Hondo Supeno, M. D.

Blunt Chest Trauma (BCT)

Seen in about of blunt trauma cases
~20% of trauma deaths attributable to BCT
Etiology: typically deceleration injury
Radiographic evaluation should begin
immediately after initial trauma team assessment
Initial study usually supine chest
CT for aortic, pulmonary, airway, skeletal, diaphragm

injury
Limited role for MRI

Pneumothorax
~20% of patients with penetrating trauma
30-40% of patients with BCT
Usually small but potential for problems with

mechanical ventilation or GA
Pleural air will rise to non-dependent portions of the
lung:
Upright Apex

Supine

anterior/caudal

Pneumothorax
Supine Signs (CXR)
1. Deep sulcus sign = deep lucent costophrenic
sulcus
2. Increased lucency at effected lung base
3. Double diaphragm sign ventral and dorsal
portions of PTX adjacent to anterior and
posterior aspects of hemi-diaphragm
CT: PTX seen in 10-50% of pts with neg. CXR in head or
BCT

Deep Sulcus Sign

Tension Pneumothorax
High intrathoracic pressure causes decreased cardiac

filling
Compression of ipsilateral lung
Displaced mediastinum away from PTX
Kinking of the great vessels can lead to hemodynamic
collapse

Tension pneumothorax
Air leak through lung or chest wall

One-way valve lung collapse

Mediastinum shifts to opposite side
Inferior vena cava kinks on diaphragm

decreased venous return cardiovascular

collapse

Inferior vena cava

Tension PTX

Pulmonary Parenchymal Injury

Contusion
Laceration
Hematoma

Contusion

Def: Edema and alveolar/interstitial hemorrhage

30-70% of BCTs, Mortality = 25%
Assoc. with multiple rib fractures and flail chest
Occurs in children and young adults w/o associated
rib fracture
Usually develops within 6 hrs and resolves in 2-3
days

Contusion
Findings: CT and CXR
Non-segmental consolidation usually in lung periphery,
adjacent to area of trauma
CT is far more sensitive than CXR
DDX of opacification = aspiration, atelectasis, cardio-

and non-cardiogenic edema

Contusion
Pulmonary Contusion
Focal areas of consolidation representing areas of edema, and

parenchymal hemorrhage.
Nonsegmental consolidation usually in the periphery and
adjacent to chest wall trauma.
Usually resolves in 2-3 days.
Must be differentiated from aspiration, atelectasis, and
pulmonary edema.
Best characterized on CT scan.

Zinck SE, Primack SL. Radiographic and CT Findings in Blunt Chest Trauma. Journal of Thoracic Imaging. 15(2) pp 87-96 2000

Pulmonary Contusion

Contusion

Laceration
Def: disruption of alveolar spaces with

formation of a cavity filled with blood/air

Etiology: penetrating trauma or shear forces
Often obscured by assoc. hematoma
Findings on CT:
Swiss Cheese - Air collections within area of

consolidation
Ovoid air spaces surrounded by 2-3 mm of
pseudomembrane

Laceration with Pneumatocele

Hematoma
Due to complete filling of laceration cavity with

blood
Finding: well circumscribed, round nodule
May see air fluid levels as resolves

Traumatic Pneumatocele = air-filled cystic space

following acute laceration or resolution of

pulmonary hematoma

Pulmonary hematoma

Pneumatocele

Pulmonary Contusion with

pneumatocele

Blunt Cardiac Injury (BCI)

Occurs in 8-71% of BCT
80-90% of BCI is immediately fatal
70-80% of patients with BCI have external signs of

chest trauma
Sternal fracture does not predict BCI
Usual site is right ventricle
Can lead to hemopericardium

Hemopericardium

Hemopericardium
with tamponade

Great Vessel Injury

Deceleration vascular injury
81% Aortic rupture alone
16% aorta and branches
Left subclavian 38%, Bracheocephalic 21%, R subclavian 16.5%, L
common carotid 16.5%, Vertebral 8%
3% only branches

Concern for branch injury if perivascular superior

mediastinal or low cervical hematoma, especially

in the presence of upper rib fractures

Thoracic Aorta Injury

90% lethal before receiving emergency care
Usually a transverse laceration of part or all of
aortic circumference
60% have adventia intact = pseudoaneurysm
Injury to root or ascending aorta is nearly 100%
fatal
~90% occur at aortic isthmus just distal to left
subclavian
4-10% of cases have concomitant great vessel
injury

Aortic Injury
Findings on CXR suggestive of Aortic Injury
Wide Mediastinum traditionally >8 cm
Increased opacity of right paratrachial stripe
Loss of distinction of Aortic Arch
Rightward deviation of trachea and NG tube
Downward deviation of Left main bronchus >40-45

degrees
Left apical cap

Beware the Wide Mediastinum

Multiple Causes of simple widened mediastinum
besides trauma.
Full SVC = adequate fluid resuscitation
Mediastinal Fat
Patient positioning
Magnification due to change in x-ray plate positioning

Look for indirect signs of mediastinal hematoma

listed on previous slide. Traumatic aortic injury
rarely occurs without mediastinal hematoma.

Thoracic Aorta Injury

Initial study frontal chest radiograph
Normal study has 98% neg. predictive value
Abnormal study has high false positive rate

(PPV<20%)

Findings:
CXR: mediastinal hematoma
CT: Aortic tear, abnl contour, pseudoaneurysm,

intimal flap, active extravasation, abrupt taper

(pseudocoartation), hematoma

A negative CT has near 100% negative predictive

value for aortic injury

Traumatic aortic rupture

Radiographic signs
Wide mediastinum
(>8cm)
Fractured 1st & 2nd rib
Obliterated aortic knob
Trachea deviated to right
Pleural cap

Elevated mainstem

bronchus with shift to

right
Obliterated aortic
window
Esophagus shifted to
right (NG at T4)
Depressed left mainstem
bronchus

Rightward
deviation of
trachea
Opaque Paratracheal stripe

Decreased
definition
of aortic
arch

Normal paratracheal stripe

Rightward deviation
of trachea

Loss of distinction of Aortic

Arch

Caudad displacement
of Left Main Bronchus

Caudad dispalcement
of left main bronchus

Rightward
deviation of NG
tube

Thoracic Aorta Injury

Intimal Flap with double
lumen

Intimal Tear

Hematoma

Sternal
fracture

Thoracic Aorta Injury

Airway Injury
Tracheobronchial tears are uncommon
< 0.35-1.5% of BCT

bronchial > tracheal

75% at R mainstem usually within 2.5 cm of carina

Leads to persistent PTX

Specific Symptom: persistent PTX after chest tube
placement
Finding: Fallen Lung Sign, pneumomediastinum,
pneumopericardium, sub cut. Emphysema
ET Tube balloon inflation >2.8cm implies tracheal
rupture

Bronchial Injury
Lacerations of the Trachea and Bronchi are rare

injuries in blunt trauma, and often are missed in the

initial trauma evaluation.
Most injuries occur within 2.5 cm of the carina and
involve the bronchi more frequently than the trachea.

Tracheobronchial Tear
Radiologic Findings that point towards

tracheobronchial injury:
Pneumomediastinum, Pneumothorax, Subcutaneous

emphysema.
Persistence of pneumothorax after placement of chest
tube.
Fallen lung sign= collapse of the lung away from the
hilum.

Tracheobronchial Tear
pneumothorax

Atelectatic lung fallen

away from the hilum

Fallen Lung Sign

Bronchus Intermedius Tear

pneumomediastinum

Chest tube

Persistent pneumothorax

Presentation

2 day f/u

Persistent Pneumothorax
Lung falling away
from the hilum

Chest tube

Cord
62% of patients with thoracic spinal injuries have
neurological symptoms.
70 % of thoracic spinal fractures will result in signs

of mediastinal hematoma on the chest radiograph.

If there is concern about spinal injury dedicated
plain radiographs of the spine or CT.
The most common types of fractures are anterior
wedge fractures and burst fractures near the
thoracolumbar junction.

Wedge Compression Fracture

Anterior wedge fracture

Burst Fracture

Thoracic Spine Fracture - CT

Hematoma

Burst Fx

Rib Fx with subcutaneous

Air and underlying
pulmonary contusion

Diaphragm
Diaphragmatic injuries are rare in blunt chest trauma

patients (1-8%)
Usually left sided and posterior-lateral
More easily diagnosed in the absence of positive pressure
ventilation.
Radiographic signs include:
Collar sign= pinched stomach or loop of bowel in the chest.
Dependent viscera sign= Any segment of the GI tract in contact

with the thoracic wall without intervening diaphragm. (Seen on CT)

Unusual course of the NG tube.
Shanmuganathan, K. Imaging of Diaphragmatic Injuries. Journal of Thoracic Imaging. 15(2) pp 104-111 April 2000

Diaphragm Injury - Chest Radiograph

Collar Sign

Diaphragm Herniation

Collar Sign

Dependent Viscera Sign

Pneumomediastinum
Etiology: alveolar, tracheobronchial or esophageal
rupture
Most common cause: alveolar rupture due to

sudden increased intra-alveolar pressure

(Macklin Effect) with air tracking centrally
Findings:
Air outlining mediastinal soft tissues and parietal

pleura.
Continuous diaphragm sign

Pneumomediastinum

Pneumomediastinum

Pneumomediastinum

Pneumopericardium with
tamponade

Pneumopericardium with
tamponade resolved

Esophageal Injury
<10% of esophageal rupture is caused by trauma
< 1% of BCTs
Findings:
Pneumomediastinum
Left PTX
Left pleural effusion
Sub cut emphysema
Left lower lobe atelectasis