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Recognizing the Imaging Findings of Trauma to the Chest


Trauma is the leading cause of death, hospitalization, and disability in Americans from the age of 1 year through age 45. The major imaging findings of chest trauma will be discussed in this chapter. Table 24.1 summarizes some of the traumatic injuries that are discussed in other chapters.

Case Quiz 24 Question

This is an image from an axial CT scan of the chest in a 31-year-old male who sustained significant blunt trauma to the right side of his thorax. He has hemoptysis. There are two manifestations of pulmonary trauma demonstrated here. What are they? See the answer at the end of this chapter.

  • Trauma-related injuries can be divided by the two major mechanisms that produce them.

    • Blunt trauma is usually the result of motor vehicle accidents and is the more common of the two.

    • Penetrating trauma is usually the result of accidental or criminal stabbings and gunshot wounds.

    • Table 24.2 is an overview of the initial imaging workup for penetrating injuries to various body parts.

      TABLE 24.2
      Initial Imaging Workup of Penetrating Trauma
      Body Part Studies of Choice
      Head CT scan of the head without and then possibly with contrast.
      Neck CT angiogram of head and neck if damage to the vessels is suspected.
      Chest Chest radiographs are obtained first; ultrasound FAST scan of chest, abdomen, and pelvis; then a contrast-enhanced CT scan of the chest in almost all patients unless hemodynamically unstable.
      Abdomen Ultrasound FAST scan of chest, abdomen, and pelvis; contrast-enhanced CT scan of abdomen and pelvis and possibly chest.

  • In this chapter, we will discuss various manifestations of chest trauma, starting from the periphery (chest wall) and progressing centrally (aorta).

  • Chest injuries in trauma patients are very common and are responsible for one out of four of the trauma-related deaths. The overwhelming majority of chest trauma is the result of motor vehicle accidents.

TABLE 24.1
Other Manifestations of Trauma
Injury Discussed in
Pleural effusion/hemothorax Chapter 7
Aspiration Chapter 8
Fractures and dislocations Chapter 23
Spinal trauma Chapter 23
Abdominal and pelvic trauma Chapter 25
Head trauma Chapter 26

Chest Wall Trauma

Rib Fractures

  • Rib fractures are a common result of blunt chest trauma and the associated morbidity and mortality from such trauma increases as the number of rib fractures increases. The severity of underlying visceral injury is usually more important than the rib fractures themselves, but their presence might provide clues to unsuspected pathology.

Important Points

  • Fractures of the first three ribs are relatively uncommon and, if they occur following blunt trauma, indicate a sufficient amount of force to produce other internal injuries ( Fig. 24.1 ).

    Fig. 24.1, Rib Fractures.

  • Fractures of ribs 4 to 9 are common and especially important if they are displaced (they can produce a pneumothorax) or if there are two fractures seen radiographically in each of three or more contiguous ribs (flail chest).

    • Flail chest is almost always accompanied by a pulmonary contusion (see later). Partly because of the severity of the injuries with which it is usually associated, a flail chest has a significant mortality ( Fig. 24.2 ).

      Fig. 24.2, Flail Chest.

  • Fractures of ribs 10 to 12 may indicate the presence of underlying trauma to the liver (right side) or the spleen (left side), especially if they are displaced ( ).

  • In cases of minor trauma, it is not unusual for rib fractures to be undetectable on the initial examination but to become visible in several weeks after callus begins to form.

Subcutaneous Emphysema

  • Air can extend into the soft tissues of the neck, chest, and abdominal walls from the mediastinum, or it can dissect in the subcutaneous tissues from a thoracotomy drainage tube or a penetrating injury to the chest wall.

  • Air dissecting along muscle bundles produces a characteristic comb-like, striated appearance that superimposes on the underlying lung, sometimes making it difficult to evaluate the lungs by conventional radiography ( Fig. 24.3 ).

    Fig. 24.3, Subcutaneous Emphysema.

  • Even though it may present a striking imaging appearance, subcutaneous emphysema usually produces no serious clinical effects by itself.

  • Depending on the volume of subcutaneous air present, it may require several days to a week or longer for the air to reabsorb.

Pleural Abnormalities: Pneumothorax

Causes of a Pneumothorax

  • Spontaneous

    • Spontaneous pneumothoraces are common and often develop from rupture of an apical, subpleural bleb or bulla. They characteristically occur in tall, thin males between 20 to 40 years of age. Trauma is not a prerequisite for a spontaneous pneumothorax.

  • Traumatic

    • Trauma is the most common cause of a pneumothorax, either accidental or iatrogenic. The trauma may be:

      • Through the chest wall, e.g., stab wound

      • Internal, e.g., rupture of a bronchus from a motor vehicle collision

      • Iatrogenic, e.g., following an attempt at central venous catheter insertion

  • Diseases that decrease lung compliance

    • Chronic fibrotic disease, e.g., eosinophilic granuloma of the lung, or diseases like neonatal respiratory distress syndrome (hyaline membrane disease) in infants.

  • Rupture of an alveolus or bronchiole , e.g., asthma

Types of Pneumothoraces

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