DOI:10.2214/AJR.07.3324
AJR 2009; 192:599-612
© American Roentgen Ray Society
Chest Radiography in Thoracic Polytrauma
Mai-Lan Ho1,2 and
Fernando R. Gutierrez2
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.
Received October 19, 2007;
accepted after revision August 17, 2008.
F. R. Gutierrez is the recipient of funding from Bracco Diagnostics,
Inc.
Address correspondence to M. L. Ho, 1309 Katsura Ct., Chesterfield, MO
63005
(mailanho{at}yahoo.com).
Abstract
OBJECTIVE. Chest radiography is the first-line imaging examination
for assessment of thoracic polytrauma, serving to evaluate the extent of
injury and facilitate early triage to observation, further imaging, or
immediate surgical intervention. The objective of this article is to review
the spectrum of injuries that occur in the chest and upper abdomen after blunt
and penetrating trauma. Pathophysiology, imaging findings, and management
recommendations will be discussed for injuries to the chest wall, diaphragm,
pleura, lungs, mediastinum, heart, aorta, and great vessels.
CONCLUSION. Chest radiography plays an important role in the initial
evaluation of blunt and penetrating chest trauma, providing rapid imaging
information to supplement the history and physical examination. In the
emergency department, familiarity with the spectrum of injuries that can occur
in the chest and upper abdomen is important for accurate interpretation of
chest radiographs as well as establishment of appropriate recommendations for
management and follow-up.
Keywords: blunt injury • chest • penetrating injury • thoracic radiography • trauma
Introduction
Chest radiography is the first-line imaging examination in patients with
thoracic polytrauma. Proper interpretation is essential for accurate diagnosis
and treatment and can render additional studies unnecessary. When patients are
in critical condition, chest radiography may be the only imaging examination
that can feasibly be performed without risking further injury or
decompensation.
Ideally, chest radiographs should be obtained in the posteroanterior and
lateral views with the patient sitting upright and in full inspiration.
However, trauma patients often must be imaged in the supine position, which
complicates injury visualization and localization. Single-view anteroposterior
radiographs do not provide the ability to distinguish superimposed soft-tissue
and bone lesions from underlying viscera. Air–fluid levels are not
visible because of the perpendicular orientation of the x-ray beam. Poor
inspiratory effort and magnification effects can produce pseudocardiomegaly
and apparent increases in pulmonary vascularity. Nevertheless, when analyzed
with respect to these limitations, the chest radiograph can be an invaluable
tool that provides a wide spectrum of information regarding a number of organ
systems.
The manifestations of thoracic polytrauma are diverse, depending on both
the mechanism of injury and the organ system or systems affected. Blunt trauma
refers to closed, nonpenetrating physical trauma caused by impact injury or
other compressive and shear forces. Common examples include deceleration
injuries (motor vehicle accidents, falls) and blunt force injuries (physical
attacks, crush injuries). Complications include abrasions, contusions, organ
laceration or rupture, and bone fractures
[1–4].
In contrast, penetrating trauma occurs when an object pierces the skin and
enters the body. Injury severity is determined by the pathway and momentum of
the object. Low-velocity items, such as knives, are propelled by hand and
damage only areas that are in direct contact. Higher-velocity projectiles,
including bullets and other shrapnel, create pressure waves that force out
adjacent tissue as the projectile enters the body. This damages regions in
direct contact while also causing cavitation injury to a large surrounding
area [1,
5,
6].
This article discusses the utility of chest radiography in the evaluation
of thoracic polytrauma. The pathophysiology, imaging manifestations, and
management recommendations for injuries to the chest wall, diaphragm, pleura,
lungs, mediastinum, heart, aorta, and great vessels will be reviewed. Several
classic trauma-related signs in chest radiology will also be defined and
illustrated.
Chest Wall
Soft Tissues
Subcutaneous emphysema refers to the presence of air in the extrathoracic
soft tissues. This condition can result from chest wall infection, blunt
trauma with damage to the respiratory or gastrointestinal systems, and
penetrating injuries that introduce external air into the soft tissues. Chest
radiography shows air in the subcutaneous tissues, which may create
radiolucent striations outlining the individual fibers of the pectoralis major
muscles ("ginkgo leaf" sign)
(Fig. 1). Air can spread via
fascial planes to the rest of the chest wall and abdomen and even to the head,
neck, and extremities. The condition is usually self-limiting, but severe
cases may compress the trachea and require intervention. Sources of persistent
air leakage will require corrective surgery.
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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).
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Subcutaneous hematomas are produced by accumulation of blood in the soft
tissues. This condition may result from damage to thoracic vessels, muscles,
or ribs during blunt or penetrating chest trauma. On chest radiographs,
nonspecific opacities are visualized in the soft tissues
(Fig. 2). Localization to the
chest wall may not be possible without lateral radiographs. Most hematomas
resolve spontaneously, but persistent bleeding may be seen with severe trauma,
coagulopathies, and vascular malformations. Foreign bodies, such as knife
blades and bullet shrapnel, also can become lodged in the soft tissues after
penetrating trauma (Fig. 3).
Operative removal is indicated when surgically feasible
[7–10].
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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.
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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.
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Bones
Blunt chest trauma can result in a variety of skeletal injuries depending
on the mechanism involved. Forceful shoulder injuries can produce scapular
fractures, which are shown on chest radiographs and scapular views
(Fig. 4). Scapulothoracic
dissociation, or flail shoulder, occurs when strong forces pull the shoulder
girdle away from the thorax. This can predispose to muscle, vascular, and
nerve injury. Scapular dislocation, edema, and hematoma formation are noted on
chest radiographs.
Clavicle fractures are common in trauma patients and are generally of minor
clinical significance (Fig. 4).
Sternoclavicular dislocations or fractures occur after severe shoulder trauma
and may be identified on angled chest radiographs
(Fig. 5). Posterior
dislocations may injure the mediastinal organs and great vessels. These
injuries require closed or surgical reduction.
Fractures to the upper ribs are rare and suggest severe downward trauma
with damage to the great vessels and brachial plexus. Lower rib fractures may
also involve upper abdominal organs such as the liver, spleen, and kidneys,
and CT should be ordered if suspicion for injury is high. Fractured rib ends
can lacerate the pleura or lung, leading to the formation of pulmonary
hematomas, hemothorax, or pneumothorax. Most fractures can be visualized on
chest radiographs, and a radiodense fracture callus develops after several
weeks (Fig. 6A). Flail chest
occurs when at least five contiguous single fractures or three adjacent
segmental rib fractures are present, resulting in paradoxical motion during
the respiratory cycle (Fig.
6B). Posterior flail segments are supported by overlying muscles
and scapulae, and therefore may not cause serious complications. Anterior and
lateral flail segments, which are free-moving, can severely impair respiratory
function and predispose to atelectasis and infection. Positive-pressure
ventilation or surgical fixation may be required for stabilization.
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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.
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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.
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Sternal injuries are seen in anterior chest trauma. Most fractures occur in
the upper or mid body of the sternum and are seen in conjunction with
retrosternal hematoma and myocardial contusion. These injuries are difficult
to identify on frontal chest radiographs and often require lateral or sternal
views for enhanced visualization (Fig.
7). Surgical fixation is unnecessary, and healing occurs over
several weeks.
Spinal fractures can result from compression or whiplash injury and are
associated with damage to neurologic and vascular structures. Optimal
evaluation requires dedicated frontal and lateral spine radiographs.
Immobilization and surgical fixation are necessary to prevent further damage.
Infection of the intervertebral disks (diskitis) can produce disk space
narrowing and erosion with adjacent abscess formation. Immobilization with
antibiotic treatment is required
[7–10]
(Figs. 8A,
8B, and
8C).
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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).
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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).
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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.
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Diaphragm
Diaphragmatic rupture may be secondary to blunt or penetrating injury.
Hemidiaphragmatic elevation may be seen, and upper abdominal organs, including
the stomach (collar sign), liver ("cottage loaf" sign), spleen,
small bowel, and colon, may herniate into the thoracic cavity. Associated
findings include basilar lung opacities, irregular diaphragmatic contours, and
lower rib fractures. In addition, pneumoperitoneum can result from open
thoracoabdominal communication or perforated abdominal viscera, with air seen
accumulating beneath the diaphragm superolaterally on erect radiographs or
anteromedially on supine radiographs (cupola sign). However, other conditions
such as basilar lung atelectasis, subpulmonic effusion, subphrenic abscess,
colonic interposition (Chilaiditi syndrome), diaphragmatic eventration,
congenital diaphragmatic hernia, and phrenic nerve injury can have a similar
appearance on chest radiographs, and CT is required for diagnosis. Surgical
repair is necessary to prevent late complications such as bowel incarceration
or strangulation, thoracic organ compression, and diaphragmatic paralysis.
Splenosis is a rare complication of left-sided thoracoabdominal trauma in
which thoracic autotransplantation of splenic tissue results in the formation
of left-sided chest wall masses. Heat-damaged RBC scanning is diagnostic, and
no interventions are necessary
[7,
8,
11,
12] (Figs.
9A,
9B,
9C,
9D,
9E, and
9F).
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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).
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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.
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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.
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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.
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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).
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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.
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Pleura
After chest trauma, air may enter the pleural cavity from the outside
environment (open pneumothorax) or from within the body (closed pneumothorax).
Open or communicating pneumothorax, also called "sucking chest
wound," develops when the skin and pleura are injured by penetrating
trauma. Immediate closure and chest tube placement are indicated. Closed, or
simple, pneumothorax develops after blunt trauma, usually due to pleural
laceration by fractured ribs. Conservative management is recommended, and tube
thoracostomy should be performed only if the patient is symptomatic. Diagnosis
of pneumothorax requires visualization of the "visceral pleural line
sign," which represents separation of the visceral and parietal pleura.
On supine radiographs, anterocaudal movement of pleural air may produce
hyperlucent lung bases, a deep and radiolucent costophrenic sulcus (deep
sulcus sign), and outlining of the anterior and posterior portions of the
hemidiaphragm (double diaphragm sign). Tension pneumothorax occurs when a
pneumothorax permits entry into but not exit of air from the thoracic cavity.
Increasing intrathoracic pressure leads to collapse of the ipsilateral lung,
followed by compression of the contralateral lung and mediastinum. Associated
findings include unilateral hyperlucent lung, widened intercostal spaces,
hemidiaphragmatic depression, and tracheal deviation. However, diagnosis is
primarily clinical because of the emergent nature of the condition and the
lack of specificity of early imaging findings. Suspected tension pneumothorax
should be immediately decompressed with large-bore needle thoracostomy before
radiographs are obtained. A postprocedure radiograph is obtained to verify
subsequent tube placement and to assess the effectiveness of therapy (Figs.
10A,
10B, and
10C).
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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.
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Simple hemothorax can result from vascular rupture or laceration in blunt
and penetrating trauma. On chest radiographs, the appearance is similar to
serous pleural effusion (hydrothorax), with layering of fluid and blunting of
the costophrenic angles. Rarely, effusions can be subpulmonic, loculated, or
lamellar. Small hemothoraces usually resolve spontaneously, and drainage is
rarely required. However, a large hemothorax can fill the entire pleural space
and present radiographically as an opacified hemithorax. Chronic hemothorax
can be complicated by infection (empyema or pyothorax) with chest wall erosion
(empyema necessitatis) or fibrosis (fibrothorax) requiring decortication.
Tension hemothorax can result from massive intrathoracic bleeding causing
ipsilateral lung compression and mediastinal displacement. Emergent
exploratory thoracotomy is indicated to identify and repair the site of
bleeding (Figs. 11A and
11B).
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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.
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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.
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Chylothorax results from damage to the thoracic duct, with chylous fluid
recovered through thoracentesis. Left-sided chylothorax is seen in ruptures of
the upper thoracic duct, whereas right-sided chylothorax is produced by
lower-level injuries in which the thoracic duct has crossed the midline
(Fig. 12). CT offers enhanced
contrast resolution that is useful for distinguishing chylothorax,
hydrothorax, pyothorax, and hemothorax as well as other causes of radiographic
density [7,
8,
10].
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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.
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Lungs
Lung protrusion or herniation can occur through trauma-induced weakening or
tears of the cervical, intercostal, and diaphragmatic fascia. Chest
radiography identifies regions of lung extending beyond the thoracic cage
(Fig. 13). Conservative
management is advisable unless respiratory distress, incarceration, or
strangulation occurs.
Lobar atelectasis or collapse may result from foreign body obstruction,
aspiration, or bronchial rupture. Any lobe can be involved, and classic chest
radiographic signs have been described for upper and middle lobe
("juxtaphrenic peak" sign or "Katten" sign), left
upper lobe (luftsichel sign), left lower lobe ("flat waist" sign,
"ivory heart" sign), and right lower lobe (superior triangle sign)
collapse. Pneumothorax ex vacuo is a rare complication of acute lobar collapse
that increases the negative intrapleural pressure around the collapsed lobe.
This selectively draws gas into the space surrounding the collapsed lobe
without affecting the visceral and parietal pleura of adjacent lobes. The
pneumothorax resolves spontaneously after relief of the bronchial obstruction
with reexpansion of the corresponding lobe. Identification of this condition
is important for directing treatment toward the affected bronchus rather than
inserting a chest tube into the pleural space (Figs.
14A,
14B,
14C,
14D, and
14E).
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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).
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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).
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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).
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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).
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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.
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Pulmonary contusions occur when injury to the lungs results in leakage of
blood and edema into the interstitial and alveolar spaces. On chest
radiographs, contusions appear as geographic areas of peripheral air-space
opacity or ground-glass opacification, usually adjacent to bony structures.
Lesions are evident within 6 hours after trauma and generally resolve within
5–7 days. Pulmonary lacerations are more severe injuries involving
disruption of the lung architecture. Organ ruptures and foreign body trauma
may introduce air (pneumatocele), blood (hematoma), and infection (abscess)
into the lung parenchyma. On chest radiographs, localized air collections are
seen within areas of air-space opacity. Injuries take weeks or months to
resolve, and chronic scarring may develop (Figs.
15A and
15B).
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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.
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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.
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Acute respiratory distress syndrome (ARDS) can develop secondary to a
variety of insults, including trauma, infection, shock, aspiration,
transfusion, and drugs. After 12–48 hours, damage to the
alveolar–capillary barrier allows influx of fluid into the alveolar
space, which manifests radiographically as diffuse bilateral patchy lung
opacities (Fig. 16). The
imaging differential diagnosis includes atelectasis, aspiration, fat embolism,
alveolar pulmonary edema, pneumonia, and hemorrhage. Therapy involves
treatment of the underlying condition and supportive care over weeks to months
[7,
8,
10].
Mediastinum
Pneumomediastinum, or mediastinal emphysema, refers to the presence of air
in the mediastinal structures, which can result from penetrating injury or
blunt pharyngeal, tracheobronchial, or esophageal injury. Air freely tracks
throughout the mediastinum and communicating spaces via vascular sheaths and
readily ruptures through fascial planes to affect adjacent anatomic
compartments. Several chest radiographic signs have been described, including
air superior to the diaphragm (continuous diaphragm sign, continuous left
hemidiaphragm sign, extrapleural air sign), surrounding the right pulmonary
artery ("ring-around-the-artery" sign), lateral to the descending
aorta ("Naclerio's V" sign), and superior to the brachiocephalic
veins ("V" sign at confluence of brachiocephalic veins) (Figs.
17A,
17B,
17C, and
17D). In children, elevation
of the thymic lobe (thymic sail sign) can be seen. Identification and repair
of the affected organs are indicated.
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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).
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Fig. 17B —Pneumomediastinum. 25-year-old man with pneumomediastinum.
Lateral chest radiograph shows air in mediastinum outlining left hemidiaphragm
("continuous left hemidiaphragm" sign) (arrows).
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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).
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Mediastinal bleeding (mediastinal hematoma) can result from vascular
injury. Large hematomas can produce radiographic irregularity and enlargement
of the mediastinum. Proposed criteria for mediastinal widening include a width
greater than 8 cm and a mediastinal to chest width ratio greater than 0.25
(Fig. 18A).
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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.
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Esophageal rupture and foreign body injury can lead to mediastinal
infection (mediastinitis). Radiography may show edema, hemorrhage, and gas
production in the mediastinal and cervical soft tissues, as well as pleural
effusions and lower-lobe consolidation
[7,
8,
13,
14]
(Fig. 18B).
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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.
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Trachea and Bronchi
Tracheobronchial injury includes lacerations due to penetrating trauma and
ruptures from blunt airway injury, particularly when the glottis is closed.
Generally, concomitant injury to the chest wall, lungs, and great vessels is
also present. Transverse tears usually occur between cartilaginous tracheal
rings, whereas longitudinal tears are seen in the posterior tracheal membrane.
This results in massive pneumomediastinum and possible airway edema,
hemorrhage, and pneumothorax. On chest radiographs, endotracheal tube
overdistension may be seen, with herniation through the ruptured tracheal
wall. In bronchial transections, the involved lung may be visualized falling
inferiorly away from the hilum on erect radiographs and posterolaterally in
the supine position (fallen lung sign) (Figs.
19A,
19B, and
19C). Surgical repair is
required to maintain airway continuity and to prevent complications such as
tracheobronchial stricture [7,
8,
13,
14].
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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.
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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).
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Esophagus
Esophageal injury may be caused by violent vomiting (Boerhaave's syndrome),
penetrating injury, or compressive bone forces in blunt trauma. The esophagus
runs to the left of the trachea at the level of the thoracic inlet, moves to
the right at the level of the carina, and crosses back to the left as it
enters the stomach. Most esophageal tears are located in the cervical and
upper thoracic regions and present with left- and right-sided pleural
effusions, respectively. Occasionally, gastroesophageal junction lesions are
seen, typically in conjunction with left-sided effusions. Other radiographic
findings include pneumomediastinum, widened paraspinal lines, and retrocardiac
lung opacification (Fig. 20A).
CT or upper gastrointestinal studies can show oral contrast extravasation and
esophageal thickening. Corrective surgery should be performed immediately
because of the risks of edema, infection, and fistulization.
Hiatal hernias can form after blunt or penetrating trauma, with the stomach
prolapsing through the diaphragmatic esophageal hiatus. Chest radiographs show
a retrocardiac structure filled with gas and/or fluid, representing the
intrathoracic stomach (Fig.
20B). No intervention is necessary unless incarceration and
strangulation occur [7,
8,
13,
14].
Heart
Pericardium
Pericardial tears can result from severe blunt injury or penetrating
trauma. On chest radiographs, irregular convexities of the heart border may be
observed ("snow cone" sign) along with cardiac injury,
pneumomediastinum, and pneumothorax. Large pleuropericardial or diaphragmatic
pericardial ruptures can result in cardiac herniation, with marked shift of
the cardiac silhouette. This condition predisposes to cardiac volvulus with
obstruction of the great vessels and requires immediate surgical repair (Figs.
21A,
21B, and
21C).
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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.
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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.
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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.
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Organ and vascular ruptures may introduce fluid (pericardial effusion) or
air (pneumopericardium) into the pericardial cavity. Pericardial effusions can
contain transudative (hydropericardium), exudative (pyopericardium), lymphatic
(chylopericardium), or hemorrhagic (hemopericardium) fluid. In addition, organ
rupture and foreign body injury can result in pericardial inflammation and
infection (pericarditis). Radiographic signs of effusion, which are very rare,
include global enlargement of the cardiac silhouette
("water-bottle" sign) on frontal radiographs and wide separation
of the epicardial and retrosternal fat ("epicardial fat-pad,"
"Oreo cookie," sandwich, or stripe sign) on lateral radiographs
(Figs. 22A and
22B). CT can aid greatly in
the characterization of pericardial lesions and effusion contents.
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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).
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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).
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Pneumopericardium is air located within the pericardial cavity and external
to the rest of the heart. Loculation within the pericardial sac can be shown
by nondependent shift on decubitus radiographs. On erect chest radiographs, a
radiolucent band of air surrounding the heart (halo sign) and air in the
transverse pericardial sinus ("transverse band of air" sign) can
be seen. Lateral radiographs may show retrosternal hypolucency anterior to the
cardiac base and aortic root ("triangle of air" sign). In tension
pneumopericardium, marked compression of the heart with a decreased
cardiothoracic ratio may be visible ("small heart" sign) (Figs.
23A and
23B).
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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).
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Because of pericardial compliance, gradually developing effusions may not
cause noticeable symptoms. However, rapid accumulation of even small amounts
of fluid or air can produce cardiac tamponade, in which increased pericardial
pressure causes significant hemodynamic compromise. On CT, distention of the
venae cavae and hepatic and renal veins is seen, indicative of severe cardiac
congestion. Immediate pericardiocentesis is indicated for recovery of normal
cardiovascular function [7,
8,
15].
Cardiac Trauma
Myocardial contusions are caused by rupture of intramyocardial vessels
after severe cardiac trauma. On chest radiographs, chest wall hematomas and
cardiomegaly due to hemopericardium may be seen. Myocardial stunning may lead
to congestive heart failure, with pulmonary edema visualized on radiographs.
Associated findings include skeletal fractures and pulmonary contusions.
Cardiac aneurysms, which are focal outpouchings in the septal or free walls
of the cardiac chambers, can result from severe blunt trauma. They are most
commonly seen in the left ventricular anterior wall or apex. True aneurysms
can be managed conservatively, but should be monitored carefully because of
the increased risk of rupture. Cardiac pseudoaneurysms, which form when wall
ruptures are contained by epicardial hematoma and pericardial tissue, are
typically sequelae of penetrating trauma. They are usually located in the
posterolateral wall of the left ventricle. Immediate surgical repair is
necessary to prevent complete rupture
(Fig. 24A).
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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.
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Complete cardiac rupture can be seen in severe blunt and penetrating
trauma. The right ventricle is often involved because of its thinner walls and
anterior location in the chest. The left ventricle, right atrium, and left
atrium are less frequently affected. Ruptures of the free wall and
fistulization to adjacent organs can produce hemopericardium and pericarditis.
Ruptures of the interventricular septum, papillary muscles, and valves also
may occur (Fig. 24B). Severe
torsional stresses can produce cardiac avulsion, with separation of the heart
from the great vessels. Chest radiography reveals an enlarged or irregular
heart shadow, often in conjunction with pulmonary edema and pleural effusions.
Immediate surgical correction is indicated.
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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.
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Myocardial infarction is seen with increased frequency in trauma patients
because of coronary artery injury and occlusion. Chest radiography can reveal
complications such as pulmonary edema secondary to heart failure.
Thrombolysis, percutaneous coronary intervention, or coronary artery bypass
grafting may be required in severe cases. Chronic sequelae include myocardial
thinning, fibrosis, and calcification
(Fig. 24C). There is an
increased risk of cardiac aneurysm and pseudoaneurysm formation with
subsequent rupture [7,
8,
15].
Aorta
Traumatic aortic injury (TAI) refers to a spectrum of injuries caused by
blunt aortic trauma, which produces differential deceleration of thoracic
structures with associated solid and fluid mechanical effects. The aortic
isthmus is most frequently involved, followed by the aortic root and
diaphragmatic aorta. Forces affecting the aortic isthmus include shearing
stress, in which the freely movable aortic arch separates from the fixed
descending aorta; bending stress, with flexion of the aorta over the left
pulmonary artery and mainstem bronchus; and osseous pinch, involving
compression of the aorta between the spine and anterior bony structures. In
the ascending aorta, torsion stress occurs at the level of the aortic valve
because of cardiac displacement, and the water-hammer effect is produced by
abrupt increases in intraaortic pressure with possible pericardial rupture and
cardiac tamponade. Possible injuries include aortic tearing or laceration, in
which sections of the aorta are forcibly pulled apart; transection or
transverse circumferential division of the aorta; and rupture, with massive
disruption of tissue. Any or all layers of the arterial wall may be affected,
with resultant hematoma formation in a variety of locations. Survival in
complete ruptures requires pseudoaneurysm formation with containment of active
bleeding by adventitia, thrombus, or mediastinal structures. Immediate open
surgical repair or endovascular stent-grafting is advised. Indirect
radiographic signs of TAI include mediastinal widening, irregularity or
obscuration of the aortic contour, opacification of the aortopulmonary window,
depression of the left mainstem bronchus, rightward tracheal and esophageal
deviation, widened paratracheal and paraspinous stripes, and hemothorax or
left apical capping (Figs. 25A
and 25B).
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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).
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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.
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Traumatic aortic dissection is characterized by an intimomedial tear, which
allows bleeding into the medial wall layer and formation of a false lumen.
Chest radiography is nonspecific and may show an irregular aortic silhouette,
discontinuous calcification of the aortic knob ("broken halo"
sign), or intraluminal displacement of a calcified aortic intima (ring sign)
(Fig. 25C). Type B (descending
aortic) dissections can be managed conservatively, whereas type A (ascending
aortic) dissections require immediate surgery because of the risks of
pericardial bleeding, coronary artery laceration, and aortic valve
rupture.
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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.
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Traumatic aortic aneurysms represent localized dilatation of the aorta
involving all three arterial wall layers and are susceptible to rupture. An
enlarged and irregular aortic silhouette is seen on chest radiographs
(Fig. 25D). Open surgery is
recommended for ascending aortic aneurysms that are symptomatic, rapidly
expanding, or greater than 5.0–5.5 cm in diameter. Descending aortic
aneurysms exceeding 6.0 cm can usually be repaired by endovascular
stent-grafting.
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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.
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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.
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Penetrating aortic injuries depend on the mechanism of trauma and thus vary
widely in size and location. Vessel laceration, truncation, or arteriovenous
fistulization may result. Most survivors show a small pseudoaneurysm at the
site of vessel injury. Irregular aortic contours and luminal narrowing may
also be seen [7,
8,
16–21].
Vascular Trauma
Great Vessels
More than 90% of injuries to the great vessels are caused by penetrating
trauma. The aortic branch vessels, venae cavae, and pulmonary veins are also
susceptible to blunt injury via mechanisms similar to those of TAI. Formation
of local hematomas and hemopericardium are noted complications (Figs.
26A and
26B). If bleeding cannot be
controlled, surgical intervention is indicated to maintain the integrity of
the cardiovascular circulation
[7,
8,
16–20].
Pulmonary Arteries
In trauma patients, hypercoagulability and immobilization predispose to
deep venous thromboses, which can circulate to the pulmonary arteries and
produce pulmonary embolism (PE). This results in inflammation, hypoxemia,
hemodynamic compromise with right heart strain (cor pulmonale), and pulmonary
infarction with regional loss of surfactant. Chest radiography findings are
largely nonspecific and include cardiomegaly, atelectasis, pulmonary edema,
pleural effusion, and hemidiaphragmatic elevation. Classic imaging signs
include regional oligemia (Westermark sign), central pulmonary artery
enlargement (Fleischner sign), right descending pulmonary artery enlargement
("Palla" sign), and abrupt pulmonary artery tapering
("knuckle" sign). In the presence of acute infarction, focal
subpleural opacities (Hampton hump) may be seen, whereas linear fibrosis
(Fleischner lines) and centripetal infarct resolution ("melting ice
cube" sign) occur in later stages (Figs.
27A and
27B). More definitive tests
for PE include nuclear ventilation–perfusion (V/Q) scintigraphy, CT
angiography (CTA), and pulmonary angiography. Nevertheless, radiographs are
still routinely used to screen for other sources of chest pain and to aid in
the proper interpretation of V/Q scans. Immediate anticoagulation therapy is
recommended for suspected PE.
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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).
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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).
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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.
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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.
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Septic embolism occurs when infected material from organ rupture or foreign
body injury travels to the lungs. Chest radiographs show diffuse bilateral
nodules of various sizes and stages of cavitation, reflecting multiple embolic
showers. Over time, lesions can progress to wedge-shaped peripheral opacities
(Fig. 27C). Treatment requires
antibiotic therapy and possible thoracentesis.
Air embolism is caused by organ rupture or penetrating injury affecting the
systemic venous circulation. It also can be caused by barotrauma. Mortality
depends on the amount and rate of gas entry. Chest radiographs may show
hyperlucent areas in the right heart, pulmonary arteries, and systemic veins.
Signs of pulmonary oligemia, edema, or right heart congestion may also be
seen.
Fat embolism results from trauma to the long bones and pelvis, which can
release fat particles and occlude capillaries. Production of free fatty acids
causes a chemical pneumonitis within 12–72 hours of injury. Radiologic
manifestations are similar to those of ARDS—that is, diffuse parenchymal
opacities (Fig. 27D).
Management is supportive, and the condition takes 7–10 days to
resolve.
Pregnancy is a known risk factor for thromboembolic disease. The risk of
radiation exposure to the fetus should be weighed against the clinical
suspicion for PE. Affected patients should be treated with heparin because of
the teratogenic effects of warfarin. In addition, there is a risk of amniotic
fluid embolism (AFE), in which amniotic fluid enters the uterine veins during
labor or placental manipulation. Radiographically, this condition presents
with diffuse bilateral opacities indistinguishable from PE, hemorrhage, and
pneumonia (Fig. 27E). The
prognosis is poor, and management is supportive. Immediate cesarean delivery
should be performed in patients with cardiac arrest who are unresponsive to
resuscitation.
Foreign body embolism can occur with fragmentation of foreign bodies.
Material may travel through the arterial or venous circulations and become
lodged in distal sites (Fig.
27F). Mortality depends on the location, duration, and severity of
emboli. Cardiopulmonary injuries are common, and other risks include
perforation, thrombosis, and infection
[7,
8,
19,
21–23].
Conclusion
Chest radiography plays an important role in the initial evaluation of
blunt and penetrating chest trauma, providing rapid imaging information to
supplement the history and physical examination. In the emergency department,
familiarity with the spectrum of injuries that can occur in the chest and
upper abdomen is important for accurate interpretation of chest radiographs as
well as establishment of appropriate recommendations for management and
follow-up. An understanding of trauma pathophysiology and related imaging
findings for injuries to the chest wall, diaphragm, pleura, lungs,
mediastinum, heart, aorta, and great vessels will enable radiologists to
interact rapidly and effectively with the other members of the health care
team.
Acknowledgments
We thank D. Claire Anderson, Sanjeev Bhalla, Andrew Bierhals, David
Gierada, Harvey Glazer, Guillermo Geisse, Cylen Javidan-Nejad, Gilbert Jost,
Anoosh Montaser, Stuart Sagel, Janice Semenkovich, Marilyn Siegel, and Pamela
Woodard for contributing many of the cases featured in this article.
References
- Gavelli G, Canini R, Bertaccini P, Battista G, Bnà C,
Fattori R. Traumatic injuries: imaging of thoracic injuries. Eur
Radiol 2002; 12:1273
-1294[CrossRef][Medline]
- Thoongsuwan N, Kanne JP, Stern EJ. Spectrum of blunt chest
injuries. J Thorac Imaging 2005;20
: 89-97[CrossRef][Medline]
- Zinck SE, Primack SL. Radiographic and CT findings in blunt chest
trauma. J Thorac Imaging 2000;15
: 87-96[CrossRef][Medline]
- Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A. Imaging of
blunt chest trauma. Eur Radiol 2000;10
: 1524-1538[CrossRef][Medline]
- Shanmuganathan K, Matsumoto J. Imaging of penetrating chest trauma.
Radiol Clin North Am 2006;44
: 225-238[CrossRef][Medline]
- LeBlang S, Dolich M. Imaging of penetrating thoracic trauma.
J Thorac Imaging 2000;15
: 128-135[CrossRef][Medline]
- Marshall GB, Farnquist BA, MacGregor JH, Paul W, Burrowes PW. Signs
in thoracic imaging. J Thorac Imaging2006; 21:76
-90[CrossRef][Medline]
- Collins J, Stern EJ. Signs in chest radiology. In: Collins J, Stern
EJ, eds. Chest radiology: the essentials.
Philadelphia, PA: Lippincott Williams & Wilkins, 1999:18
-27
- Collins J. Chest wall trauma. J Thorac
Imaging 2000; 15:112
-119[CrossRef][Medline]
- Miller LA. Chest wall, lung, and pleural space trauma.
Radiol Clin North Am 2006;44
: 213-224[CrossRef][Medline]
- Sliker CW. Imaging of diaphragm injuries. Radiol Clin
North Am 2006; 44:199
-211[CrossRef][Medline]
- Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of
diaphragmatic injuries. J Thorac Imaging2000; 15:104
-111[CrossRef][Medline]
- Euathrongchit J, Thoongsuwan N, Stern EJ. Nonvascular mediastinal
trauma. Radiol Clin North Am 2006;44
: 251-258[CrossRef][Medline]
- Ketai L, Brandt MM, Schermer C. Nonaortic mediastinal injuries from
blunt chest trauma. J Thorac Imaging2000; 15:120
-127[CrossRef][Medline]
- Salehian O, Teoh K, Mulji A. Blunt and penetrating cardiac trauma:
a review. Can J Cardiol 2003;19
: 1054-1059[Medline]
- Fishman JE. Imaging of blunt aortic and great vessel trauma.
J Thorac Imaging 2000;15
: 97-103[CrossRef][Medline]
- Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic
injury of the thoracic aorta. RadioGraphics1997; 17:27
-45[Abstract]
- Malloy PC, Richard HM 3rd. Thoracic angiography and intervention in
trauma. Radiol Clin North Am 2006;44
: 239-249[CrossRef][Medline]
- Alkadhi H, Wildermuth S, Desbiolles L, et al. Vascular emergencies
of the thorax after blunt and iatrogenic trauma: multi-detector row CT and
three-dimensional imaging. RadioGraphics2004; 24:1239
-1255[Abstract/Free Full Text]
- Mirvis SE. Thoracic vascular injury. Radiol Clin North
Am 2006; 44:181
-197[CrossRef][Medline]
- Butler KH, Swencki SA. Chest pain: a clinical assessment.
Radiol Clin North Am 2006;44
: 165-179[CrossRef][Medline]
- Kluetz PG, White CS. Acute pulmonary embolism: imaging in the
emergency department. Radiol Clin North Am2006; 44:259
-271[CrossRef][Medline]
- Han D, Lee KS, Franquet T, et al. Thrombotic and nonthrombotic
pulmonary arterial embolism: spectrum of imaging findings.
RadioGraphics 2003;23
: 1521-1539[Abstract/Free Full Text]
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Abstract
Introduction
