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Imaging of Thoracic Injuries 2.6 Chapter Imaging of Thoracic Injuries 2.6 G. Gavelli, G. Napoli, P.Bertaccini, G. Battista, R. Fattori Contents Since the chest X ray is essential in providing informa- tion regarding life-threatening conditions, such as tension 2.6.1 Introduction . 155 pneumothorax, hemothorax, flail chest, and mediastinal 2.6.2 Clinical and Imaging Findings . 156 abnormalities, the radiologist must have deep knowledge 2.6.2.1 Chest Wall Injuries . 156 of the possibilities and limits of this modality, which may 2.6.2.2 Parenchymal Lung Injuries . 159 not point out, or may underestimate, all these conditions. 2.6.2.3 Extra-alveolar Air . 162 2.6.2.4 Pleural Effusion and Hemothorax . 163 Poor-quality radiographs are, therefore, not acceptable 2.6.2.5 Tracheobronchial Injury . 164 especially when it becomes difficult or impossible to ex- 2.6.2.6 Thoracic Esophageal Disruption . 165 clude life-threatening conditions and an alternative imag- 2.6.2.7 Diaphragmatic Injury . 166 ing study should be performed. 2.6.2.8 Blunt Cardiac and Pericardial Injury . 169 2.6.2.9 Traumatic Aortic Injury . 169 In selected cases, it could be very useful to perform an additional lateral radiograph with horizontal incidence of 2.6.3 Conclusion . 175 the ray because the evaluation of pleural effusion, pneu- mothorax, and the identification of sternal fractures may References . 176 be easier. As mentioned previously, a CT study must be per- formed in all chest trauma patients in whom there is even the smallest diagnostic doubt on plain film. 2.6.1 Introduction Computed tomography has come to assume an increas- ingly important role in the evaluation of patients with Traumatic injuries are the fourth cause of death in the known or suspected chest injuries. Chest CT is much more United States and in Western Europe, and the first cause of sensitive and accurate than chest plain film in the detection death in population less than 45 years old. Thoracic trau- of almost all thoracic lesions, particularly those involving ma, which more frequently is a blunt trauma (70%), repre- vessels, heart, pericardium, airways, mediastinum, and sents 10–15% of all traumas and is responsible for 25% of chest wall, including the spine and diaphragm. fatalities due to traumatic injuries. Moreover, CT depicts more accurately the presence and The mortality rate of chest trauma ranges from approx- the real extent of lung involvement as well as the entity imatively 15.5 to 77% if shock and head injuries (Glasgow of pneumothorax and/or pleural effusion, and has been score 3–4) are associated. shown to determine an impact on therapeutic treatment in The accurate diagnosis of injuries related to thoracic a significant number of patients. chest trauma depends on a complete knowledge of the dif- The recent introduction of multi-detector row CT ferent clinical and radiological manifestations. Even though (MDCT) has represented a real revolution in non-invasive it is well known that it is less sensitive and accurate than evaluation of trauma patients offering many advantages in computed tomography (CT), chest radiography, usually per- the imaging work-up strategy of these patients. The re- formed on supine position at the moment of hospital admis- markable increase of acquisition speed, together with the sion,represents the first diagnostic approach to patients sus- possibility of a thinner collimation, provides a higher qual- taining blunt chest trauma. Moreover, many patients have ity of the study, minimizing the motion artifacts and allow- very unstable clinical conditions which make it difficult to ing the scanning of the same or larger volume of interest in bring them to the radiology department, and therefore a less time with an increased temporal and spatial resolu- chest X-ray, performed at the bedside of the patient with tion. Such relevant increase in spatial resolution has also a limitations due to poor positioning, poor inspiration, or ar- great impact on post-processing multiplanar 2D and 3D re- tifacts related to overlying monitoring equipment, can be formations and volume-rendered images, often improving the only diagnostic tool in the evaluation of such patients. the final diagnosis. 156 G.Gavelli,G.Napoli,P.Bertaccini,G.Battista,R.Fattori Moreover the faster acquisition reduces the amount of Finally, fracture of the lower ribs (IX–XII) can be asso- contrast material needed to study both vascular structure ciated with traumatic lesions of liver, spleen, and kidneys. and parenchymal organs. Rib fractures are often accompanied by focal extra- For all these features, computed tomography of the pleural hematomas, which can be seen as a bulging of the chest is being increasingly used in the routine work-up of soft tissue density convexly bordering the lungs. the trauma patients, which often includes scans of the An apical extrapleural hematoma which increases in brain and the abdomen. dimensions is highly suggestive of active arterial bleeding Magnetic resonance imaging, despite some advantages and requires further investigation and eventually angio- (i.e., lack in ionizing radiation, no need for iodinated con- graphic intervention. trast medium), still has a limited role in evaluation of chest Flail chest, the most severe lesion of the thoracic wall trauma, and angiography is being used less and less. found in blunt chest trauma,is caused by a fracture of three The use of ultrasound at the bedside of the patient is or more ribs in at least two different sites (Fig. 1). A para- still not well defined in the study of the traumatized pa- doxical movement of this flail segment of the thoracic wall tients. occurs during respiratory cycle, which favors the onset of In the present chapter we present the principal radio- atelectasis and hinders physiological drainage of the logical features which can be reported in patients who sus- bronchial secretions. This situation can lead to respiratory tain blunt chest trauma. failure, especially if parenchymal injuries are associated, requiring intensive respiratory therapy. The resulting morbidity and mortality rates depend on the age of the patient and the extension and gravity of the 2.6.2 Clinical and Imaging Findings thoracic lesions associated (contusions and/or parenchy- mal lacerations, atelectasis, mediastinal lesions, hemotho- 2.6.2.1 Chest Wall Injuries rax, pneumothorax, and associated extrathoracic lesions). In 8–10% of blunt chest traumas, sternal fractures are Rib fractures are the most common finding after blunt found. It is a marker of a high-energy trauma and is related chest trauma, with an incidence reported up to 40%. Chest to a direct impact from the steering wheel or to the use of radiograph has a low sensitivity (18–50%) in detecting rib seat belts. The most common site of the sternal fractures is fractures, and it is even more insensitive in showing costo- approximately 2 cm down from the manubrio-sternal joint chondral fractures (Primak and Collins 2002; Tocino and (Figs. 2, 3). Sternal fracture usually cannot be diagnosed on Miller 1987). frontal chest radiographs, whereas the lateral projections Fractures of the ribs rarely have particular clinical sig- can detect it with high sensitivity. nificance but they are an indicator of the severity of trau- Sternal fractures, especially those with dislocation of ma, especially in old patients with non-compliant chest the “bony stump”(so-called displaced sternal fracture),can wall. In fact, in elderly patients, complications occurs more cause vascular lesions, mediastinal hemorrhage, and car- frequently as the number of fractures increase, with a rela- diac contusions, and therefore, carry a mortality ranging tive increase in mortality (Sirmali et al. 2003). from 25 to 45%. It is also very important to remember that, on the con- Spiral CT, with sagittal and coronal reformations, trary, children’s and young patients’ ribs are more flexible, should be the examination of choice in the suspicion of so the absence of rib or other skeletal injuries can be mis- sternal fracture, because it identifies with high accuracy leading since even severe trauma can occur without chest both the fracture, especially that with minimal dislocation wall lesions (Sirmali et al. 2003). often unrecognized on conventional radiographs, and the In the majority of cases, ribs from IV to IX are involved associated lesions. after chest trauma.Fractures of the first two or three ribs and Inspection and palpation (Shanmuganathan and Mirvis of the clavicle indicate a violent trauma since they are thick- 1999) generally suggest the presence of sternoclavicular er and well protected by the thoracic muscles and can cause fracture. lesions of the brachial plexus or the supra-aortic vessels An anterior fracture, the most common, generally (3–15%; Fermanis et al. 1985). Study of the subclavian ves- has no clinical significance, whereas a posterior fracture sels must be carried out in emergency when bone fragments of the parasternal tract of the clavicle can cause lesions of are widely dislocated, when there is evidence of mediastinal the brachiocephalic vessels, nerves, esophagus, and tra- hemorrhage, extrapleural hematoma, and if neuropathy of chea. the brachial plexus can be clinically demonstrated. A scapular fracture is indicative of a high-energy trau- Moreover, these fractures are frequently associated with ma, since it is protected by the surrounding muscles. other chest lesions, and in particular, more than 90% of Scapular fracture is missed on chest radiograph in up to tracheobronchial lesions are associated with fractures of at 43% of cases, and 72% of these fractures are visible evalu- least one of the first three ribs. ating retrospectively the initial radiographs. Chapter 2.6 Imaging of Thoracic Injuries 157 Fig. 1. Blunt trauma with chest wall injury. Supine chest X-ray shows multiple rib fractures in different points on the right (flail chest) with ipsilateral hemothorax and hematoma of the soft tissues surrounding the more cranial fractures Fig.
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