Multidetector CT of Blunt Thoracic Trauma

Introduction
Thoracic injury is significant cause of morbidity and mortality in trauma patient Account for 25% trauma-related death in United States Radiologic imaging plays an important role in the diagnosis and management of blunt chest trauma

Introduction
3rd most common injuries in trauma patients(1st:head, 2rd:extremity) Cause 1.motor vehicle ->more than 2/3 in developed countries 2.falls or of blows from blunt object Imaging
Conventional radiography: initial imaging CT: significant disease

Introduction
Injuries of 1.Pleural space 2.Lungs 3.Airways 4.Heart, aorta and great vessels 5.Diaphragm 6.Chest wall

Injuries of the Pleural Space

Pneumothorax
Air collection in pleural space Very common 15%40% of all blunt chest trauma Mechanism ->ruptured alveoli due to sudden increase in intrathoracic pressure (with or without rib fracture) Occult pneumothorax Tension pneumothorax

Occult pneumo thorax

Tension pneumot horax

Injuries of Pleural Space

Hemothorax
Blood in pleural space Massive hemothorax is defined as a hemothorax exceeding 1liter with clinical signs of shock and hypoperfusion CT : pleural fluid with attenuation of 3570 H.U.

Measurement of pleural fluid attenuation should be routine in interpretation of chest trauma CT to distinguish simple fluid from acute blood

Injury of lung
Pulmonary Contusion
Traumatic injury to alveoli with alveolar hemorrhage, but significant alveolar disruption(-) Most common 17%70% of all blunt chest trauma Occurs at the time of injury, usually at the site of impact Resolution of pulmonary contusion typically begins within 24-48hours, with complete clearing in 3-10days

Injuries of Lung

Pulmonary Laceration Disruption (tear, laceration) of lung parenchyma, resulting in a cavity in lung -Because of normal pulmonary elastic recoil, lung tissue surrounding a laceration pull back from the laceration itself.

-This results in the laceration manifesting at CT as a round or oval cavity

->Divide into 1.Traumatic pneumatocele 2.Traumatic hematocele 3.Traumatic hematopneumatocele ->Common in children & young adults - greater flexibility of chest wall

Traumatic lung herniation

Occurs when a pleura-covered part of the lung extrudes through a traumatic defect in the chest wall Usually associated with rib fracture May increase with positive-pressure ventilation

Injury of the airway

Tracheobrachial injuries are rare in clinical practice because most patients die before arriving at the emergency department Tracheobronchial injuries - 0.2%8% of all cases of blunt chest - usually occur within 2.5 cm of carina

Injuries of Airways
Bronchial(*) & Tracheal(#) Laceration
Pneumomediastinum(*,#) pneumothorax(*) cervical subcutaneous emphysema(#) Presence of a persistent pneumothorax Even with chest tube placement & suction - concern for possible bronchial injury

Bronchial injury

Tracheal injury

Injuries of Heart
Cause: motor vehicle collisions
- from contusion to frank rupture - most lethal injuries

Diagnosis of blunt cardiac injury

Relies on a high degree of clinical suspicion Imaging manifestations - hemopericardium - contrast material extravasation - pneumopericardium - displacement of heart (cardiac herniation) - abnormal bowel gas in chest (diaphragmatic pericardial tear)

Blunt cardiac injury

Injury of the aorta and great vessels

Thoracic Aortic Injury Usually fatal Accounts for 10%-15% of death following motor vehicle collisions in the United States 85% and 90% of patients die before reaching hospital Most common cause:motor vehicle collosions

Injuries of Aorta and Great Vessels

Periaortic hematoma accompany thoracic aortic injury and is believed to represent bleeding from small veins

Periaortic hematoma Conventional radiography - false-negative CT: - direct visualization of periaortic hematoma - show actual aortic injuries

Traumatic pseudoaneurysm of the proximal descending thoracic aorta

Distal descending thoracic aortic injury

Injuries of Diaphragm
0.16%5% in blunt trauma Mechanism:
Sudden increase in intraabdominal or intrathoracic Pr. Posterolateral surface of hemidiaphragm

Injuries of the chest wall

Rib fracture -The most common skeletal injury in blunt chest trauma -Occurs in approximately 50% of patients -Multiple or bilateral rib fracture may indicate more severe thoracic injury

Injuries of Chest Wall

-fractures of the first through third ribs : associated with brachial plexus injury or subclavian vascular injuries -Fractures of the lower three ribs : associated with liver, spleen, & kidney injuries

 Flail Chest
-Three or more contiguous ribs with fractures in two or more places -Usually occurs anterior and anterolateral portions of middle to lower ribs -Theses fracture create a flail segment that can move paradoxically relative to the remainder of the chest during respiration

 Serves as a marker for significant intrathoracic injury, since more than onehalf of affected patients may have associated injuries requiring sirgical treatment These patients often require mechanical ventilation for prolonged period

Rib fractures and flail chest

 Sternal fracture -May result from direct blow of the anterior chest wall -Marker for high energy trauma -Best demonstrated at CT on multiplanar reformatted images, especially sagittal images