Journal Reading

CHEST RADIOGRAPHY IN
THORACIC POLYTRAUMA
Disusun Oleh :
Winda Chandra (406152082)

Pembimbing :
dr. Luh Putu Endyah Santi Maryani, sp.Rad

Kepaniteraan Klinik Ilmu Radiologi

RSUD K.R.M.T Wongsonegoro Semarang
Fakultas Kedokteran Universitas Tarumanagara
INTRODUCTION
Chest radiography is the first line imaging examination in patient with
thoracic polytrauma. (to examine mediastinum, lung, pleura, heart,
aorta, and chest wall)
Chest radiography is feasible to be performed in this case
Obtained with posteroanterior and lateral view
Manifestations are diverse, depend on the mechanism of trauma
(blunt or penetrating)
NORMAL CHEST X RAY
SOFT TISSUE (CHEST WALL)
SUBCUTANEOUS EMPHYSEMA
Presence of air in the extrathoracic tissues
Can result from : chest wall infection, blunt trauma of GI
& respiration system, and penetrating injuries.
Chest x-ray radiograph shows : GINKGO LEAF Sign
The air can spread to chest wall, abdomen, head,
neck and even to extremities.
 SUBCUTANEOUS HEMATOMA
Produced by accumulation of blood in the soft tissues.
Result from damage to thoracic vessels, muscles, or ribs
during BLUNT or PENETRATION TRAUMA.
Frontal chest radiography shows
RADIODENSE OPACITY overlying
chest wall.

[Patients with superficial anterior

chest trauma CT confirmed
subcutaneous hematoma]
BONES (CHEST
SCAPULOTHORACIC DISLOCATIONWALL)
(FLAIL SHOULDER)

Occurs when strong forces pull the shoulder girdle away from the thorax
muscle, vascular, and nerve injury

Radiographs shows scapular dislocation. (can be followed by edema,

hematoma)
 CLAVICLE FRACTURE common in trauma patients, generally minor clinical significance

STERNOCLAVICULAR DISLOCATION OR FRACTURES identified on angled chest radiographs

occur after severe shoulder trauma

posterior dislocation may injure the mediastinal organs and great vessels
require closed or surgical reduction

CLAVICLE FRACTURE STERNOCLAVICULAR DISLOCATION

 UPPER RIBS Rare, suggest severe damage to the
great vessels and brachial plexus

RIB FRACTURES

LOWER RIBS Involves damage to upper abdominal

organs

Ribs fracture can lead to : laceration of pleura & lung, pulmonary

hematomas, hemothorax, or pneumothorax.
 Rib fracture can cause FLAIL CHEST if :
At least FIVE contiguous fractures or THREE adjacent SEGEMENTAL rib
fractures are present.
Posterior flail segments may not cause serious complication
Anterior and lateral flail segments can severely impaired respiratory
function atelectasis or infections
Positive ventilation or surgical fixation for stabilization is required.
 STERNAL INJURIES require lateral view of
radiograph.
Surgical intervention unnescessary, healing
occurs in several weeks.
 SPINAL INJURIES caused by compression injury.
Frontal chest radiograph Lateral view radiograph

Widening of paraspinal lines Angulation of thoracic spine, Focal disc narrowing MRI
Paraspinal hematomas Adjacent wedge compression shows diskitis with abscess
fracture formation.
 DIAPHRAGM
Rupture diaphragm hemidiaphragm elevation; stomach,
liver, spleen, and colon may herniate to thoracic cavity
Associated findings : basilar lung opacities, irregular
diaphragmatic contour, lower rib fractures.
Rupture diaphragm can lead to PNEUMOPERITONEUM.

Multiple masses of left ribs Collar Sign

causes ruptured Cottage Loaf Sign
hemidiaphragm
PNEUMOPERITONEUM

Cupola sign Rigler sign

 PLEURA
PNEUMOTHORAX

Open Skin and pleura are injured by Treatment : immediate closure

penetrating traumas. & chest tube
(sucking chest wound)

Laceration of pleura caused Chest tube placement

Closed
by blunt trauma (rib fracture)

Permits air to entry but not Lung collapses +

Tension
Exitting Compression of contralateral lung & mediastinum
Visceral pleural line

Deep sulcus sign Double diaphragm sign

 TENSION
PNEUMOTHORAX
 HEMOTHORAX
laceration or
Chest radiographs:
Simple Vascularisation rupture
Similar to hydrothorax
caused by blunt/penetrating trauma

Complicated by infection
Chronic
(empyema), chest wall
erosion and fibrosis.

Tension Massive intrathoracic bleeding compressed ipsilateral lung + mediastinal shift

CYLOTHORAX results from damage to the thoracic duct caused by thoracocentesis.

CT can distinguish cylothorax, hemothorax, hydrothorax, and pyothorax.

Massive hemothorax with
mediastinal shift Patient with chronic empyema.
CT confirmed (pleural effusion with chest wall
attenuation 50 HU defect)
(hemothorax)
 LUNG PROTRUSION or HERNIATION tears of the
cervical, intercoastal, and diaphragmatic fasia.
Treatment conservative treatment unless
strangulation or incarceration occur.
Left sided lung herniation (both on CT and Xray)
 LOBAR ATELECTASIS caused by obstruction,
aspiration, or bronchial rupture.

Luftsichel sign
Juxtaphrenic peak
Superior triangle sign
 PULMONARY CONTUSION leakage of blood and
edema into the interstisial and alveolar spaces.
Chest radiographs ground glass opacification,
adjacent to bony structure
Lesions are evident within 6 hrs after trauma, resolve
within 5-7 days.
 PULMONARY LACERATION severe injuries involving disruption of
lung architecture.
Caused by : ruptures of organs and foreign body trauma that can
introduce air (pneumatocele), hematoma, and abscess.
Usually resolve in weeks or months and chronic scarring may develop.

Source: radiopaedia.org

Source: radiopaedia.org
 ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Can develop secondary to a variety insults : trauma, infection, shock,
aspiration, transfusion, and drugs.
Damaged alveolar-capillary barrier influx of fluid into the alveolar
space diffuse bilateral patchy lung opacities.
Imaging DD : atelectasis, aspiration, fat embolism, pneumonia,
alveolar pulmonary edema, and hemorrhaga.
 MEDIASTINUM
PNEUMOMEDIASTINUM presence of air in the mediastinal structures. (blunt
or penetrating trauma)
result from penetrating or blunt pharyngeal, tracheobronchial, or
esophageal injury.

Naclerios V sign
Continuos diaphragm sign
Thymic sail sign
Ring around the artery sign
 MEDIASTINAL BLEEDING mediastinal widening and
irregularity caused by vascular injury
 MEDIASTINITIS esophageal rupture and foreign body
injury.
Radiography findings edema, hemorrhage, gas
production in mediastinal, cervical soft tissues, pleural
effusions, and lower lobe consolidation
 TRACHEOBRONCHIAL INJURY lacerations due to
penetrating trauma and ruptures from blunt injuries,
esp when glottis is closed.
Injury to the chest wall, lungs, and great vessels is also
present.
transversal tears between cartilagenous tracheal rings
caused Pneumomediastinum, hemorrhage, and
pneumothorax

A B C
 ESOPHAGEAL INURIES caused by violent vomitting
(Boeerhave syndrome), penetrating injury or bone
forces in blunt trauma.
Most esophageal tears are located in the cervical and
upper thoracic regions and present with pleural
effusions.
Radiologival findings pneumomediastinum, widened
parasternal line, and retrocardiac lung opacification.
CT oral extravasation and esophageal thickening.
patient with boerhave syndrome + pneumomediastinum
 HIATAL HERNIA result from blunt or penetrating
trauma, with the stomach prolapsing through the
diaphragmatic esophageal hiatus.
Radiological findings retrocardiac structure filled with
gas and/or fluid, represnting in the intrathiracic
stomach.
No intervention is necesarry unless incarceration and
strangulation occurs.

woman with hiatal hernia, retrocardiac space opacity

PERICARDIUM
PERICARDIAL TEARS result from severe blunt injury or
penetrating trauma.
Radiological findings snow cone sign,
pneumomediastinum, and pneumothorax.
CARDIAC HERNIATION caused by large
pleuropericardial or diaphragmatic ruptures. (shift of
cardiac silhouette)
Cardiac herniation can predispose to cardiac volvulus
with obstruction of great vessels and requires
immediate surgical repair
Convexity at normal location of main pulmonary artery
CT confirmed pericardial tear with cardiac herniation
Lefyward shift of heart silhouette
CT confirmed pericardial rupture
complete rotation of heart silhouette with apex pointing toward right
 PERICARDIAL EFFUSION organ and vascular ruptures
may introduce fluid into the percardial cavity.
Contains transudation (hydropericardium), exudative
(pyopericardium), hemorrhagic (hemopericardium)
fluid.
Water bottle sign Oreo cookie or stripe sign
 PNEUMOPERICARDIUM air located within the
pericardial cavoty and external to the rest of the heart.

Halo sign Transverse band of air sign

 Small heart in pneumocardium, marked compression of
the heart with a decreased ctr may be visiblle
 CARDIAC TRAUMA
MYOCARDIAL CONTUSIONS rupture of
intramyocardial vessels after severe cardiac trauma.
Radiological findings (chest x-ray) chest wall
hematomas and cardiomegaly due to hemopericardium.
Myocardial stunning CHF pulmonary edema
visualized on the chest x-ray
Associated findings skeletal fractures and pulmonary
contusions.
 CARDIAC ANEURYSMS focal outpouchings in the septal of free
walls of the cardiac chambers (severe blunt trauma)
Mostly seen in the left ventricular anterior wall or apex
Should be monitored carefully bcs of increased risk of rupture

Rounded opacity continuos with the cardiac silhouette

CT confirmed left ventricular aneurysms
 CARDIAC RUPTURE can be seen in blunt and penetrating
trauma
Mostly affects the right ventricle.
Hemopericardium and Pericarditis ruptures of the
free wall and fistulization to adjacent organs
Radiologic findings irregular shadows, pulmonary
edema, pleural effusion

Pulmonary edema, ct confirmed rupture of

Mitral valve
 MYOCARDIAL INFARCTION coronary artery injury and
occlusion
Radiological findings pulmonary edema secondary to
CHF, myocardial thinning, fibrosis and calcification

Calcification of the left ventricular walls

 AORTA
TRAUMATIC AORTIC INJURY spectrum of injuries
caused by blunt aortic trauma which produces
differential deceleration of thoracic sturctures with
associated solid and fluid mechanical effects.
Location : aortic isthmus, ascending aorta.
Forces affecting the aortic isthmus shearing stress,
bending stress, osseous pinch.
Another possible injuries aortic tearing.
Immediate open surgical repair is advised.
 Indirect radiographic sign of Traumatic Aortic Injury
- Mediastinal widening
- Irregularity of the aortic contour
- Opacification of the aortopulmonary window,
- depression of the left mainstem bronchus, rightward tracheal and
esophageal deviation
- Widened paratracheal and paraspinous stripes
- Hemothorax
 Mediastinal widening, obscuration of aortic contour,
And opacification of aortopulmonary window.

Calcified aortic intima (Ring sign)

 TRAUMATIC AORTIC ANEURYSMS localized dilatation
of the aorta involving all three arterial wall layers and
are susceptible to rupture
Open surgery is recommended for ascending aortic
aneurysms that are symptomatic, rapidly expanding, or
> 5.0 5.5 cm.
Patient with post-traumatic aortic aneurysms enlarged and
tortuous aortic silhouettes.
 GREAT VESSELS (VASCULAR TRAUMA)
Mostly (90%) caused by penetrating trauma.
In blunt injury the aortic branch, venae cavae, and
pulmonary veins.
Complication formation of local hematomas and
hemopericardium.
Surgical intervention is indicated to maintain the
integrity of cardiovascular circulation.
Widening of superior mediastinum, suggestive of hematoma
PULMONARY ARTERIES (GREAT VESSELS)
PULMONARY EMBOLISM hypercoagulability and immobilization
predispose to deep venous thromboses, which can circulate to the
pulmonary arteries.
Can cause inflammation, hypoxemia, hemodynamic compromise
with cor pulmonale, and pulmonary infarction with regional loss of
surfactant.
Radiographic findings (nonspecific) cardiomegaly, atelectasis,
pulmonary edema, pleural effusions
Radiographic findings Westermark sign, Fleischner sign, Palla sign,
and knuckle sign, hampton hump sign
More definitive test for PE ventilation perfusion angiography, CT
Lobar atelectasis of right lung
Pulmonary edema
Peribronchial cuffing
Batwing sign
Fleischner SIgn Arrows: Palla sign & asterisks: Knuckle sign
 Septic embolism occurs when infected material from organ rupture
or foreign body ijury travels to the lungs.
Treatment requirres AB therapy and possible thoracentesis

Diffuse patchy nodular opacities in

Septic embolism.
 Air embolism ruptured organs or penetrating injury affecting the
systemic venous circulation, can also caused by barotrauma.
Radiological findings hyperlucent areas in the right heart,
pulmonary arteries, and systemic veins.
 Fat embolism trauma to the long bones and pelvis that can release
fat particles and occlude capillaries.
Radiologic findings diffuse parenchymal opacities (similar to ARDS)
Management is supportive, and the condition takes 7-10 days to
resolve.
 Pregnancy is a known risk for thromboembolic disease.
Affected patient should be treated with Heparin.
Radiological findings diffuse bilateral opacities (indistinguishable
from PE, Hemorrhage, and pneumonia)
Prognosis poor,; caesarean delivery should be performed.
 Foreign body embolism fragmentation of foreign bodies that may
travel through the arterial or venous circulations and become lodged
in distal sites.
Mortality depends on the location, duration, and severity of emboli.
CONCLUSION
Chest radiography plays an important role in the initial evaluation of
blunt and penetrating chest trauma.
In emergency department, familiarity with the spectrum of injuries
that can occur in the chest and upper abdomen is important for
accurate interpretation and management + follow ups.
Understanding the pathophysiology of trauma and the imaging
findings of chest xray will enable radiologists to interact rapidly with
the other members of the health care team.