BASIC XRAY INTERPRETATION IN

TRAUMA (CXR)
INTRODUCTION
• Trauma is 4th leading cause of death in
developing countries
• Loss of productive years of life-young
individuals
• Rapid diagnosis important to avoid morbidity
and mortality
• Thoracic injuries: 10-15% of all trauma, 25% of
trauma fatalities
Checklist
• Penetration – the spine should be just seen‘
through the mediastinum
•Well-centeredness – the medial ends of the clavicle
should be equal distant from midline
• Exposure - scapular end should be outside of the
lung fields
•In full inspiration, 6th anterior or 10th posterior rib
should touch the hemidiaphragm
Medial end of clavicle equal
distant from midline
Hemidiaphragm

The highest point of the right diaphragm is usually 1–

1.5 cm higher than that of the left. Each costophrenic
angle should be sharply outlined.
Mediastinum structures
Approach to Chest Radiology in
Trauma
• A- Aorta • F- Fracture
• B- Bronchi • G- Gas
• C- Contusions • H- Heart
• D- Diaphragm • H- Hemothorax
• E- Esophagus • H- Hematoma
• F- Flail Chest • H- Hemorrhage
• I- Iatrogenic
 Monitoring and evaluating the
patient with Thoracic trauma
• Roentgenograms of the thorax
(Chest wall i.e. ribs, sternum,
vertebral, clavicles).
• Mediastinum (wide or
normal) shifted or not.
• Lung parenchyma
(Contusion).
• The heart (cardiac
tamponade).
• Diaphragm.
• Pneumothorax,
hemothorax.
Radiologic features due to
mediastinal hematoma
• Wide mediastinum
•Indistinct or distorted aortic knob or proximal descending
aorta
•Opacification of the aorticopulmonary window
•Wide right paratracheal stripe
•Left paraspinal line displaced and extending superior to
aortic knob
• Left apical pleural cap
•Right paraspinal line displaced
•Mass effect due to periaortic blood at the aortic arch
•Trachea or nasogastric tube displaced to the right
•Depressed left mainstem bronchus
CXR may demonstrate 2ry
findings: pneumothorax,
pneumomediastinum
Definite dx: bronchoscopy
Mx: Endotracheal
intubation, Thoracotomy
Contusion
• Pulmonary contusion is an injury
to lung parenchyma, leading to
oedema and blood collecting in
alveolar spaces and loss of normal
lung structure & function
• Cough may be present with
blood-tinged sputum.
• Pulmonary contusions tend to
worsen over a 24– to 48–hour
period and then slowly resolve
unless complications occur
(infection, ARDS).
• Patients with severe contusions
may require endotracheal
intubation and mechanical
ventilation
Flail chest
The breaking of 2 or
more ribs in 2 or more
places, resulting in
free- floating rib
segments.
Pneumothorax (Gas)

Remember: Tension pneumothorax is a clinical

diagnosis, NOT a radiological diagnosis
• When the patient is supine, a pneumothorax
collects anteriorly and may be impossible to detect.
A large pneumothorax may widen the costophrenic
sulcus—the ―deep sulcus‖ sign
• ACCP (2001): ―small‖ a < 3 cm;
―large‖ a 3 cm
• BTS (2003): ―small‖ m < 2 cm;
―large‖ m 2 cm

• Small pneumothoraces can be

managed by observation, as
long as the patient is stable, has
only mild symptoms, and has no
underlying lung disease.
•Large pneumothoraces need
chest tube or catheter aspiration
to reexpand the lung.
Hemothorax

• Occurs when pleural

space fills with blood
• Usually occurs due to
lacerated blood vessel in
thorax
• Source:chest wall, lung
parenchyma, heart or
great vessel
• 300-500ml required for
blunt CP angle on erect
CXR
• Massive hemothorax
(>1.5L)
THANK YOU