imaging in trauma

IMAGING IN TRAUMAIMAGING IN TRAUMA

SCOPE OF DISCUSSION:SCOPE OF DISCUSSION:

A. BASIC CONCEPTS REGARDING TRAUMAA. BASIC CONCEPTS REGARDING TRAUMA

B. FOCUSSED DISCUSSIONB. FOCUSSED DISCUSSION::- Craniocerebral Trauma (Head Injury with special Craniocerebral Trauma (Head Injury with special

emphasis on CT).emphasis on CT).- Spinal trauma with focus on X-ray Cervical spine .Spinal trauma with focus on X-ray Cervical spine .- Chest trauma with focus on CXRChest trauma with focus on CXR- Pelviacetabular Trauma with focus on X-Ray PelvisPelviacetabular Trauma with focus on X-Ray Pelvis

A.A. Basic Trauma Considerations:Basic Trauma Considerations:Initial Assessment and Management of TraumaInitial Assessment and Management of Trauma

IntroductionIntroduction TraumaTrauma

Leading killer from ages 1 to 44Leading killer from ages 1 to 44 Up to one-third of deaths are preventableUp to one-third of deaths are preventable

Golden HourGolden Hour Time to reach operating roomTime to reach operating room NOTNOT time for transport time for transport NOTNOT time in Emergency Department time in Emergency Department

EMS does EMS does NOTNOT have a Golden Hour have a Golden Hour EMS has a EMS has a Platinum Ten MinutesPlatinum Ten Minutes

Initial Assessment (Primary Survey)Initial Assessment (Primary Survey)

Find life threatsFind life threats If life threat present, If life threat present, CORRECT IT!CORRECT IT! If life threat can’t be correctedIf life threat can’t be corrected

Support ABCsSupport ABCs TRANSPORT!TRANSPORT!

Primary SurveyPrimary Survey With critical trauma you may never get beyond primary surveyWith critical trauma you may never get beyond primary survey Noisy breathing is obstructed breathingNoisy breathing is obstructed breathing But all obstructed breathing is not noisyBut all obstructed breathing is not noisy Anticipate airway problems withAnticipate airway problems with Open, Clear, MaintainOpen, Clear, Maintain

The Primary SurveyThe Primary Survey

AA - Airway and C-Spine - Airway and C-SpineBB - Breathing - BreathingCC - Circulation - Circulation

(with hemorrhage control) (with hemorrhage control)DD - Disability - DisabilityEE - Exposure - Exposure

Initial AssessmentInitial Assessment If the patient looks sick, he’s sick!!!If the patient looks sick, he’s sick!!!

Treat as you go!Treat as you go! Initial ResuscitationInitial Resuscitation

Immobilize C-spine (rigid collar)Immobilize C-spine (rigid collar) Keep airway openKeep airway open OxygenateOxygenate Rapidly extricate to long boardRapidly extricate to long board ExposeExpose TransportTransport Reassess and report in routeReassess and report in route

Minimum Time On Scene Maximum Treatment In Route

Detailed Exam (Secondary Survey)Detailed Exam (Secondary Survey)

History and Physical ExamHistory and Physical Exam

You You WILLWILL get here with get here with MOSTMOST trauma patients trauma patients Perform Perform ONLYONLY after initial assessment is completed and life threats corrected after initial assessment is completed and life threats corrected Do Do NOTNOT hold critical patients in field for detailed exam hold critical patients in field for detailed exam Physical ExamPhysical Exam Stepwise, organizedStepwise, organized Every patient, same way, every timeEvery patient, same way, every time Superior to inferior; proximal to distalSuperior to inferior; proximal to distal Look--Listen--FeelLook--Listen--Feel HistoryHistory Chief complaintChief complaint

What What PATIENTPATIENT says problem is says problem is Not necessarily what you seeNot necessarily what you see

HistoryHistory A = AllergiesA = Allergies M = MedicationsM = Medications P = Past medical historyP = Past medical history L = Last oral intakeL = Last oral intake E = Events leading up to incidentE = Events leading up to incident

Definitive Field CareDefinitive Field Care Performed Performed ONLYONLY on stable patients on stable patients

Definitive Field CareDefinitive Field Care Stable patients can receive attention for individual injuries before transportStable patients can receive attention for individual injuries before transport

BandagingBandaging SplintingSplinting

Reassess carefully for hidden problemsReassess carefully for hidden problems If patient becomes unstable at any time,If patient becomes unstable at any time, TRANSPORTTRANSPORT Reevaluation Ventilation and perfusion statusReevaluation Ventilation and perfusion status Repeat vital signsRepeat vital signs Continued stabilization of identified problemsContinued stabilization of identified problems Continued reassessment for unidentified problemsContinued reassessment for unidentified problems

Rules of TriageRules of Triage

Greatest good for greatest numberGreatest good for greatest number Save lives, then limbsSave lives, then limbs One Chief, many IndiansOne Chief, many Indians Squeaky wheels don’t need greaseSqueaky wheels don’t need grease You can’t save everyone! So don’t try!You can’t save everyone! So don’t try!

MST: Until proven otherwise:MST: Until proven otherwise: ChestChest trauma involves trauma involves heart, great vesselsheart, great vessels!! ChestChest trauma trauma below fourth intercostal spacebelow fourth intercostal space involves involves

abdomenabdomen!! AbdominalAbdominal trauma trauma above umbilicusabove umbilicus involves chest! involves chest! Extremity trauma = Neurovascular involvement until proven Extremity trauma = Neurovascular involvement until proven

otherwise otherwise Noisy breathing = Obstructed breathingNoisy breathing = Obstructed breathing

But all obstructed breathing is But all obstructed breathing is NOTNOT noisy noisy Most reliableMost reliable indicator of severity of injury, effectiveness of indicator of severity of injury, effectiveness of

resuscitation = resuscitation = Level Of ConsciousnessLevel Of Consciousness Orthopedic injury usually Orthopedic injury usually NOTNOT life-threat life-threat Exceptions:Exceptions:

Pelvic fracturePelvic fracture Femur fracturesFemur fractures

Assess, treat proximal to distalAssess, treat proximal to distal

Where should the patient go?Where should the patient go?

The most appropriate facility

Not necessarily the closest one!

BRAIN & SPINE TRAUMABRAIN & SPINE TRAUMA

Injuries to BrainInjuries to Brain

Craniocerebral TraumaCraniocerebral Trauma

CNS trauma is a major cause of morbidity and CNS trauma is a major cause of morbidity and mortality.mortality.

Prompt and precise diagnosis is critical for Prompt and precise diagnosis is critical for further management.further management.

CT is the best initial investigation of brain CT is the best initial investigation of brain injury.injury.

Plain films are critical to evaluate Plain films are critical to evaluate vertebral/spinal injury.vertebral/spinal injury.

Assessment of Head InjuryAssessment of Head Injury

Level of consciousness is Level of consciousness is BESTBEST indicator of indicator of patient’s conditionpatient’s condition Glasgow scaleGlasgow scale

Assessment of Head InjuryAssessment of Head Injury

Other Indicators of Increased ICPOther Indicators of Increased ICP HeadacheHeadache NauseaNausea Vomiting (often projectile)Vomiting (often projectile) SeizuresSeizures

TraumaTrauma

Axial injury:Axial injury: Concussion:Concussion:

Brain damage at the microscopic level.Brain damage at the microscopic level. Usually associated with normal imagingUsually associated with normal imaging

Contusion:Contusion: Focal area of edema that can be associated with Focal area of edema that can be associated with

hemorrhage..hemorrhage.. Usually involves the fronto-temperal lobesUsually involves the fronto-temperal lobes

Skull FracturesSkull Fractures

Injury to rigid box around brainInjury to rigid box around brain Indicates significant forceIndicates significant force What happened to brain and neck?What happened to brain and neck?

Types of Skull FractureTypes of Skull Fracture

LinearLinear Most commonMost common Crack in skullCrack in skull Detected only on Detected only on

x-rayx-ray

ComminutedComminuted Multiple cracks Multiple cracks

radiate from radiate from impact pointimpact point

Types of Skull FractureTypes of Skull Fracture

DepressedDepressed Bone fragments pressed Bone fragments pressed

inwardinward Places pressure on brainPlaces pressure on brain Brain tissue may be exposed Brain tissue may be exposed

through injurythrough injury

BasilarBasilar Fractures in floor of skullFractures in floor of skull Diagnosis made clinicallyDiagnosis made clinically Signs and symptomsSigns and symptoms

Periorbial ecchymosis Periorbial ecchymosis (Raccoon eyes)(Raccoon eyes)

Battle’s signBattle’s sign CSF drainage from nose, CSF drainage from nose,

earsears

Skull FracturesSkull Fractures

DO NOT TRY TO STOP FLOW OF BLOOD, FLUID FROM

NOSE OR EARS

MAY CAUSE INCREASED INTRACRANIAL

PRESSURE AND BRAIN INFECTION

ConcussionConcussion

Temporary disturbance in brain functionTemporary disturbance in brain function Probably due to brain being “rattled” inside the skull Probably due to brain being “rattled” inside the skull

by a blow to the headby a blow to the head Usually confused or unconsciousUsually confused or unconscious Retrograde amnesia--“What happened?”Retrograde amnesia--“What happened?” Effects clear without residual effectsEffects clear without residual effects

Cerebral ContusionCerebral Contusion

Bruising, swelling Bruising, swelling Results from brain hitting skull’s insideResults from brain hitting skull’s inside Coup-contra coup patternCoup-contra coup pattern Since brain is in closed box, pressure increases as Since brain is in closed box, pressure increases as

brain swells, blood flow to brain decreasesbrain swells, blood flow to brain decreases

TraumaTrauma

Extra-axial injury:Extra-axial injury: Blood can accumulate in different spaces around Blood can accumulate in different spaces around

the brain.the brain. Subarachnoid hemorrhage is usually has a benign Subarachnoid hemorrhage is usually has a benign

self-limiting course.self-limiting course. Its presence is suggestive of significant trauma.Its presence is suggestive of significant trauma.

Epidural HematomaEpidural Hematoma

Usually associated with skull fracture(85-95%). Usually associated with skull fracture(85-95%). Results from injury to middle meningeal artery or one of its branches. Results from injury to middle meningeal artery or one of its branches.

About 10% are of venous origin.About 10% are of venous origin. It has the characteristic biconvex shape.It has the characteristic biconvex shape. Limited by the suture lines.Limited by the suture lines. Fracture damages artery on skull’s insideFracture damages artery on skull’s inside Blood collects in epidural space between skull and dura materBlood collects in epidural space between skull and dura mater Since skull is closed box, intracranial pressure risesSince skull is closed box, intracranial pressure rises More than 90% occurs supratentorialMore than 90% occurs supratentorial and more than 95% are and more than 95% are

unilateral.unilateral. Usually attain their final size quickly.Usually attain their final size quickly. Only 23% of EDH will enlarge, mostly within 36 hours.Only 23% of EDH will enlarge, mostly within 36 hours. Has the characteristic lucent period.Has the characteristic lucent period.

Subdural HematomaSubdural Hematoma

Usually results from tearing of large veins between dura Usually results from tearing of large veins between dura mater and arachnoidmater and arachnoid

Blood accumulates more slowly than in epidural Blood accumulates more slowly than in epidural hematomahematoma

characteristic concavo-convex shapecharacteristic concavo-convex shape Signs and symptoms may not develop for days to weeksSigns and symptoms may not develop for days to weeks It crosses the suture lineIt crosses the suture line

Cerebral LacerationCerebral Laceration

Tearing of brain tissueTearing of brain tissue Can result from penetrating or blunt injuryCan result from penetrating or blunt injury Can cause:Can cause:

Massive destruction of brain tissueMassive destruction of brain tissue Bleeding into cranial cavity with increased intracranial Bleeding into cranial cavity with increased intracranial

pressurepressure

TraumaTrauma

Shear injury(diffuse axonal injury):Shear injury(diffuse axonal injury): significant brain damage results from significant brain damage results from

acceleration/deceleration mechanism.acceleration/deceleration mechanism. Associated with poor prognosis.Associated with poor prognosis. MRI is more accurate in evaluating the extent of MRI is more accurate in evaluating the extent of

injury.injury.

SAHSAH

Blood in basal cisternsBlood in basal cisterns

Spinal InjuriesSpinal Injuries

Most important spinal injury indicator…

MECHANISMMECHANISM

Common MechanismsCommon Mechanisms

CompressionCompression FlexionFlexion ExtensionExtension RotationRotation

Lateral bendingLateral bending DistractionDistraction PenetrationPenetration

Suspect spinal injury with...Suspect spinal injury with... Sudden decelerations (MVCs, falls)Sudden decelerations (MVCs, falls) Compression injuries (diving, falls onto Compression injuries (diving, falls onto

feet/buttocks)feet/buttocks) Significant blunt trauma above claviclesSignificant blunt trauma above clavicles Very violent mechanisms (explosions, cave-ins, Very violent mechanisms (explosions, cave-ins,

lightning strike)lightning strike)

Significant Head Injury = Neck Injury Until Proven

Otherwise

Or, there may be no signs at all. . .Or, there may be no signs at all. . .

Neurologic deficits are a result of Neurologic deficits are a result of cordcord injury injury Spinal injury without cord involvement may produce Spinal injury without cord involvement may produce

no significant signs and symptomsno significant signs and symptoms

STABILITY: A Word or TwoSTABILITY: A Word or Two

We talk about it, but what is it?We talk about it, but what is it? A useful definition: An injury is STABLE if A useful definition: An injury is STABLE if

putting the spinal column through normal putting the spinal column through normal range of motion does not increase neurological range of motion does not increase neurological or mechanical deficits.or mechanical deficits.

Three Column Theory of DenisThree Column Theory of Denis

Spinal column divided Spinal column divided into an ANTERIOR, into an ANTERIOR, MIDDLE and MIDDLE and POSTERIOR column.POSTERIOR column.

Injury to one column is Injury to one column is stable, two or three are stable, two or three are unstable.unstable.

ANTERIOR COLUMNANTERIOR COLUMN

The anterior The anterior longitudinal ligament, longitudinal ligament, anterior 2/3 of the body anterior 2/3 of the body and disc.and disc.

MIDDLE COLUMNMIDDLE COLUMN

Posterior longitudinal Posterior longitudinal ligament and posterior ligament and posterior 1/3 of body and disc.1/3 of body and disc.

POSTERIOR COLUMNPOSTERIOR COLUMN

The posterior osseous The posterior osseous arch and ligaments.arch and ligaments.

DOES IT WORK?DOES IT WORK?

If two or three columns injured, lesion is If two or three columns injured, lesion is unstable: Works well for C3 to T1.unstable: Works well for C3 to T1.

Does not work so well for C1-2, so consider Does not work so well for C1-2, so consider most or all injuries here unstable.most or all injuries here unstable.

HOW DO YOU IMAGE THE HOW DO YOU IMAGE THE CERVICAL SPINE?CERVICAL SPINE?

Plain films?Plain films?CT?CT?MRI? MRI? A combination of modalities?A combination of modalities?Is there a consensus?Is there a consensus?

Imaging Minor TraumaImaging Minor Trauma

LATERAL view from skull base through at LATERAL view from skull base through at least the top one-half of T1. May need to least the top one-half of T1. May need to supplement with Swimmer’s view.supplement with Swimmer’s view.

Anterior-posterior (AP)Anterior-posterior (AP) Open Mouth Odontoid (OMO)Open Mouth Odontoid (OMO) If patient is not in cervical collar: Adding If patient is not in cervical collar: Adding

Oblique views is an option.Oblique views is an option.

MINOR TRAUMA: ViewsMINOR TRAUMA: Views

Imaging Major Blunt TraumaImaging Major Blunt Trauma

Cross-table LATERAL Cross-table LATERAL plain film in Trauma plain film in Trauma Suite.Suite.

CT entire cervical spine.CT entire cervical spine. MRI also in selected MRI also in selected

cases.cases.

If you wish, AP, OMO, If you wish, AP, OMO, and Swimmer’s views and Swimmer’s views also -- IF they DO NOT also -- IF they DO NOT cause delay.cause delay.

CT: Axial sections base CT: Axial sections base of skull through T1- of skull through T1- AND- Sagittal (like a AND- Sagittal (like a lateral) and Coronal lateral) and Coronal (like AP and OMO) (like AP and OMO) reformatting.reformatting.

MAJOR TRAUMA: ImagingMAJOR TRAUMA: Imaging

Cross-table Lateral in Cross-table Lateral in Trauma SuiteTrauma Suite

CT Base of skull CT Base of skull through T1through T1

Swimmer’s View in Major Swimmer’s View in Major TraumaTrauma

A SUPPLEMENTARY A SUPPLEMENTARY view to see C7-T1 in lateral view to see C7-T1 in lateral projection. NOT a substitute projection. NOT a substitute for a bad lateral. One arm for a bad lateral. One arm must be elevated, so must be elevated, so THEORETICALLY could THEORETICALLY could worsen a mechanical or worsen a mechanical or neurological injury.neurological injury.

A state-of-the-art CT A state-of-the-art CT sagittal reformat is sagittal reformat is preferable: don’t need to preferable: don’t need to move patient and imaging move patient and imaging easier and better.easier and better.

CTCT

Axial sections from Axial sections from base of skull through base of skull through T1.T1.

ALWAYS do the ALWAYS do the ENTIRE cervical spine.ENTIRE cervical spine.

DON’T do selective DON’T do selective imaging with modern imaging with modern scanners. scanners.

CT: Sagittal Reformatting CT: Sagittal Reformatting

Reconstructed by Reconstructed by computer from axial computer from axial data: no additional data: no additional imaging needed.imaging needed.

Outstanding Outstanding “lateral/swimmer’s” “lateral/swimmer’s” imaging.imaging.

CT: Coronal ReformattingCT: Coronal Reformatting

Excellent “OMO”Excellent “OMO”

Excellent “AP”Excellent “AP”

MRIMRI

Gold standard for cord, Gold standard for cord, thecal sac, nerve root thecal sac, nerve root and disc injuries.and disc injuries.

Very good for ligament Very good for ligament injuries.injuries.

Fairly good for Fairly good for fractures, but does miss fractures, but does miss some. CT much better.some. CT much better.

NEUROLOGIC NEUROLOGIC DEFICITDEFICIT

In my view, ANY neurologic deficit, In my view, ANY neurologic deficit, extant or transient, is MAJOR extant or transient, is MAJOR

trauma, and will need CT followed by trauma, and will need CT followed by MRI.MRI.

Any abnormality on Plain Any abnormality on Plain FilmsFilms

or worrisome examination: or worrisome examination: do CT!do CT!

Remember: Fractures often come in 2’s Remember: Fractures often come in 2’s and 3’s. The more serious injury may be and 3’s. The more serious injury may be

the one that is occult. the one that is occult.

Remember: The lesions Remember: The lesions are the SAME regardless are the SAME regardless of the imaging modalityof the imaging modality

Plain films are still the most common Plain films are still the most common modality.modality.

If you learn on them, you can If you learn on them, you can translate your knowledge to CT and translate your knowledge to CT and

MRI.MRI.

PLAIN FILM SeriesPLAIN FILM Series

LATERALLATERAL ANTERIOR-POSTERIOR (AP)ANTERIOR-POSTERIOR (AP) OPEN MOUTH ODONTOID (OMO)OPEN MOUTH ODONTOID (OMO) *REVERSE WATERS*REVERSE WATERS *SWIMMER’S*SWIMMER’S *OBLIQUES*OBLIQUES

LATERAL viewLATERAL view This is your MAIN view This is your MAIN view

where 90% of injuries are where 90% of injuries are detected.detected.

You MUST see T1. If not You MUST see T1. If not seen, do Swimmer’s view, seen, do Swimmer’s view, unless not safe to do so. unless not safe to do so.

You did lateral and You did lateral and Swimmer’s and still no Swimmer’s and still no luck? DON’T QUIT: DO luck? DON’T QUIT: DO CT! Once you start an exam CT! Once you start an exam you must complete it.you must complete it.

LATERAL View: First SurveyLATERAL View: First Survey

Look for gross fracture Look for gross fracture or dislocation.or dislocation.

Count vertebrae.Count vertebrae. Look at skull, entire Look at skull, entire

airway and adjacent soft airway and adjacent soft tissues.tissues.

LATERAL View: Prevertebral LATERAL View: Prevertebral Soft TissuesSoft Tissues

Contour is more Contour is more important than important than measurements: straight measurements: straight or concave anteriorly, or concave anteriorly, except at larynx.except at larynx.

Top normal limits: C2 Top normal limits: C2 6mm; C6 22mm for 6mm; C6 22mm for adult, 14mm for young adult, 14mm for young child.child.

LATERAL View: AlignmentLATERAL View: Alignment

Anterior body line.Anterior body line. Posterior body line.Posterior body line. Spino-laminar line Spino-laminar line

(called posterior (called posterior cervical line at C1-3).cervical line at C1-3).

LATERAL View: AlignmentLATERAL View: Alignment

Turning the lateral view HORIZONTALLY can help Turning the lateral view HORIZONTALLY can help detect subtle malalignment.detect subtle malalignment.

LATERAL View: SpacesLATERAL View: Spaces

Disc spaces: too wide, Disc spaces: too wide, too narrow, not too narrow, not uniform?uniform?

Facet joints: too wide, Facet joints: too wide, not uniform?not uniform?

Interspinous distances: Interspinous distances: too wide, too narrow, too wide, too narrow, not uniform?not uniform?

LATERAL View: C1 and C2LATERAL View: C1 and C2

Basion-dens distance: Basion-dens distance: average 8mm, top average 8mm, top normal 12mm.normal 12mm.

C1: Anterior and C1: Anterior and posterior arch.posterior arch.

C2: Dens, Harris’ ring, C2: Dens, Harris’ ring, body especially ant/inf body especially ant/inf corner, pars and corner, pars and posterior arch.posterior arch.

LATERAL VIEW: LATERAL VIEW: Predental SpacePredental Space

In an adult, upper In an adult, upper normal is 2.5mm. normal is 2.5mm. Space is parallel or Space is parallel or narrow “V” shape.narrow “V” shape.

In a young child, upper In a young child, upper normal is 4.5mm.normal is 4.5mm.

LATERAL VIEW: Predental LATERAL VIEW: Predental SpaceSpace

LATERAL View: C3-T1LATERAL View: C3-T1

Body: loss of straight or Body: loss of straight or concave anterior concave anterior contour, loss of height?contour, loss of height?

Posterior arch: subtle Posterior arch: subtle cortical irregularity, cortical irregularity, overt fracture line?overt fracture line?

LATERAL VIEW: ChildLATERAL VIEW: Child

Vertebral bodies are bullet Vertebral bodies are bullet shaped.shaped.

Physiologic Physiologic pseudosubluxations are pseudosubluxations are common, especially C2-4.common, especially C2-4.

Predental space is wider.Predental space is wider. Lymphoid tissue makes soft Lymphoid tissue makes soft

tissues more prominent.tissues more prominent.

SWIMMER’S ViewSWIMMER’S View

A supplemental view to A supplemental view to see C7-T1.see C7-T1.

Must raise one arm. Must raise one arm. Probably not a good Probably not a good idea if neurologic idea if neurologic deficit, altered level of deficit, altered level of consciousness, upper consciousness, upper arm injury. Could arm injury. Could worsen an injury.worsen an injury.

ANTERIOR-POSTERIOR ViewANTERIOR-POSTERIOR View

Look at first few ribs, Look at first few ribs, sterno-clavicle junction, sterno-clavicle junction, lung apices. lung apices.

Contour of lateral margins Contour of lateral margins of lateral masses.of lateral masses.

Uncovertebral joints.Uncovertebral joints. Alignment and contour of Alignment and contour of

spinous processes.spinous processes. Position and contour of Position and contour of

trachea.trachea.

The ODONTOID ViewsThe ODONTOID Views

Open Mouth Odontoid Open Mouth Odontoid (OMO) is main view.(OMO) is main view.

Reverse Waters view is Reverse Waters view is supplementary, to see supplementary, to see top half of dens ONLY.top half of dens ONLY.

OMOOMO

C1-2 lateral mass alignment of C1-2 lateral mass alignment of lateral margins.lateral margins.

Dens: cortical margin Dens: cortical margin irregularities, fracture lines, irregularities, fracture lines, tilt.tilt.

Upper body of C2 for fracture Upper body of C2 for fracture lines.lines.

Mach lines can be confusing.Mach lines can be confusing.

The INJURIESThe INJURIES

C1 and C2: by anatomic locationC1 and C2: by anatomic location

C3 to T1: by mechanism of injuryC3 to T1: by mechanism of injury

((Modified from the classification of John Modified from the classification of John Harris, et alHarris, et al.).)

The Atlas and the AxisThe Atlas and the Axis

C1 and C2 injuries differ from the rest of the C1 and C2 injuries differ from the rest of the cervical spine and are considered separately.cervical spine and are considered separately.

Although controversial, best to consider ALL Although controversial, best to consider ALL C1 and C2 injuries as UNSTABLE in the C1 and C2 injuries as UNSTABLE in the acute trauma setting.acute trauma setting.

Occipital-atlantic InjuriesOccipital-atlantic Injuries

Occipital condyle Occipital condyle fractures: lateral fractures: lateral bending, uncommon, bending, uncommon, seen only on CT.seen only on CT.

Occipital-atlantic Occipital-atlantic dissociation (OAD): dissociation (OAD): rare distraction injury, rare distraction injury, usually fatal. Basion-usually fatal. Basion-dens distance is dens distance is abnormal, 12+mm.abnormal, 12+mm.

The ATLAS: C1The ATLAS: C1

Anterior arch fracture: extension, uncommon.Anterior arch fracture: extension, uncommon. Posterior arch fracture: extension, more Posterior arch fracture: extension, more

common.common. JEFFERSON fracture: axial load, commonJEFFERSON fracture: axial load, common

C1: Isolated Arch FracturesC1: Isolated Arch Fractures

Anterior archAnterior arch Posterior archPosterior arch CAUTION: You may CAUTION: You may

be dealing with a be dealing with a Jefferson fracture with Jefferson fracture with occult components: occult components: Best to CT all C1 Best to CT all C1 fractures.fractures.

JEFFERSON Fracture: C1JEFFERSON Fracture: C1

Axial load (“burst”) injuryAxial load (“burst”) injury Pure (4) or variant (2 or 3) Pure (4) or variant (2 or 3)

fractures, involving both fractures, involving both ant. & post. arches of C1ant. & post. arches of C1

Cord injury in 15%Cord injury in 15% Lateral view: anterior and Lateral view: anterior and

posterior arch fracturesposterior arch fractures OMO view: lateral OMO view: lateral

displacement of C1 lateral displacement of C1 lateral massesmasses

JEFFERSON Fracture: C1JEFFERSON Fracture: C1 The lateral masses of C1 The lateral masses of C1

and C2 must be aligned on and C2 must be aligned on the OMO view.the OMO view.

1-2mm of lateral 1-2mm of lateral displacement on one side displacement on one side and an EQUAL medial and an EQUAL medial displacement on the other is displacement on the other is head rotation.head rotation.

ANY other pattern: lateral ANY other pattern: lateral displacement on both sides displacement on both sides or lateral on one side, and or lateral on one side, and none on the other is none on the other is abnormal.abnormal.

JEFFERSON FractureJEFFERSON FractureCTCT

Classical Jefferson: 4 Classical Jefferson: 4 fractures, 2 ant./2 post.fractures, 2 ant./2 post.

Jefferson variants: 2 or Jefferson variants: 2 or 3 fractures, but at least 1 3 fractures, but at least 1 ant. & 1 post.ant. & 1 post.

The AXIS: C2The AXIS: C2

Dens fracturesDens fractures Pars fracturesPars fractures Extension teardrop Extension teardrop

fracturesfractures

DENS FracturesDENS Fractures

Type I: alar ligament Type I: alar ligament avulsion of the tip; rare.avulsion of the tip; rare.

Type II: the dens excluding Type II: the dens excluding the tip; 2/3.the tip; 2/3.

Type III: high C2 body; 1/3.Type III: high C2 body; 1/3.

Mechanism of Type II and Mechanism of Type II and III is controversial.III is controversial.

TYPE II Dens FractureTYPE II Dens Fracture

Interrupted cortical Interrupted cortical margin, lucent fracture margin, lucent fracture line, tilt especially line, tilt especially anterioranterior

Cord injury in 15%Cord injury in 15% Delayed or non-union Delayed or non-union

50+%50+%

TYPE II Dens FractureTYPE II Dens Fracture

CT axialCT axial

TYPE III Dens FractureTYPE III Dens Fracture

Interrupted Harris ring, Interrupted Harris ring, fat C2, lucent fracture fat C2, lucent fracture line, tilt especially ant.line, tilt especially ant.

Cord injury in 15%Cord injury in 15% Heals well.Heals well.

C2: PARS FractureC2: PARS Fracture

Called Hangman’s or Called Hangman’s or pedicle fracture, both pedicle fracture, both wrong.wrong.

Extension injury.Extension injury. Cord injury in 15%.Cord injury in 15%. Non-displaced, Non-displaced,

displaced, subluxed.displaced, subluxed.

C2: Extension Teardrop C2: Extension Teardrop FractureFracture

Avulsion by the anterior Avulsion by the anterior longitudinal ligament of longitudinal ligament of the anterior-inferior the anterior-inferior corner of the body.corner of the body.

Extension mechanism.Extension mechanism. Cord injury is low.Cord injury is low.

C3 to T1C3 to T1

These levels are so similar they will These levels are so similar they will be considered as a unit.be considered as a unit.

The injuries are grouped by The injuries are grouped by mechanism into “families”.mechanism into “families”.

The “FAMILIES”The “FAMILIES”

FlexionFlexion

Flexion-rotationFlexion-rotation

ExtensionExtension

Axial loadingAxial loading

““FAMILY FLEXION”FAMILY FLEXION”Motto: “Anterior impaction, Motto: “Anterior impaction,

posterior distraction.”posterior distraction.”

Family members:Family members: Wedge compression fractureWedge compression fracture Hyperflexion sprainHyperflexion sprain Bilateral interfacetal dislocationBilateral interfacetal dislocation Hyperflexion teardrop fracture-dislocationHyperflexion teardrop fracture-dislocation Spinous process fractureSpinous process fracture

Wedge Compression Fracture Wedge Compression Fracture Anterior-superior margin of Anterior-superior margin of

the body is fractured.the body is fractured. If loss of height less than If loss of height less than

50%, one column injury and 50%, one column injury and so stable.so stable.

If height loss greater than If height loss greater than 50%, posterior ligaments 50%, posterior ligaments presumed torn and so 3 presumed torn and so 3 column unstable injury.column unstable injury.

If 3 bodies fractured, If 3 bodies fractured, unstable even if less than unstable even if less than 50% height loss each.50% height loss each.

Hyperflexion SprainHyperflexion Sprain Tear of the posterior Tear of the posterior

(stable), posterior/ middle (stable), posterior/ middle (unstable) and posterior/ (unstable) and posterior/ middle/ anterior (unstable) middle/ anterior (unstable) ligaments without fracture.ligaments without fracture.

One column stable, 2 or 3 One column stable, 2 or 3 unstable.unstable.

Delay in healing with Delay in healing with eventual surgical fusion eventual surgical fusion fairly common.fairly common.

Can be a difficult diagnosis.Can be a difficult diagnosis.

Flexion-Extension FilmsFlexion-Extension Films

May be helpful in May be helpful in ligament injuriesligament injuries

-but are--but are-

Frequently useless due Frequently useless due to muscle spasmto muscle spasm

Flexion-Extension filmsFlexion-Extension films

Rules: Patient must be Rules: Patient must be alert, awake, not alert, awake, not intoxicated, able to sit intoxicated, able to sit or stand, able to or stand, able to understand commands, understand commands, and without neurologic and without neurologic deficit.deficit.

It is an Active, patient-generated It is an Active, patient-generated STRESS TESTSTRESS TEST

NEVER “help” the NEVER “help” the patient to “improve” patient to “improve” ROM.ROM.

NEVER do passive NEVER do passive ROM: this is a ROM: this is a neurosurgical procedure neurosurgical procedure done under fluoroscopic done under fluoroscopic control and is control and is controversial.controversial.

MRIMRI

Gold Standard for spinal Gold Standard for spinal canal, cord, disc lesions.canal, cord, disc lesions.

Silver Standard for Silver Standard for ligament injuries, but ligament injuries, but there is no Gold and there is no Gold and much better than plain much better than plain films, CT, and films, CT, and flexion/extension.flexion/extension.

Bilateral Interfacetal DislocationBilateral Interfacetal Dislocation

BID, also called “locked BID, also called “locked facets” is anything but facets” is anything but locked. It is a severe 3 locked. It is a severe 3 column injury that is column injury that is completely unstable.completely unstable.

Cord is injured in 2/3.Cord is injured in 2/3. Body is subluxed anteriorly Body is subluxed anteriorly

at least 50%.at least 50%. Marked posterior Marked posterior

distraction.distraction.

Hyperflexion Teardrop Fracture- Hyperflexion Teardrop Fracture- dislocation dislocation

Among the worst Among the worst survivable injuries, with survivable injuries, with nearly 100% severe nearly 100% severe cord lesion.cord lesion.

Completely unstable.Completely unstable. Little chance of Little chance of

neurologic neurologic improvement.improvement.

Hyperflexion Teardrop Fracture-Hyperflexion Teardrop Fracture-dislocationdislocation

CT Sagittal ReformatCT Sagittal Reformat

Spinous Process FractureSpinous Process Fracture

The “clay shoveler’s The “clay shoveler’s fracture”.fracture”.

Usually flexion, but can Usually flexion, but can be extension or direct be extension or direct blow.blow.

Stable if isolated, but do Stable if isolated, but do CT to look for CT to look for associated posterior associated posterior arch fractures.arch fractures.

Spinous Process FractureSpinous Process Fracture


FLEXION-ROTATIONFLEXION-ROTATIONInjuriesInjuries

Unilateral Interfacetal Dislocation Unilateral Interfacetal Dislocation and Fracture-dislocationand Fracture-dislocation

Unilateral Interfacetal Unilateral Interfacetal DislocationDislocation

UID is not stable, as the UID is not stable, as the contralateral capsule contralateral capsule ligaments are torn.ligaments are torn.

Cord injury is uncommon, Cord injury is uncommon, but root injury is common, but root injury is common, and HNP also occurs.and HNP also occurs.

Findings can be subtle: less Findings can be subtle: less than 50% subluxation, than 50% subluxation, malalignment of spinous malalignment of spinous processes.processes.

CT: This is a normal facet joint, CT: This is a normal facet joint, normal “hamburger sign”normal “hamburger sign”

UIDUID

CT: UID has “reversed CT: UID has “reversed hamburger sign” of hamburger sign” of facet joint.facet joint.

CT is also more CT is also more sensitive for associated sensitive for associated lateral mass fractures.lateral mass fractures.

UIDUID

Oblique viewOblique view


EXTENSION INJURIESEXTENSION INJURIESFamily motto:Family motto:

“Anterior distraction, “Anterior distraction,

posteriorposterior impactionimpaction””

Posterior arch fracturesPosterior arch fractures

Extension teardrop fracturesExtension teardrop fractures

Extension fracture-dislocationsExtension fracture-dislocations

Posterior Arch FracturesPosterior Arch Fractures Plain films are insensitive, CT Plain films are insensitive, CT

is outstanding.is outstanding. Isolated: pedicle, lateral mass, Isolated: pedicle, lateral mass,

lamina or spinous process.lamina or spinous process. Multiple fractures are common. Multiple fractures are common.

Pedicle/lamina fractures cause Pedicle/lamina fractures cause free-floating lateral mass.free-floating lateral mass.

May be additional element of May be additional element of lateral bending.lateral bending.

Stability depends on what is Stability depends on what is fractured.fractured.

Extension Teardrop FractureExtension Teardrop Fracture

Avulsion fracture caused by Avulsion fracture caused by anterior longitudinal anterior longitudinal ligament.ligament.

Vertical narrow fracture of Vertical narrow fracture of anterior-inferior corner of anterior-inferior corner of body.body.

Most common site is C2.Most common site is C2. Unstable.Unstable.

EXTENSION Fracture- EXTENSION Fracture- dislocationdislocation

More severe force More severe force fractures the body along fractures the body along end plate and causes end plate and causes subluxation, usually subluxation, usually posterior.posterior.

Fracture is oriented Fracture is oriented longitudinally, and there longitudinally, and there is malalignment of the is malalignment of the bodies. bodies.

AXIAL LoadingAXIAL Loading

““Burst” fractures Burst” fractures explode the body.explode the body.

All are very unstable All are very unstable and cause cord injury in and cause cord injury in 2/3 (except C1).2/3 (except C1).

There is usually an There is usually an element of flexion also.element of flexion also.

BURST FracturesBURST Fractures

On lateral, body is On lateral, body is compressed anteriorly, compressed anteriorly, inferior end plate often inferior end plate often fractured, posterior fractured, posterior body contour is convex.body contour is convex.

On AP, body fracture is On AP, body fracture is vertical or oblique and vertical or oblique and pedicles spread.pedicles spread.

BURST FracturesBURST Fractures

CT more accurately CT more accurately displays the fracture displays the fracture pattern and the very pattern and the very important degree of important degree of narrowing of the spinal narrowing of the spinal canal.canal.

The CXR: RevisitedThe CXR: Revisited

CXRCXR

Fullest inspiration if possible (see example of Fullest inspiration if possible (see example of difference in expiration and inspiration in difference in expiration and inspiration in module)module)

DimensionsDimensions A:P < 2 years – 1:1A:P < 2 years – 1:1 > 2 years – 2:1> 2 years – 2:1

Normal Chest X-rayNormal Chest X-ray

1. Soft tissue structures1. Soft tissue structures Shadows, most commonly, breastShadows, most commonly, breast

2.2. Bony structuresBony structures Count the ribsCount the ribs ~ 8 – 9 ribs should be visible on inspiration~ 8 – 9 ribs should be visible on inspiration Clavicle placement at ~ 2-3 intercostal space (if Clavicle placement at ~ 2-3 intercostal space (if

not, may be malrotated)not, may be malrotated)


Cardiac StructuresCardiac Structures PositionPosition

More central in younger infants and childrenMore central in younger infants and children More on the L side in older infants and teensMore on the L side in older infants and teens

SizeSize In AP view if < 2 years – take up to ~ 65%In AP view if < 2 years – take up to ~ 65% If > 2 years - ~ 50%If > 2 years - ~ 50%


3.3. DiaphragmDiaphragm ContourContour Rounded with sharp pointed costophrenic and Rounded with sharp pointed costophrenic and

costocardiac anglescostocardiac angles Right diaphragm is usually 1-2 cm higherRight diaphragm is usually 1-2 cm higher


Start at the top and compare the R and LStart at the top and compare the R and L Trachea should be midline over the thoracic Trachea should be midline over the thoracic

vertebrae and air filledvertebrae and air filled Lung parenchyma becomes lighter as you go Lung parenchyma becomes lighter as you go

down the lung. If not, it may indicate a lower down the lung. If not, it may indicate a lower lobe or pleural effusionlobe or pleural effusion

LungsLungs

Abnormal Chest X-rayAbnormal Chest X-ray

Radiopacity (whiteness) means increased densityRadiopacity (whiteness) means increased density

Radiotranslucency (blackness) means decreased Radiotranslucency (blackness) means decreased densitydensity

CXR: PositionsCXR: Positions

P-A viewP-A view A-PA-P A-P supineA-P supine Lateral (Lt’/Rt’)Lateral (Lt’/Rt’) Lateral decubitus Lateral decubitus

(Lt’/Rt’)(Lt’/Rt’) LordoticLordotic Oblique(Rt’/Lt’; Oblique(Rt’/Lt’;

post/anterior)post/anterior)

PositionsPositions

Special position for special purposeSpecial position for special purpose A-P supine: Ambulatory limit A-P supine: Ambulatory limit A-P Lateral (Lt’/Rt’): AnatomyA-P Lateral (Lt’/Rt’): Anatomy readingreading Lateral decubitus: EffusionLateral decubitus: Effusion or thickeningor thickening Lordotic: ApicalLordotic: Apical lesionlesion Oblique: Eliminate superimposed lesionOblique: Eliminate superimposed lesion

PositionsPositions

P-A view

Rt’ Lateral view

Rt’ Lateral decubitus view

Density: 4 basic radiographic densitiesDensity: 4 basic radiographic densities

Air FatWater(soft tissue)Bone metal)

You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

IDEAL Kv EXPOSURE:

IDEAL Kv & EXPOSURE factors:

small pneumothorax present on the radiograph to the left.

The importance of exposure factorsThe importance of exposure factors

Anatomy & projection

General anatomy

•Rib(Ant/Post)•Left 2/Right 4•Costothoracic ratio•Central trachea•Hilar: Lt>Rt

Lung field: •Central> Peripheral•Pleura: Linear•Diaphragm: Right >left/ Angle/Gastric pattern•Subcutaneous tissue

Lobar anatomySegmental anatomy

Normal AnatomyNormal Anatomy

Anatomy of lateral Anatomy of lateral viewview

Right diaphragmRight diaphragmLeft diaphragmLeft diaphragmSpineSpineScapulaScapulaAxillary foldAxillary foldSternumSternumSubcutaneous tissueSubcutaneous tissueTracheaTracheaAortic archAortic archMain bronchusMain bronchusPulmonary arteryPulmonary arteryHeartHeartRetrosternal clear spaceRetrosternal clear spaceRetrocardiac clear spaceRetrocardiac clear spaceCostophrenic angleCostophrenic angle

Lobar anatomy

MEDIASTINUMMEDIASTINUM SUPERIOR MEDIASTINUM SUPERIOR MEDIASTINUM

Begins - Begins - root root of the neck and of the neck and Ends - line drawn Ends - line drawn T-4 vertebrae T-4 vertebrae --- ---

sternomandible junctionsternomandible junction. . line skims the top of the aortic line skims the top of the aortic

arch. Tarch. T MediastinumMediastinum

Begins - this line Begins - this line End- diaphragm End- diaphragm Further divided into three regionsFurther divided into three regions

AnteriorAnterior MiddleMiddle Posterior. Posterior.

SUPERIOR MEDIASTINUM - PASUPERIOR MEDIASTINUM - PA

Overall width for normal size, Overall width for normal size, Look for Look for

MassesMasses CalcificationsCalcifications Free air. Free air.

Detailed search for subtle Detailed search for subtle distortion of distortion of several major pleural mediastinal several major pleural mediastinal

interfaces. interfaces. Not all of the following Not all of the following

structures are seen on every structures are seen on every filmfilm Try to find themTry to find them

MEDIASTINUMMEDIASTINUM

Overall size/ shape Overall size/ shape on PA & lateral views on PA & lateral views Decide if it is normal & age. Decide if it is normal & age. Any shiftAny shift

Look for Look for Obvious masses Obvious masses CalcificationsCalcifications Double check for foreign projectsDouble check for foreign projects

TubesTubes Electrical leads Electrical leads PacemakerPacemaker Artificial valvesArtificial valves

Neck and Cervical spinesNeck and Cervical spines Overall(soft tissue)Overall(soft tissue)

calcifications, calcifications, subcutaneous subcutaneous

emphysema emphysema TracheaTrachea

position position sizesize

Cervical spine, Cervical spine, alignment alignment congenital abnormality. congenital abnormality.

Specific parts of the Specific parts of the vertebra and disc spacesvertebra and disc spaces

CheckCheck erosions erosions lytic or sclerotic lesions lytic or sclerotic lesions disc and vertebral / joint disc and vertebral / joint

narrowing narrowing Other abnormalities.Other abnormalities.

Thoracic spine and Rib cageThoracic spine and Rib cage

Overall alignment- spine Overall alignment- spine Symmetry - rib cageSymmetry - rib cage Double check bone densityDouble check bone density Two reminders at this Two reminders at this

point:point: Principle of general Principle of general

More detailed More detailed review in each review in each section.section.

concentrate on the concentrate on the skeletal detail skeletal detail

““Look through" Look through" the mediastinum the mediastinum and lungs.and lungs.

Thoracic spineThoracic spine

Specific parts ( EachSpecific parts ( Each)) Vertebra Vertebra Disc spaces Disc spaces

heightheight integrity integrity of cortical margins/pedicles/laminaof cortical margins/pedicles/lamina presence of any presence of any lytic lytic or or sclerotic sclerotic areasareas synovial joints normalsynovial joints normal /narrowing /sclerosis /narrowing /sclerosis spacing spacing ))

Compare Compare frontal & lateral projectionsfrontal & lateral projections

Thoracic spineThoracic spine

RibsRibs

1. Posterior Rib 1. Posterior Rib

2. Anterior Rib2. Anterior Rib

RibsRibs

Compare Compare Side to side, Side to side, Cortical margins, Cortical margins, Trabecular patterns. Trabecular patterns.

Note calcified anterior cartilagesNote calcified anterior cartilages may may obscure obscure or or mimic mimic underlying lung lesions.underlying lung lesions.

The shoulder girdle

Pathophysiology of Thoracic Pathophysiology of Thoracic TraumaTrauma

Penetrating TraumaPenetrating Trauma Low EnergyLow Energy

Arrows, knives, handgunsArrows, knives, handguns Injury caused by direct contact Injury caused by direct contact

and cavitationand cavitation

High EnergyHigh Energy Military, hunting rifles & high Military, hunting rifles & high

powered hand gunspowered hand guns Extensive injury due to high Extensive injury due to high

pressure cavitationpressure cavitation

Trauma.org

Pathophysiology of Thoracic Pathophysiology of Thoracic TraumaTrauma

Penetrating Injuries (cont.)Penetrating Injuries (cont.) ShotgunShotgun

Injury severity based upon the distance between the victim and Injury severity based upon the distance between the victim and shotgun & caliber of shotshotgun & caliber of shot

Type I: >7 meters from the weaponType I: >7 meters from the weapon Soft tissue injurySoft tissue injury

Type II: 3-7 meters from weaponType II: 3-7 meters from weapon Penetration into deep fascia and some internal organsPenetration into deep fascia and some internal organs

Type III: <3 meters from weaponType III: <3 meters from weapon Massive tissue destructionMassive tissue destruction

Gunshot WoundGunshot Wound

Special type of puncture woundSpecial type of puncture wound Transmitted energy can cause injury remote Transmitted energy can cause injury remote

from bullet trackfrom bullet track Bullets change direction, tumbleBullets change direction, tumble Impossible to assess severity in field or ERImpossible to assess severity in field or ER Patient must go to ORPatient must go to OR

Trauma.org

Injuries Associated with Injuries Associated with Penetrating Thoracic TraumaPenetrating Thoracic Trauma

Closed pneumothoraxClosed pneumothorax Open pneumothorax Open pneumothorax

(including sucking chest (including sucking chest wound)wound)

Tension pneumothoraxTension pneumothorax PneumomediastinumPneumomediastinum HemothoraxHemothorax HemopneumothoraxHemopneumothorax Laceration of vascular Laceration of vascular

structuresstructures

Tracheobronchial tree Tracheobronchial tree lacerationslacerations

Esophageal lacerationsEsophageal lacerations Penetrating cardiac injuriesPenetrating cardiac injuries Pericardial tamponadePericardial tamponade Spinal cord injuriesSpinal cord injuries Diaphragm traumaDiaphragm trauma Intra-abdominal penetration Intra-abdominal penetration

with associated organ injurywith associated organ injury

ContusionContusion

HemothoraxHemothorax

Accumulation of blood in the pleural Accumulation of blood in the pleural spacespace

Serious hemorrhage : 1,500 mL of Serious hemorrhage : 1,500 mL of bloodblood

Mortality rate of 75%Mortality rate of 75%

Each side of thorax may hold up Each side of thorax may hold up to 3,000 mLto 3,000 mL

Blood loss in thorax causes a decrease Blood loss in thorax causes a decrease in tidal volumein tidal volume

Ventilation/Perfusion Mismatch Ventilation/Perfusion Mismatch & Shock& Shock

Typically accompanies Typically accompanies pneumothoraxpneumothorax

HemopneumothoraxHemopneumothorax

PneumothoraxPneumothorax

Tension PneumothoraxTension Pneumothorax

•Buildup of air under pressure in Buildup of air under pressure in the thorax.the thorax.

•Excessive pressure reduces Excessive pressure reduces effectiveness of respirationeffectiveness of respiration

•Air is unable to escape from inside Air is unable to escape from inside the pleural spacethe pleural space

Gas under diaphragmGas under diaphragm

The CXR: Check List (1)The CXR: Check List (1)

1.1. Check patient name, position, technical qualityCheck patient name, position, technical quality.. 2.2. Initial surveyInitial survey3.3. Soft tissue including breast, chest wall, companion shadow.Soft tissue including breast, chest wall, companion shadow.

• Review soft tissues and skeletal structures of shoulder girdles and chest Review soft tissues and skeletal structures of shoulder girdles and chest wall.wall.

• Review abdomen for bowel gas, organ size, abnormal calcifications, free Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.air, etc.

• Review soft tissues and spine of neck.Review soft tissues and spine of neck. • Review spine and rib cage: check alignment, disc space narrowing, lytic Review spine and rib cage: check alignment, disc space narrowing, lytic

or blastic regions, etc.or blastic regions, etc. 4.4. Review mediastinum:Review mediastinum:

overall size and shapeoverall size and shape trachea: positiontrachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, margins: SVC, ascending aorta, right atrium, left subclavian artery,

aortic arch, main pulmonary artery, left ventricleaortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal lines and stripes: paratracheal, paraspinal, paraesophageal

(azygoesophageal), paraaortic(azygoesophageal), paraaortic retrosternal clear spaceretrosternal clear space

Check List (2)Check List (2)

Review hila:Review hila: normal relationshipsnormal relationships sizesize

Review lungs and pleura:Review lungs and pleura: compare lung sizescompare lung sizes evaluate pulmonary vascular pattern: compare upper evaluate pulmonary vascular pattern: compare upper

to lower lobe, right to left, normal tapering to peripheryto lower lobe, right to left, normal tapering to periphery pulmonary parenchymapulmonary parenchyma pleural surfacespleural surfaces

fissures - major and minor - if seenfissures - major and minor - if seen compare hemidiaphragmscompare hemidiaphragms follow pleura around rib cagefollow pleura around rib cage

Lastly remember the A-B-C-D-E-F-G-HLastly remember the A-B-C-D-E-F-G-H of CXR !! of CXR !!

o AA: : AAirwayirwayo BB: : BBoneoneo CC: : CCPAPAo DD: : DDiaphragmiaphragmo EE: : EExtra-pulmonary xtra-pulmonary o FF: : LLung ung ffieldieldo GG: : GGastric bubbleastric bubbleo HH: : HHilum / ilum / HHerniaernia

Pelvi-acetabular FracturesPelvi-acetabular Fractures

The X-Ray PelvisThe X-Ray Pelvis

BASIC PRINCIPLES IN RADIOLOGY

OF

BONE TRAUMA

Radiograph should include the joint nearest to the trauma/ joint above & joint below

The paired bone concept.

The weakest link concept (Adult vs. Children).

Comparison films.

BASIC PRINCIPLES IN RADIOLOGY

OF

BONE TRAUMA

The weakest link

• The soft tissue structures (muscles/ ligaments/ tendons) in AdultsAdults

• The physeal plate (growth plate) in ChildrenChildren

Normal pelvic bone anatomy.Normal pelvic bone anatomy.

Surface-rendering 3D CT of pelvis in lateral view with femur and right hemipelvis removed shows Surface-rendering 3D CT of pelvis in lateral view with femur and right hemipelvis removed shows anterior column (anterior column (greengreen), posterior column (), posterior column (blueblue), and sciatic buttress (), and sciatic buttress (redred). ).

Normal Pelvic X-RayNormal Pelvic X-Ray

Normal pelvic bone anatomy. Anteroposterior radiograph shows Normal pelvic bone anatomy. Anteroposterior radiograph shows iliopectineal line (iliopectineal line (greengreen), ilioischial line (), ilioischial line (blueblue), anterior acetabular wall ), anterior acetabular wall ((yellowyellow), posterior acetabular wall (), posterior acetabular wall (pinkpink), and obturator foramen (O). ), and obturator foramen (O).

Illustrations of classification of five most Illustrations of classification of five most common acetabular fractures. common acetabular fractures.

Common acetabular fractures can easily be classified using Common acetabular fractures can easily be classified using disruption of the obturator ring as the basis of a decision tree disruption of the obturator ring as the basis of a decision tree

Fracture of obturator ring indicates both-column or T-Fracture of obturator ring indicates both-column or T-shaped fracture, with additional iliac wing involvement shaped fracture, with additional iliac wing involvement differentiating the both-column from the T-shaped fracture. differentiating the both-column from the T-shaped fracture.

Sparing of the obturator ring commonly indicates transverse, Sparing of the obturator ring commonly indicates transverse, transverse with posterior wall, or isolated posterior wall transverse with posterior wall, or isolated posterior wall fracture.fracture.

Disruption of both the iliopectineal and ilioischial lines Disruption of both the iliopectineal and ilioischial lines indicates a transverse fracture, and comminution of the indicates a transverse fracture, and comminution of the posterior wall indicates a posterior wall fracture. posterior wall indicates a posterior wall fracture.

A both-column fracture is in coronal plane, whereas transverse A both-column fracture is in coronal plane, whereas transverse or T-shaped fracture is in sagittal oblique plane on CT. or T-shaped fracture is in sagittal oblique plane on CT.

T-shaped fractureT-shaped fracture

T-shaped fractureT-shaped fracture

show obturator ring fractures (show obturator ring fractures (arrowheadsarrowheads) and transverse ) and transverse component (component (arrowsarrows) through acetabulum. ) through acetabulum.

Transverse fracture.Transverse fracture.

Transverse with posterior wall fractureTransverse with posterior wall fracture

Isolated posterior wall fracture.Isolated posterior wall fracture.

both-column acetabular fractureboth-column acetabular fracture

both-column acetabular fracture and spur signboth-column acetabular fracture and spur sign

spur sign (spur sign (arrowarrow), which represents displacement of fracture involving ), which represents displacement of fracture involving sciatic buttress (sciatic buttress (arrowheadsarrowheads). Note that sciatic buttress (). Note that sciatic buttress (arrowheads,arrowheads, BB) ) no longer connects to weight-bearing portion of acetabulum. no longer connects to weight-bearing portion of acetabulum.

THANK YOU !!THANK YOU !!

imaging in trauma

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