Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience

PURPOSE: To prospectively compare the accuracy of ultrasonography (US) with that of supine chest radiography in the detection of traumatic pneumothoraces, with computed tomography (CT) as the reference standard. MATERIALS AND METHODS: Thoracic US, supine chest radiography, and CT were performed to assess for pneumothorax in 27 patients who sustained blunt thoracic trauma. US and radiographic findings were compared with CT findings, the reference standard, for pneumothorax detection. For the purpose of this study, the sonographers were blinded to the radiographic and CT findings. RESULTS: Eleven of 27 patients had pneumothorax at CT. All 11 of these pneumothoraces were detected at US, and four were seen at supine chest radiography. In the one false-positive US case, the patient was shown to have substantial bullous emphysema at CT. Sensitivity and negative predictive value of US were 100% (11 of 11 and 15 of 15 patients, respectively), specificity was 94% (15 of 16 patients), and positive predictive value was 92% (11 of 12 patients). Chest radiography had 36% (four of 11 patients) sensitivity, 100% (16 of 16 patients) specificity, a 100% (four of four patients) positive predictive value, and a 70% (16 of 23 patients) negative predictive value. CONCLUSION: In this study, US was more sensitive than supine chest radiography and as sensitive as CT in the detection of traumatic pneumothoraces.     

Role of CT in excluding major arterial injury after blunt thoracic trauma

The role of CT in the diagnosis of major vascular rupture following blunt decelerating chest trauma is controversial. Its value in excluding major arterial injury has not yet been determined. During a 12-month period we obtained dynamic enhanced thoracic CT studies in 20 patients with blunt decelerating thoracic trauma who had abnormal or equivocal mediastinal contours on chest radiographs. In all cases diagnosis was confirmed by either digital subtraction (18 patients) or conventional thoracic angiography (two patients). CT scans showed evidence of direct aortic injury in three patients and evidence of mediastinal hematoma in five others. Four of these eight patients had major arterial injury verified angiographically and at surgery. In two patients the CT scan was considered equivocal; both patients had normal thoracic angiograms. CT excluded direct vascular injury or mediastinal hematoma in 10 patients. All 10 had normal thoracic angiograms. This preliminary study suggests that, in patients sustaining blunt decelerating thoracic trauma, thoracic CT may be more valuable than chest radiography in excluding major vascular injury and, in some cases, may reduce the need for thoracic angiography.     

Asbestos-related pleural disease and asbestosis: a comparison of CT and chest radiography

High-resolution CT (HRCT) has the ability to demonstrate both asbestos-related pleural disease and parenchymal abnormalities consistent with asbestosis. The role of CT in the diagnosis of asbestosis can be defined by comparing it with radiography. We evaluated 60 men who had a history of occupational exposure to asbestos and whose outside chest radiographs were considered abnormal. Chest radiographs (inside films) and HRCT were performed in all patients at our institution and were interpreted independently by experienced radiologists. Outside film results were compiled from the submitted reports. The final conclusion regarding the interpretation of the radiologic examinations was determined by consensus when disagreements existed. Positive predictive values (the likelihood that a positive report is correct) for pleural disease were: outside films 56%, inside films 79%, HRCT 100%. The positive predictive values for parenchymal disease were: outside films 51%, inside films 83%, HRCT 100%. The addition of HRCT to chest radiography is most useful in eliminating false-positive diagnoses of asbestos-related pleural disease caused by subpleural fat and false-positive diagnoses of parenchymal asbestosis in patients with extensive plaques or emphysema obscuring lung detail. The interpretation of chest radiographs in patients exposed to asbestos is often extremely difficult and subjective, and we recommend that positive findings (except calcified plaques) be confirmed with HRCT.     

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.     

Chest wall, lung, and pleural space trauma

Chest radiographs frequently underestimate the severity and extent of chest trauma and, in some cases, fail to detect the presence of injury. CT is more sensitive than chest radiography in the detection of pulmonary, pleural, and osseous abnormalities in the patient who has chest trauma. With the advent of multidetector CT (MDCT), high-quality multiplanar reformations are obtained easily and add to the diagnostic capabilities of MDCT. This article reviews the radiographic and CT findings of chest wall, pleural, and pulmonary injuries that are seen in the patient who has experienced blunt thoracic trauma.     

Computerized tomography in thoracic trauma

Chest CT scans were obtained in 86 patients suffering from serious blunt or penetrating chest trauma. The finding of mediastinal widening was by far the most common CT indication. CT proved to be a more sensitive method for detection of parenchymal lung lesions and occult pneumothorax than bedside radiographs. CT contributed substantially in differentiation of lung abscess and empyema, exclusion of mediastinal pathology and spinal injuries. Aortography is still indicated, even when CT findings are normal if aortic laceration is clinically suspected. Despite all of the technical problems combined with CT examinations in the critically ill patient, we consider CT a valuable diagnostic tool for certain problems in the traumatized patient.     

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.     

The value of thoracic computed tomography in the detection of recurrent Hodgkin's disease

Fifty chest radiographs and concurrent thoracic computed tomography (CT) scans obtained in a total of 44 patients with 50 separate episodes of suspected recurrent Hodgkin's disease were reviewed. Recurrent disease was present in 18 episodes, involving the mediastinum in 12, the lung parenchyma in five and both mediastinum and lung parenchyma in one. In four episodes, mediastinal recurrence was demonstrated on both the chest radiograph and CT scan. In a further two cases, the chest radiograph appeared normal but CT detected recurrence in the mediastinum. In 20 cases, the mediastinal appearances on chest radiography were suspicious but not diagnostic of recurrence, usually because of previous radiotherapy resulting in residual mediastinal widening. Computed tomography diagnosed recurrent disease which was subsequently proven in seven of these cases. Recurrent disease was suggested by CT in a further case, subsequently shown to be radiation fibrosis. Of the 12 remaining chest radiographs in which the mediastinal assessment was indeterminate, CT was true negative for recurrent disease in 10 cases and was also indeterminate in two. Recurrent disease in the lung parenchyma was demonstrated on the chest radiograph and CT scan on five occasions. There was one incident in which the chest radiograph was normal but CT detected recurrent parenchymal disease. The appearances of the lung parenchyma were indeterminate for recurrent disease on three chest radiographs but CT was helpful in only one case in which radiation change alone was diagnosed. In eight cases the diagnosis of recurrent disease by CT resulted in a decision to initiate treatment. Computed tomography is of value in detecting relapse in patients with suspected recurrent Hodgkin's disease when the chest radiograph is inconclusive, and may enable differentiation of radiation change from recurrent disease in the mediastinum.     

Evaluation of the role of chest computed tomography in the management of trauma patients

The role of chest computed tomography (CT) in the management of trauma patients is evolving. The present study reviews the chest radiographic and chest CT findings in a group of trauma patients to determine the clinical impact of findings noted exclusively on chest CT.Fifty-five trauma patients examined with chest radiography and chest CT and whose clinical charts were available for review were retrospectively identified. There were 46 men and 9 women, with a mean age of 39 years. The presence (and size) of pneumothorax, hemothorax, pulmonary contusion, and fractures was tabulated for the chest radiographs and CT scans. The presence of mediastinal widening on chest radiographs and all mediastinal findings on CT were noted. The results of aortography, when applicable, were correlated. The clinical charts were reviewed to assess the impact of CT findings on patient management.Pneumothorax (P<0.05), hemothorax (P<0.05), pulmonary contusions, and fractures were noted more frequently on chest CT than on chest radiography. However, clinical management was affected in only three (5%) of these patients. Chest CT findings related to the mediastinum affected patient management in 13 (24%) patients. CT obviated the need for aortography in 7 of 10 patients with mediastinal widening on chest radiographs. Six other patients had aortography, four for mediastinal hematoma with a normal-appearing aorta on contrast medium-enhanced CT, and two for mediastinal hematoma and aortic injury on CT.Despite detection of significantly more pneumothoraces and hemothoraces on chest CT, clinical management was affected in only a small minority (5%) of cases. CT did prove useful in evaluating the mediastinum, obviating the need for aortography in 7 of 10 patients with a widened mediastinum on chest radiography and accurately diagnosing the presence and site of aortic injury in the two patients with that diagnosis.     

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.     

Classification of parenchymal injuries of the lung

Pulmonary contusion, implying interstitial and alveolar injury without significant laceration, has been accepted as the primary lung injury in nonpenetrating chest trauma. Computed tomographic (CT) findings were compared with those of chest radiography in 85 consecutive patients with chest trauma in which there was a pulmonary radiodensity consistent with pulmonary contusion or patients with a history of severe chest trauma with normal parenchyma despite rib fractures, hemothorax, pneumothorax, or widened mediastinum. CT was found to be more sensitive than radiography in that 151 abnormalities (excluding rib fractures) were demonstrated on radiographs versus 423 abnormalities on CT scans, and 99 lacerations were seen on CT scans versus five on radiographs. Pulmonary lacerations were classified into four types on the basis of CT findings and mechanism of injury: compression rupture, compression shear, rib penetration, and adhesion tears. In these cases, pulmonary laceration was shown to be an integral component of the mechanism of injury in pulmonary contusion, pulmonary hematoma, pulmonary cyst or pneumatocele, or cavitation in pulmonary contusion.     

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     

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.     

Thoracic CT scan in intensive care unit patients: information supplementary to thoracic radiography

PURPOSE: To assess the diagnostic value of thoracic CT-scans in comparison with conventional chest radiographs in ICU-patients. METHODS: Chest radiographs and corresponding thoracic CT-scans of 25 consecutive surgical ICU-patients were reviewed and interpreted independently by two radiologists. We analyzed the additional information provided by CT-scans and the diagnostic and therapeutic relevance of these findings. RESULTS: In 22 patients (88%), thoracic CT revealed 35 single additional findings, in comparison with the corresponding bedside radiographs. In 7 cases (28%), these findings (tube-malpositioning, mediastinitis, mediastinal abscess and pneumothorax) required modification of patient management. Of 7 patients with tube thoracostomy, 3 tubes were malpositioned, which was only depicted on CT-scans. In 10 of 21 cases (48%), pleural effusions could only be visualized by CT. 3 of 5 (60%) pneumothoraces were detected by CT-scans only. There were no significant complications during transport or CT-examination. CONCLUSION: Thoracic CT may provide significant information in addition to plain chest radiographs, particularly when specific problems or questions, referring to the management of ICU-patients, arise.     

Interstitial lung disease in progressive systemic sclerosis: high-resolution CT versus radiography

High-resolution computed tomographic (HRCT) scans and chest radiographs were obtained in 23 patients with progressive systemic sclerosis (PSS) to assess the diagnostic merits of HRCT compared with chest radiography in detecting interstitial lung involvement in these patients. HRCT scans showed interstitial disease in 21 patients (91%). The most frequent finding was the so-called subpleural lines, which were demonstrated in 17 patients (74%). Honeycombing was seen in seven patients (30%), while parenchymal bands were seen in six patients (26%). Chest radiographs, on the other hand, showed definite interstitial opacification patterns in only nine patients (39%); six patients (26%) had equivocal reticular areas of attenuation, while eight patients (35%) had normal chest radiographs. Thus, HRCT is much more sensitive than chest radiography when assessing minimal interstitial lung involvement in patients with PSS.     

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

Preoperative diagnosis of diaphragmatic rupture caused by blunt injury is often difficult because of serious concurrent injuries, a lack of specific clinical signs, and simultaneous lung disease that may mask or mimic the diagnosis radiologically. Previous reports have suggested that a preoperative diagnosis is established on the basis of chest radiographs in only one third of patients. In order to assess the value of chest radiographs and other imaging techniques in diagnosing traumatic rupture of the diaphragm, we retrospectively reviewed all preoperative diagnostic imaging performed in 50 patients with surgically proved hemidiaphragmatic rupture due to blunt trauma. Chest radiographs were diagnostic in 20 (46%) of 44 patients with left-sided rupture and were considered suspicious enough to warrant further diagnostic studies in an additional eight patients (18%). Five patients with initially normal findings on chest radiographs had diagnostic findings on delayed chest radiographs. Chest radiographs were strongly suggestive in only one (17%) of six patients with right-sided hemidiaphragmatic rupture. CT was diagnostic for diaphragmatic rupture in only one (14%) of seven instances in which it was performed. MR was diagnostic in both patients in whom it was performed. Our experience indicates that chest radiographs obtained at admission and repeated soon after are more valuable in suggesting the diagnosis of traumatic rupture of the diaphragm than previously reported, particularly in the more frequent, left-sided injuries. This increased sensitivity may be due to a greater level of suspicion maintained in a trauma referral center in which this injury is not uncommon.     

The role of computed tomography in gunshot lesions of the chest. The authors' personal experience

PURPOSE: CT is a valuable tool in assessing thoracic gunshot wounds. CT is also the method of choice in emergency, because it permits rapid depiction of bullet damage to the chest and to other body districts. This in turn permits correct assessment of the main thoracic injuries, plus adequate and prompt planning of surgical treatment or support intensive care. We report on the role of CT in diagnosing the complex pleuropulmonary, cardiovascular and thoracic wall injuries caused by gunshot wounds, with their specific and acute signs which differ greatly from those of other types of chest trauma. MATERIAL AND METHODS: In the last 4 years, we observed 76 cases of gunshot injury, twenty-six of them involved the chest. The patients, 25 men and 1 woman (mean age: 32 years, range: 17-48), were all submitted to emergency CT with i.v. contrast agent injection and the CT-angiography technique. The reanimator was always present to monitor the patients' vital functions and shock state. CT of the chest was integrated with CT of the abdomen and pelvis in 4 cases and with CT of the skull in 3 cases, to detect associated bullet wounds if any. RESULTS: The most frequent CT finding was lung parenchyma tear and bruise (25 cases), followed by hemothorax (18 cases) and subcutaneous chest wall emphysema (9 cases). Pneumothorax was seen in 5 cases, associated with hemothorax in 6; rib injuries were found in 7 cases; pneumomediastinum was found in 4 cases and areas of pulmonary atelectasis in 3; the diaphragm was ruptured in 4 cases. CT showed spinal involvement in 11 patients, with injury of D3 and D5 in 4 and 3 cases, respectively; signs of interrupted spinal marrow were found in 7 cases. Damage from gunshot wounds was detected in the liver, spleen, skull and limbs in 3, 2, 3 and 10 cases, respectively. DISCUSSION AND CONCLUSIONS: Chest radiography shows major gunshot wound damage to the chest and lungs, except for heart injuries and minimal pneumothorax. When abdominal and skull injuries are associated, CT should be the method of choice because it permits prompt and panoramic assessment of the severity of pulmonary and extrathoracic damage. This results in prompt and targeted treatment, avoiding unnecessary delays which may damage the patient further.     

Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries

OBJECTIVE: The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography. MATERIALS AND METHODS: The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared. RESULTS: Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800. CONCLUSION: Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.     

The radiological diagnostic and clinical approach to the patient with stab and cut wounds of the chest. The authors' personal experience

PURPOSE: To report our personal experience with the clinical and radiological diagnostic approach to stab and cut wounds of the thoracic cage and its content, a type of injury whose diagnosis and treatment, as well as the surgical approach, vary case by case. CT of deep penetrating wounds permits correct assessment of severe changes such as pneumothorax, hemothorax and pneumomediastinum. MATERIAL AND METHODS: In the last three years we examined 57 patients (48 men and 9 women; mean age 34 years, range 16-54): chest radiography was performed in 51 of them, with orthogonal projections in the standing and sitting positions. Chest CT was performed in emergency with i.v. contrast agent injection, with scans from the midneck to the diaphragm insertion to study border regions. Thoracostomy with pleural drainage was performed in 35 patients with pneumothorax and hemothorax while thoracotomy was performed in 8 patients, namely 4 with injury to the diaphragm, 2 to the heart, 1 with tear of the main bronchial artery and 1 of the aortic arch. RESULTS: The most frequent symptoms we found were chest pain (100% of cases) and dyspnea (84%); laboratory data showed anemia and decreased hematocrit levels in 28 cases. Chest radiography was negative in 14 cases. The patients were then examined with CT to exclude radiographic underestimation of minimal pneumothorax, small lacerocontusive or hemorrhagic foci and hemothorax, which were observed in 4, 2 and one cases, respectively, and where radiography was actually negative for traumatic changes. Chest radiography was positive in 43 cases: the most frequent finding was pneumothorax, with 37 cases (86%)--8 of them associated with hemothorax and 5 with pneumomediastinum. Lacero-hemorrhagic foci of lung parenchyma were found in 5 cases and single pulmonary hematoma from punch crossing was seen in 1 case. DISCUSSION AND CONCLUSIONS: CT was an accurate tool and had higher sensitivity than chest radiography in detecting and detailing pneumothorax, pneumomediastinum and lacero-hemorrhagic foci, as well as in quantifying hemothorax. Chest radiography had 12% false negatives and therefore we decided to perform CT in all the patients with penetrating wounds to prevent radiographic underestimation. Given the low rate of false negatives (7/57 cases) CT might appear superfluous but since in 2 of these 7 cases we had massive pneumothorax and pneumomediastinum associated with neck emphysema we suggest its use to prevent complications, clinical failures and medicolegal problems. CT permits correct assessment of penetrating stab and cut wounds of the chest and efficient and targeted treatment, which can be conservative, with thoracostomy with pleural drainage, or surgical.     

Is there need for thoracic spine radiographs following a negative chest CT in trauma patients?

The purpose of this study was to assess the need for conventional radiographs of the thoracic spine for routine clearance of trauma patients in whom chest CT has revealed no spinal trauma. The study was in the form of a retrospective review of trauma patients over the previous five years who underwent conventional radiographs of the thoracic spine following a chest CT that revealed no spinal trauma. Two hundred thirty-five trauma patients were found to have undergone conventional thoracic spine series following a chest CT that showed no spinal trauma. In 234 of the cases, the thoracic spine series was also negative. In one case, the thoracic spine series revealed mild anterior compression of the T7 vertebral body. This injury was stable and required no specific intervention. CT of the chest is an adequate evaluation of the thoracic spine in trauma patients who require routine thoracic spine clearance, making subsequent conventional radiographs of the thoracic spine unnecessary. Electronic Publication