Diagnostic radiology: trauma

Question 1

What can be affected in chest trauma?

Answer 1

• Mediastinum (aorta, heart)
• Lung
• Diaphragm
• Chest wall and ribs

Question 2

What can be affected in abd trauma?

Answer 2

• Visceral organs:
• Liver
• Spleen
• Pancreas
• Kidneys
• Vessels – aorta, IVC
• Bowel

Question 3

What can be affected in pelvic trauma?

Answer 3

• Bony pelvis
• Vascular structures

Question 4

What is the standard trauma series plain films?

Answer 4

Cervical spine: to clear cervical spine
CXR: chest trauma
Pelvis: pelvic trauma

LS spine, limbs, face X ray according to clinical scenario
AXR: limited value (low sensitivity for pneumoperitoneum/ haematoma unless gross)

Question 5

What areas does FAST Scan assess?

Answer 5

Question 6

If FAST scan positive, what imaging done next?

Answer 6

CT for better delineation of injury

Question 7

What imaging for abdomen in trauma?

Answer 7

CT (IV contrast is needed inless contnraindicated)
High sensitivity to detet visceral injury, abnormal fluid/gas

Question 8

Answer 8

Question 9

Answer 9

Question 10

Answer 10

Question 11

Answer 11

Question 12

Answer 12

Pneumothorax

Question 13

Answer 13

Pneumothorax on supine CXR
Deep sulcus sign

Question 14

What treatment is necessary and why?

Answer 14

Tension pneumothorax
Mass effect: trachea deviated contralaterally
Lung collapse
Positive pressure compressing on venous return compromising cardiac output

Requires needle decompression at 2nd ICS MCL or 5th ICS anterior axillary line

Question 15

Answer 15

Lung contusion

Question 16

Answer 16

Rupture of airway/lung parenchyma or repeated vomiting causing tear of esophagus can give rise to pneumomediastinum

surgical emphysema (bubbly sensation at supraclavicular region)

Question 17

Answer 17

Gas in prevertebral space
Supraclavicular and axillary region accumulation of gas

Pneumomediastinum and surgical emphysema

Question 18

Answer 18

Question 19

Associated injury with lower ribs and 1st/2nd ribs

Answer 19

Lower ribs: splenic, hepatic, diaphragmatic
1st, 2nd ribs: mediastinal injury, thoracic aorta

Question 20

Answer 20

-Widened mediastinum-Abnormal aortic contour-Airspace shadowing-Thickened right and left para tracheal stripe-Deviation of trachea

Dx: acute traumatic aortic injury (ATAI)

Question 21

Where does ATAI occur?

Answer 21

Question 22

What are the CXR appearances of mediastinal haematoma?

Answer 22

Patient most likely lying down in haemothorax (supine = will observe contusion and haziness)

Question 23

What imaging may be indicated in ATAI?

Answer 23

-Contrast enhanced CT with CT angiography
Transoesophagealechocardiography (TEE)
-Arteriography

Question 24

ATAI

Answer 24

-Mediastinal haematoma-Displaced oesophagus-Bilateral haemothoraces-Contrast outside aorta

Question 25

What imaging best for ATAI (acute traumatic aortic injury)?

Answer 25

CT: fast with high sensitivity If CT equivocal, then TEE/arteriography indicated. Risks with arteriography are related to catheter technique and intra-arterial contrast reactions

Question 26

-A 35-year old night club bouncer with increasingly SOB for 2 weeks -Involved in a fight with some sailors a month previously -Was kicked several times in the abdomen

Answer 26

-Opacity in the left lower zone-Left hemidiaphragm not seen-Hyperlucent area within opacity-Rest of lungs clear

Question 27

Answer 27

Herniation of stomach through the perforated diaphragmatic wall Loss of gastric bubble in CXR

Question 28

Answer 28

Water soluble contrast follow through Defect/perforation in diaphragm Bowel loops herniate into hemithorax

Question 29

A 16 year old girl was knocked down by a tram while rushing to school. On admission, her abdomen was tender with some rebound localisedto the left upper quadrant. Her vital signs were quite stable although her HB was only 10gm/dl. What imaging to consider?

Answer 29

FAST scan: perisplenic fluid

Question 30

A 16 year old girl was knocked down by a tram while rushing to school. On admission, her abdomen was tender with some rebound localisedto the left upper quadrant. Her vital signs were quite stable although her HB was only 10gm/dl. What is done after fast scan

Answer 30

Post contrast the normal organs are enhanced hence making the blood appear more hypodense Splenic haematoma

Question 31

In abd trauma, what do you look for in pre contrast and post contrast scan?

Answer 31

Blood in precontrast scan, blood = hyperdense fluid (Bright) Post contrast scan: laceration/contusion of organs

Question 32

Answer 32

Liver laceration

Question 33

Answer 33

Pancreatic laceration Look out for duodenal injury, fracture of spine (T12,L1)

Question 34

Answer 34

Perinephric haematoma Laceration of kidney with contrast extravasation

Question 35

Answer 35

Question 36

What is the causes of pneumoperitoneum?

Answer 36

- From ruptured viscus (small bowel, stomach) penetrating wound, diagnostic peritoneal lavage or recent surgery - CT excellent for detecting small pockets of free gas particularly in a traumatized patient - Gas trapped within the mesentery suggests bowel perforation

Question 37

What is a cause of pneumoretroperitoneum in surgery?

Answer 37

ERCP (puncture duodenum) - Rupture of hollow viscus in retroperitoneum - Second to forth part of duodenum - Ascending/descending colon

Question 38

Use of CT in pelvic fractures?

Answer 38

Visualize vascular injury Associated visceral injury: bladder, bowel

Question 39

What is important to assess in the rupture of bladder

Answer 39

Extraperitoneal (conservative treatment)/intraperitoneal bladder rupture (requires repair of urinary bladder)