of C1 on C2. (2) AARF refers to an inability to return the head to a neutral position. This may be due to trauma resulting in subluxation or dislocation or may be due to muscle spasm in torticollis. TIAP: (1) Radiographic diagnosis depends on visualizing ipsilateral pedicle and lamina fractures. (2) Rotation of an articular mass from its normal orientation on radiographs implies the presence of this injury. However, rotation of the articular mass is not always present, and the ipsilateral pedicle and lamina fractures must be seen on radiographs or CT. UID: (1) Less rotational discrepancy than expected can occur in two circumstances: articular mass fracture with dislocation or significant subluxation on the contralateral side. (2) Less anterolisthesis than expected can occur if there is articular mass fracture with dislocation.     

Can CT eliminate the initial portable lateral cervical spine radiograph in the multiple trauma patient? A review of 200 cases

Purpose: This investigation examines whether there is a continued role for the initial screening lateral portable radiograph in patients whose cervical spine is “cleared” by a CT examination. Methods: A retrospective review of 200 multiple trauma patients suspected of cervical spine injury (CSI) was performed. All patients had a screening lateral portable cervical spine radiograph (LPCSR) followed by cervical spine CT (CSCT). All scans were helical and included coronal and sagittal reformations. Reports of both examinations were compared for all patients. For those patients with signs of acute CSI, the two reports were compared to determine whether the LPCSR contained any information affecting patient outcome that was not detected by CSCT. Results: The CSCT showed no signs of acute CSI injury in 190 patients. Ten CSCT scans showed signs of fracture. In these 10 patients, the screening LPSCR showed signs of fracture in 1 patient, question of fracture in 2 patients, and no fracture in 7 patients. No LPCSR demonstrated significant information not seen on the accompanying CSCT. No LPSCR showed a finding that altered patient management prior to CSCT. Conclusion: The data suggest that an initial LPCSR is unnecessary if the patient is having a screening CSCT.     

Can chest and abdominal trauma CT eliminate the need for plain films of the spine? – Experience with 329 multiple trauma patients

Purpose: To compare the accuracy of spine plain films with chest and abdominal trauma CT in detection of spine fractures. Methods: The study prospectively enrolled 329 multiple trauma patients. Of these, 38 patients had both chest CT for trauma and thoracic spine plain films, and 87 patients had both abdominal CT for trauma and lumbar spine plain films. Results: Of the fractures visible at either chest trauma CT or thoracic spine plain film examination, all were diagnosed on CT and 62 % on plain films. Of fractures visible at either abdominal trauma CT or lumbar spine plain films, 94 % were diagnosed on CT and 67 % on plain films. The one false negative CT involved an articular process fracture, which was visible but not mentioned, in a patient with a sacral fracture. Conclusion: Evaluation of the digital scout images and bone windows when a patient has chest and abdominal trauma CT appears to be as accurate as thoracic and lumbar spine plain films in the evaluation of spinal trauma.     

Cervical spine injury in the very elderly

Background: Elderly patients are known to be at increased risk of cervical spine injuries. This propensity for injury becomes more important as the population of mobile elderly individuals increases. The present study seeks to examine the incidence and spectrum of spine injury among patients aged 80 years or greater, and to examine the efficacy of a decision rule for obtaining cervical spine radiography in this extreme age group. The decision rule would determine whether imaging could be avoided in patients who have none of the following: (1) posterior midline cervical spine tenderness; (2) focal neurological deficit; (3) abnormal level of alertness; (4) evidence of intoxication; or (5) clinically apparent distracting painful injury. Methods: All blunt trauma victims presenting to participating emergency departments underwent clinical evaluation prior to radiographic imaging. The elements of the decision rule were assessed and documented in each patient prior to radiographic imaging. The presence or absence of cervical spine injury was subsequently based on the final interpretation of all radiographic studies supplemented by a review of neurosurgical and risk management logs from each participating hospital. Data on all patients aged 80 years or greater were sequestered from the main database for separate analysis. Results: The study enrolled 34,069 individuals, including 818 patients (2.4 %) with cervical spine injuries. This population contained 1,070 patients (3.1 % of all cases) aged 80 or greater, 50 of whom (4.7 %) sustained cervical spine injuries. Injuries to the craniocervical junction (particularly C2 and the odontoid) accounted for 47.3 % of the injuries in the elderly, but only 28.6 % of injuries in younger patients. Older fracture victims were also likely to have more injuries (2.54 injuries/patient) than their younger counter parts (1.78 injuries/patient). The decision rule correctly identified all very elderly cervical spine injury victims [sensitivity 100.0 %; confidence interval (CI) 92.9–100.0 %], and designated 132 patients as “low-risk,” yielding a negative predictive value of 100.0 % (CI 97.3–100.0 %). Conclusions: The very elderly are at increased risked of cervical spine injury, particularly injury to the craniocervical junction. They also tend to have more extensive injuries than younger patients. Despite the increased risk of injury, the decision rule performed well in the very elderly, and allowed correct identification of all cervical spine injury victims.     

Post-traumatic recto-spinal fistula

Acquired recto-spinal fistula has been described elsewhere as a rare complication of colorectal malignancy and Crohn's enterocolitis. We treated a young man who developed a recto-spinal fistula as a result of a high fall injury. The patient presented with meningeal signs, sepsis and perianal laceration. Computerized axial tomography revealed air in the supersellar cistern. Gastrografin enema showed that contrast material was leaking from the rectum into the spinal canal. Surgical management included a diverting sigmoid colostomy, sacral bone curettage and wide presacral drainage. To the best of our knowledge, rectospinal fistula of traumatic origin has not been previously reported in the English literature. Received: 7 December 1998; Revised: 10 May 1999; Accepted: 10 May 1999     

Normal cervical spine variations mimicking injuries in children

Evaluation of the cervical spine is a constant problem. This communication deals with the various normal variations and congenital anomalies that are frequently misinterpreted for traumatic lesions. Emphasis is on how to identify these anomalies and how to differentiate them from traumatic injuries of the cervical spine.     

车祸伤致脊柱骨折临床特点分析

目的分析车祸伤致脊柱骨折的临床特点,以提高车祸伤致脊柱骨折的预防及救治水平。方法总结沈阳军区总医院骨科自2006年1月至2016年1月收治的166例脊柱骨折患者的临床资料,并进行流行病学统计分析。结果本组166例患者,年龄分布主要集中在40~59岁,占50.0%(83/166)。驾驶员是主要致伤身份,占48.2%(80/166)。235个损伤节段中,颈椎、胸椎、腰椎及骶尾椎损伤所占比例依次为40.9%(96/235)、30.2%(71/235)、28.1%(66/235)、0.9%(2/235),其中,L1、C2、T12分别为17.0%(40/235)、14.0%(33/235)、12.3%(29/235)。合并症及神经损伤发生率在年龄≤19岁组最高,分别为50.0%和50.0%。行人组的合并症发生率最高为43.5%,驾驶员组的神经损伤发生率最高为55.0%。结论由车祸伤致脊柱骨折的流行病学特点可见,驾驶员是主要车祸伤来源,根据车祸时的身份不同,神经损伤和合并症发生情况有所不同,应根据其特点进行防治。     

Perisplenic pseudolesion: a case report and literature review

Distinguishing a normal variant from true pathology is a frequent task of the imager. In the assessment of the trauma patient, rapid determination of the presence or absence of intraabdominal injury is of paramount importance. We present the sonographic findings of an anatomic variant detected in a patient following blunt abdominal trauma. Trauma sonogram revealed an elongated left lobe of the liver mimicking a subcapsular splenic hematoma. This case illustrates the importance of recognizing this potential pitfall in the setting of abdominal trauma. An equivocal trauma sonogram can lead to critical delays in treatment of associated injuries and unnecessary additional imaging or even surgery.     

A longitudinal insufficiency fracture of the tibia in association with a healed chronic osteomyelitis

Longitudinal stress fracture of the tibia often present with an atypical clinical presentation which can be mistaken for osseous tumor or osteomyelitis. We present a case of longitudinal stress fracture of the tibia which occurred in a patient with healed chronic osteomyelitis of the tibia. Magnetic resonance imaging failed to make the correct diagnosis. Accurate diagnosis was only obtained by helical CT which showed the longitudinal fracture line. Magnetic resonance imaging showed only non-specific signs of bone marrow edema, suggesting recurrence of osteomyelitis. Magnetic resonance imaging can be misleading in the absence of direct visualization of the fracture line. Received: 30 September 1999; Revised: 26 April 2000; Accepted: 2 May 2000     

MACHO fracture: distal fifth metacarpal fracture revisited

Background: The term “boxer's fracture” has been used to describe fractures to the fifth metacarpal. In fact, boxers do not fracture their fifth metacarpal but their second or third metacarpals. Methods: We reviewed demographic data for 51 patients with boxer's fractures. Sex, age, hand involved, hand dominance, method of injury, ethanol intoxication, and presence of anger at the time of injury were evaluated. Results: Only 18 % of our cases involved a patient hitting another person. Fifty-one percent of the cases occurred when the patient intentionally struck a hard object. Thirty-one percent of fractures were accidental or due to crush injury. Of those injured from an intentional blow, nearly all of the patients were male. Patients were commonly angry at the time of injury. Conclusions: Based on the characteristics of our patients with these fractures, we believe a more appropriate name for this injury is the MACHO fracture (Men Angrily Cuffing Hard Objects).     

Assessing radiographically occult upper extremity fractures with dedicated extremity MRI

Purpose: To examine the utility of low-field, dedicated extremity MRI for assessing acute upper extremity trauma in patients with radiographs that are negative for fracture. Secondly, to determine which sequences are most useful when screening for fractures. Methods: Forty-four of 46 patients with acute upper extremity trauma and initial radiographs negative for fracture were imaged with a 0.2-T MRI system. Findings were verified with follow-up clinical assessment and plain radiography. Results: In 21 patients, dedicated extremity MRI demonstrated 26 ultimately proven occult fractures, none of which were seen on the initial conventional radiographs. True fractures demonstrated marrow edema and a linear fracture line on low-field MRI. One bone contusion showed edema with no fracture line and was misdiagnosed as a fracture. Low-field MRI correctly identified 23 remaining patients with no fracture. Sensitivity and specificity for fracture in the 44 patients successfully imaged were 100 % and 96 %, respectively. Additionally, 21 soft-tissue injuries were found incidentally by MRI. However, these may not merely be incidental findings of an acute nature, but may very well be chronic, and therefore merit no specific treatment. T1-weighted gradient-echo and short-tau inversion recovery sequences demonstrated the fracture line and marrow edema to best advantage, and were thus the most useful sequences to assess fractures on low-field MRI. Conclusion: Extremity MRI is highly sensitive and specific for radiographically occult fractures of the upper extremity and can also identify associated soft-tissue injuries. In our study, the management was altered in 45 % of the patients following MRI. When adequate sequences are used this modality can direct appropriate therapy while obviating the added expense and morbidity of unnecessary immobilization and follow-up imaging of patients without fracture.     

Imaging of cervical spine trauma: are the anteroposterior and odontoid radiographs needed when CT of the entire cervical spine is routine?

Objective: To evaluate the contribution of the anteroposterior (AP) and odontoid radiographs in cervical spine trauma when helical CT of the entire cervical spine is performed in routine screening. Methods: In part 1 of the study, 47 patients with cervical spine fracture (positive) and 92 patients without fracture (negative) were retrospectively assembled into a study population. For each patient, the lateral radiograph and the CT were evaluated for the presence or absence of fracture. The results were compared to the radiology report at the time of injury which was based on the lateral, AP, and odontoid radiographs plus the CT (gold standard). In part 2 of the study, the individual sensitivities of CT and each radiograph were determined by review of the 47 positive patients with the fracture locations known a priori. Results: In all 47 positive patients, the presence of fracture was correctly identified using only the lateral radiograph and the CT. In none of the 92 negative patients was the lateral radiograph plus CT incorrectly interpreted as positive for fracture. The sensitivities for fracture of CT, the lateral radiograph, the AP radiograph, and the odontoid radiograph were 100, 47, 28, and 18 % respectively. Conclusion: The AP and odontoid radiographs did not contribute to the evaluation of suspected cervical spine fracture when the lateral radiograph and helical CT of the entire cervical spine were performed in routine screening.