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Chest Radiography in Thoracic Polytrauma

¹ St. Luke's Hospital, 222 S Woods Mill Rd., Suite 760 N, Chesterfield, MO 63110.
² Washington University School of Medicine, St. Louis, MO 63110.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —37-year-old man 2 weeks after knife wound to chest. Frontal chest radiograph shows extensive subcutaneous emphysema (arrows) and air outlining fibers of pectoralis muscles bilaterally ("ginkgo leaf" sign) (asterisks).

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —31-year-old woman with superficial anterior chest trauma. Frontal chest radiograph shows radiodense opacity (asterisk) overlying right chest wall. CT confirmed presence of subcutaneous hematoma.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —15-year-old boy with gunshot wound to axilla. Frontal chest radiograph shows bullet (asterisk) and surrounding shrapnel in soft tissues of axilla.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —41-year-old woman injured in motor vehicle collision. Frontal chest radiograph shows scapular body fracture (short arrow) and multiple left clavicular fractures (long arrows).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —26-year-old man with blunt trauma to right shoulder. Frontal chest radiograph shows inferior displacement of medial end of right clavicle (asterisk). CT revealed posterior sternoclavicular joint dislocation.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Fractures of the ribs. 21-year-old man with remote history of bilateral rib fractures who was injured in motor vehicle crash. Frontal chest radiograph shows radiodense fracture callus (asterisks), indicative of healed fracture.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Fractures of the ribs. 30-year-old man injured in motor vehicle crash. Frontal chest radiograph shows left-sided fractures in posterior segments of at least seven adjacent ribs (arrows), creating flail chest physiology.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —25-year-old man injured in motor vehicle collision. Lateral chest radiograph shows fracture and displacement of sternum (double-headed arrow).

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —Injuries of the spine. 22-year-old man after motor vehicle collision. Frontal chest radiograph (A) shows widening of left and right paraspinal lines (arrows), suggestive of paraspinal hematoma. Lateral chest radiograph (B) identifies acute angulation of thoracic spine, indicating fracture (arrow), as well as adjacent vertebral wedge compression fracture (asterisk).

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —Injuries of the spine. 22-year-old man after motor vehicle collision. Frontal chest radiograph (A) shows widening of left and right paraspinal lines (arrows), suggestive of paraspinal hematoma. Lateral chest radiograph (B) identifies acute angulation of thoracic spine, indicating fracture (arrow), as well as adjacent vertebral wedge compression fracture (asterisk).

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —Injuries of the spine. 29-year-old woman 2 weeks after penetrating injury to back. Frontal chest radiograph identifies focal disk space narrowing (arrows) and large paraspinal opacities (asterisks). MRI showed diskitis with surrounding abscess formation.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Injuries to the diaphragm and abdominal organs. 24-year-old man after motor vehicle crash. Frontal chest radiograph shows intrathoracic herniation of stomach (thick arrows) through ruptured left hemidiaphragm, along with internal air–fluid level (thin arrows).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Injuries to the diaphragm and abdominal organs. 37-year-old man after fall injury. Frontal chest radiograph shows focal rounded opacity (asterisk) arising from left hemidiaphragm (collar sign). CT confirmed herniation of stomach through ruptured hemidiaphragm.

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —Injuries to the diaphragm and abdominal organs. 27-year-old woman injured in motor vehicle crash. Frontal chest radiograph shows focal rounded opacity (asterisk) arising from right hemidiaphragm ("cottage loaf" sign). CT confirmed herniation of liver through ruptured hemidiaphragm.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9D —Injuries to the diaphragm and abdominal organs. 18-year-old woman injured in motor vehicle crash. Erect frontal chest radiograph shows bilateral pneumoperitoneum (arrows) in superolateral abdominal region.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9E —Injuries to the diaphragm and abdominal organs. 32-year-old man injured in motor vehicle crash. Supine frontal chest radiograph shows pneumoperitoneum with anteromedial accumulation of air (cupola sign) (arrows).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9F —Injuries to the diaphragm and abdominal organs. 61-year-old woman with remote history of chest trauma and diaphragmatic rupture. Frontal chest radiograph shows multiple left-sided rib masses (asterisks) and irregularities (bracket). Heat-damaged RBC scintigraphy was diagnostic for splenosis.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —Pneumothorax injuries. 18-year-old woman injured in motor vehicle crash. Erect frontal chest radiograph shows left-sided pneumothorax ("visceral pleural line" sign) (arrows).

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —Pneumothorax injuries. 16-year-old boy injured in motor vehicle crash. Supine frontal chest radiograph shows pneumothorax in costophrenic sulcus (deep sulcus sign) (asterisk).

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —Pneumothorax injuries. 24-year-old man with penetrating knife wound to right chest. Frontal chest radiograph shows complete right lung collapse (unilateral hyperlucent lung) (asterisk) with ipsilateral hemidiaphragmatic depression, widened intercostal spaces, and contralateral mediastinal shift (arrows) indicative of tension pneumothorax. Patient was immediately decompressed using large-bore needle thoracostomy.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —Complicated pleural injuries. 45-year-old man with stab wound to left chest. Frontal chest radiograph shows pleural effusion (asterisk) opacifying entire left hemithorax (opacified hemithorax) with contralateral mediastinal shift (arrows). CT attenuation was 50 HU, confirming tension hemothorax.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —Complicated pleural injuries. 42-year-old man with chronic empyema and opening in right chest wall. Frontal chest radiograph shows right-sided pleural effusion (asterisk) and chest wall defect (arrow). CT confirmed empyema necessitatis.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12 —15-year-old girl with blunt injury to lower thorax. Frontal chest radiograph shows pleural effusion (asterisk) opacifying entire right hemithorax. CT attenuation was –30 HU, and thoracentesis confirmed chylothorax.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13 —64-year-old man injured in motor vehicle collision. Frontal chest radiograph shows left-sided lung herniation (asterisk).

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —Lobar collapse injuries. 21-year-old patient with asthma with left upper lobe collapse. Frontal radiograph shows compensatory hyperexpansion of superior segment of left lower lobe creating paraaortic crescent of hyperlucency (luftsichel sign) (asterisks).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —Lobar collapse injuries. 36-year-old patient with history of interstitial lung disease and new left upper lobe collapse. Frontal radiograph shows tenting of ipsilateral hemidiaphragm with visualization of inferior accessory fissure ("juxtaphrenic peak" or "Katten" sign) (arrow).

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14C —Lobar collapse injuries. 51-year-old mechanically ventilated patient with history of smoking and bronchogenic carcinoma presenting with right upper and left lower lobe collapse. Frontal radiograph shows dense opacification of heart silhouette ("ivory heart" sign) and loss of concavity of left heart border ("flat waist" sign) (arrow).

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14D —Lobar collapse injuries. 31-year-old patient after abdominal surgery with right lower lobe collapse. Frontal radiograph shows triangular opacity (arrow) representing traction on superior mediastinum (superior triangle sign).

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14E —Lobar collapse injuries. 48-year-old patient in intensive care unit with acute bronchial obstruction from mucus plugging. Frontal radiograph shows pneumothorax ex vacuo developing around collapsed right upper lobe (arrows), which resolved after bronchoscopy.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —Pulmonary parenchymal injuries. 48-year-old woman 1 hour after motor vehicle collision. Frontal chest radiograph shows diffuse bilateral opacities, suggestive of pulmonary contusions.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —Pulmonary parenchymal injuries. 37-year-old man 1 week after blunt chest trauma. Frontal chest radiograph shows diffuse bilateral opacities and right-sided cavitary lung lesion (asterisk), reflecting sequela of prior lung laceration.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16 —35-year-old woman 24 hours after motor vehicle collision. Frontal chest radiograph shows diffuse patchy lung opacities, suggesting acute respiratory distress syndrome.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17A —Pneumomediastinum. 30-year-old woman with pneumomediastinum. Frontal chest radiograph shows air in mediastinum outlining central portion of diaphragm (continuous diaphragm sign) (arrows).

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17B —Pneumomediastinum. 25-year-old man with pneumomediastinum. Lateral chest radiograph shows air in mediastinum outlining left hemidiaphragm ("continuous left hemidiaphragm" sign) (arrows).

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17C —Pneumomediastinum. 32-year-old woman with esophageal rupture after blunt trauma. Frontal chest radiograph shows triangular radiolucency in left cardiophrenic angle ("Naclerio's V" sign) (asterisk).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17D —Pneumomediastinum. 41-year-old woman with pneumomediastinum. Lateral chest radiograph shows air surrounding right pulmonary artery ("ring-around-the-artery" sign) (arrows).

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —Mediastinal bleeding and infection. 43-year-old man with penetrating injury to chest. Frontal chest radiograph identifies mediastinal widening (double-headed arrow), suggestive of vascular injury. CT confirmed mediastinal hematoma.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —Mediastinal bleeding and infection. 28-year-old man with history of mediastinal infection. Frontal chest radiograph identifies mediastinal widening (double-headed arrow) and pulmonary edema. CT confirmed presence of mediastinitis.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19A —Tracheobronchial injuries. 39-year-old man injured in motor vehicle crash. Frontal chest radiograph shows irregularity of left main bronchus (arrow) and mediastinal widening (double-headed arrow), indicative of paratracheal hematoma.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19B —Tracheobronchial injuries. 21-year-old woman 1 week after tracheobronchial injury. Frontal chest radiograph shows collapse of left lung with inferolateral displacement (fallen lung sign) (asterisk).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19C —Tracheobronchial injuries. 40-year-old man 4 months after tracheobronchial injury. Frontal chest radiograph shows diffuse tracheal stenosis (arrows).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 20A —Esophageal injuries. 31-year-old man with Boerhaave's syndrome. Frontal chest radiograph shows bilateral pneumomediastinum (arrows).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 20B —Esophageal injuries. 34-year-old woman with hiatal hernia. Frontal chest radiograph shows large retrocardiac opacity (arrows).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 21A —Pericardial tears and ruptures. 32-year-old woman injured in motor vehicle crash. Frontal chest radiograph shows convexity at normal location of main pulmonary artery (arrow). CT confirmed pericardial tear with focal cardiac herniation.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 21B —Pericardial tears and ruptures. 24-year-old man injured in motor vehicle crash. Frontal chest radiograph shows leftward shift of heart silhouette (asterisk). CT confirmed left-sided pericardial rupture.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 21C —Pericardial tears and ruptures. 36-year-old man injured in motor vehicle crash. Frontal chest radiograph shows complete rotation of heart silhouette (asterisk) with apex pointing toward right. CT confirmed diagnosis of right-sided pericardial rupture with resulting cardiac volvulus.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 22A —Pericardial effusion. 33-year-old woman with pericardial effusion. Frontal chest radiograph shows globular bilateral enlargement of cardiac silhouette ("water-bottle" sign) (asterisks).

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 22B —Pericardial effusion. 27-year-old man with pericardial effusion. Lateral chest radiograph shows separation of retrosternal and epicardial fat ("epicardial fat-pad," "Oreo cookie," sandwich, or stripe sign) (arrows).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 23A —Pneumopericardium. 43-year-old woman with pneumopericardium. Frontal chest radiograph shows band of air outlining heart (halo sign) inferiorly (arrows).

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 23B —Pneumopericardium. 34-year-old man with gunshot wound to chest. Frontal chest radiograph shows left-sided pneumothorax (asterisk) and bilateral pneumopericardium compressing heart ("small heart" sign) (arrows).

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 24A —Cardiac injuries. 28-year-old woman injured in motor vehicle crash. Frontal chest radiograph shows rounded opacity continuous with cardiac silhouette (asterisk). CT confirmed left ventricular aneurysm.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 24B —Cardiac injuries. 35-year-old man injured in motor vehicle crash. Frontal chest radiograph shows pulmonary edema predominantly in right upper lobe (asterisk). CT confirmed rupture of mitral valve.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 24C —Cardiac injuries. 61-year-old woman 2 years after myocardial infarction. Frontal chest radiograph shows calcification of left ventricular wall (arrows).

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 25A —Aortic injuries. 42-year-old woman with traumatic aortic injury. Frontal chest radiograph shows mediastinal widening (double-headed arrow), obscuration of aortic contour and opacification of aortopulmonary window (asterisk), depression of left mainstem bronchus (thick arrow), and rightward tracheal and esophageal deviation (thin arrows).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 25B —Aortic injuries. 37-year-old man 1 year after traumatic aortic injury. Frontal chest radiograph shows rounded opacity with peripheral calcification (asterisk) that arises from aortopulmonary window and exerts mass effect on trachea. CT confirmed presence of pseudoaneurysm.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 25C —Aortic injuries. 43-year-old woman with traumatic aortic injury. Frontal chest radiograph shows intraluminal displacement of calcified aortic intima (ring sign) (arrows). CT confirmed dissection at level of aortic arch.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 25D —Aortic injuries. 62-year-old woman with posttraumatic aortic aneurysm. Frontal chest radiograph shows markedly enlarged and tortuous aortic silhouette (double-headed arrows).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 26A —Subclavian artery injuries. 33-year-old man injured in motor vehicle collision. Frontal chest radiograph shows widening of superior mediastinum (arrows), suggestive of hematoma. CT confirmed left subclavian artery transsection.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 26B —Subclavian artery injuries. 18-year-old man with knife wound to chest. Frontal chest radiograph shows right superior mediastinal opacity (asterisk), suggestive of hematoma. CT confirmed right subclavian artery transsection.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27A —Pulmonary embolism. 42-year-old man with pulmonary embolism and infarction. Frontal chest radiograph shows pleura-based wedge-shaped opacity with apex pointing toward hilum (Hampton hump) (asterisk).

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27B —Pulmonary embolism. 57-year-old man with massive pulmonary embolism. Frontal chest radiograph shows enlargement of main (Fleischner sign) (P) and right descending ("Palla" sign) (arrows) pulmonary arteries as well as abrupt tapering of right pulmonary artery ("knuckle" sign) (asterisk).

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27C —Pulmonary embolism. 44-year-old woman with septic embolism. Frontal chest radiograph shows diffuse patchy nodular opacities of various sizes.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27D —Pulmonary embolism. 25-year-old woman who has femoral fracture from motor vehicle collision. Frontal chest radiograph obtained 1 week after collision shows diffuse patchy lung opacities, suggestive of fat embolism.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27E —Pulmonary embolism. 31-year-old pregnant woman with acute drop in oxygen saturation during labor. Frontal chest radiograph shows diffuse bilateral lung opacities, suggestive of amniotic fluid embolism.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 27F —Pulmonary embolism. 35-year-old man 1 day after gunshot wound to chest. Pelvic radiograph shows massive foreign body embolism in left lower quadrant of abdomen.

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