Early imaging, rather than admission and observation for neurological deterioration, will reduce time to detection for life threatening complications and is associated with better outcomes

1. Introduction to trauma imaging
Guidelines and highlights for different
imaging techniques.
ASSIUT UNIVERSITY TRAUMA COURSE
(AUTC) MARCH 2010.
Dr. Hazem Abu Zeid Yousef MD
Lecturer of Radiodiagnosis.

2. INTRODUCTION
More than 3000 people die on the world's
roads every day. Tens of millions of people
are injured or disabled every year. Road
traffic accidents are the leading cause of
death in the first study of global patterns of
death among people aged between 10-24
years of age (WHO 2009).

3. Time is of the Essence in Trauma
Time is the eenneemmyy ffoorr ttrraauummaa vviiccttiimmss
TTrraauummaa ssuurrggeeoonnss aarree rruulleedd bbyy tthhee
““GGoollddeenn HHoouurr””..

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PART (1)
HEAD TRAUMA

5. “Early HimEagAingD, rIaNtherJ UthaRn IEadmSis.sion and
observation for neurological deterioration, will
reduce time to detection for life threatening
complications and is associated with better outcomes
(NICE clinical guideline 2008).

6. CLICK SKULL RA DHIOGERARPHEY ( STXRO) ADD TEXT
Advantages
Quick
No need for radiologist
Low dose of radiation
(0.14mSv)
Inexpensive
Disadvantages
Increased workload
Inconclusive

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8. SYSTEMATIC INSPECTION
OF THE SXR
Step (1) : Scrutinize the site of the injury.
Step (2) : Look for:
Fissure fracture.
Depressed fracture.
Fluid level in the sphenoid sinus.
Step (3) : Look for less common finding (e.g.
pneumocephalus).

9. Fissure versus VM
Fissure black VM gray.
VM is branching.
VM has sclerotic edges.
Fissure versus suture
The fracture is more radiolucent
than the other sutures, has no
serration along its edges, and is
blind ending.

10. Depressed fractures are
often difficult to see. Look
for increased or double
density

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This study shows that skull x rays can successfully be abandoned in
children aged 1 to 14 years with head injuries without any
significant increase in admission rate, radiation dose per head
injury, or missed intracranial injuries. We suggest that routine
skull x rays have no place in the paediatric emergency department
for those children aged 1 year and over. Mechanism of head injury
(falls of more than 1 metre and road traffic accidents carrying
higher risk), a history of drowsiness or loss of consciousness, and a
reduced score on the Glasgow coma scale are probably the most
important indicators of serious head injury in children (Reed wt
al., 2005).

16. Head CT
Advantages for TBI include: availability, short scan times,
detailed anatomic information - including evaluation of facial
and temporal bone fractures.
Less sensitive for small parenchyma bleeds such as those seen
with DAI.

17. CLICK Anatomic HPaEttRernEs Tof O ADD TEXT
Traumatic Brain injury
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aaxxoonnaall iinnjjuurryy..

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Diffuse axonal injury
Diffuse axonal injury (DAI) is a major form of traumatic
brain injury and is caused by shearing stress primarily in
white matter). Various outcomes are reported (ie, learning
disorders, moderate to severe disability, and vegetative
state) but were unable to correlate the extents of early
injury with the prognoses.

22. Among patients eventually
proven to have DAI, 50-80%
demonstrate a normal CT scan
upon presentation. Delayed CT
scanning may be helpful in
demonstrating edema or
atrophy, which are later
findings. Small petechial
hemorrhages located at the
gray-white matter junction, as
well as in the corpus callosum
and brainstem, are
characteristic of CT-scan
findings in the acute setting.

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The ability to detect DAI by using imaging, whether
the lesions are hemorrhagic or nonhemorrhagic, has
substantially improved with the advent of MRI. MR
imaging has been helpful in defining patterns of
injury in adults with DAI—depicting involvement
predominantly in the frontal white matter, corpus
callosum, brainstem, and diencephalon.

24. Figure 1. Patient 2.
Tong K A et al. Radiology 2003;227:332-339
©2003 by Radiological Society of North America

25. Figure 2. Patient 4.
Tong K A et al. Radiology 2003;227:332-339
©2003 by Radiological Society of North America

26. Figure 3. Patient 2.
Tong K A et al. Radiology 2003;227:332-339
©2003 by Radiological Society of North America

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28. PART 2
CHEST TRAUMA

29. After chest trauma, imaging plays a key role for both,
the primary diagnostic work-up, and the secondary
assessment of potential treatment. Despite its well-known
limitations, the AP chest radiograph remains
the starting point of the imaging work-up. Adjunctive
imaging with CT, that recently is increasingly often
performed on MDCT units, adds essential
information not readily available on the CXR. This
allows better definition of trauma-associated thoracic
injuries not only in acute traumatic aortic injury, but
also in pulmonary, tracheobronchial, cardiac,
diaphragmal, and thoracic skeletal injuries.

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• Blunt
• Penetrating
Types of Chest trauma
• Explosion Related
Chemical Agent Related
Biological Agent Related

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32. Trauma Chest Radiograph
• Usually AP, often supine,
frequently in poor inspiration.
• So, a challenge to interpret.

33. CT Chest
More sensitive and specific

34. CT Chest: Reformat
The new MDCT scanners
do awesome reformats
without additional scanning.

35. Blunt chest trauma
• Factures and dislocations
• Air where it shouldn’t be
• Hemothorax
• Pulmonary contusion and
laceration
• Diaphragm injuries

36. Fractures and Dislocations
• Spine
• Ribs
• Clavicles
• Sternum
• Shoulders

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• Spine Injuries
• Look for loss of
alignment, fractures and
paraspinal hematoma.
• The findings may be very
subtle.

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• CT is the imaging
modality of choice for
evaluation of these
injuries.

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Simple rib fractures are
frequently encountered on chest
radiographs and rarely require
further studies. However,
complication of rib fractures such
as pneumothorax, hemothorax,
lung contusions, and lacerations
are of more important clinical
impact than the fracture itself

40. Multiple fractures of the
same rib or simple
fractures of three or more
contiguous ribs comprise a
flail segment of the chest
wall. This results in
paradoxical motion and
inhibits normal respiratory
motion, leading to
impaired ventilation.

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Sterno-Clavicular Dislocations
• Anterior: Not much of a
problem.
• Posterior: Less common; can
injure great vessels or trachea.

43. Sterno-clavicle dislocation: CT
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44. Shoulder Injuries
Look particularly for
dislocations and scapula
fractures

45. Sternum Fractures
• Not usually a problem.
• Controversial association with
myocardial injury.

46. AIR where it shouldn’t be
• Pneumothorax
• Pneumomediastinum
• Subcutaneous emphysema
• Systemic venous air embolism
• Pneumopericardium
• Pneumoperitoneum/retroperitoneum

47. PNEUMOTHORAX
• Simple
• Tension
• Open

48. PNEUMOTHORAX: CT
Much more sensitive than plain films. Even a small
traumatic pneumothorax is important, especially if
patient mechanically ventilated or going to OR: A
simple pneumothorax can be converted into a life-threatening
tension pneumothorax.

49. Pneumothorax: Simple
• Erect AP/PA view best
• Visceral pleural line
• No vessels or markings
• Variable degree of lung
collapse
• No shift

50. PNEUMOTHORAX: Tension
• Erect AP/PA view best.
• Shift of mediastinum away
from PTX side.
• Depressed hemidiaphragm.
• Degree of lung collapse is
variable.

51. PNEUMOTHORAX:
Diagnostic limitations of supine view
Supine AP view has limited sensitivity: 50%.
Deep sulcus sign.
Too sharp heart border/hemidiaphragm sign.
Increased lucency over lower chest.
Subpulmonic air sign.
Can see vessels.

53. PNEUMOMEDIASTIUM
• Usually from ruptured alveoli.
• Can also be from trachea,
bronchi, esophagus, bowel and
neck injuries.

54. CLICK HERE PNEUMOMEDIASTIUM
TO ADD TEXT
Signs:
• Linear paratracheal lucencies
• Air along heart border
• “V” sign at aortic-diaphragm
junction
• Continuous diaphragm sign

57. Surgical Emphysema

58. Pneumopericardium
Penetrating injuries

59. Pneumoperitoneum

60. Systemic venous air embolism

61. HEMOTHORAX
• Venous or arterial bleeding
• 60% controlled by chest tube,
40% need operative
management
• Can miss hundreds of cc’s on
supine film
• Can be tension

62. Traumatic aortic rupture

65. PULMONARY CONTUSION and LACERATION
Contusion: Blood in intact lung parenchyma
Laceration: Blood in torn lung parenchyma
Can’t tell difference on chest film. Contusions peak
in 2-3 days, begin to resolve in a week; lacerations
take much longer to resolve and may leave scars

67. CT: Pulmonary laceration
The tear in the lung can fill
with blood or air.

68. DIAPHRAGM Injuries
• 5% of major blunt trauma,
also thoraco-abdominal
penetrating trauma
• Left clinically injured
more than right 60/40
• Sensitivity of Chest film
40%. CT better, but still
misses some
• Sure signs: NGT through
g.e. junction then up into
chest, and hollow viscus
above diaphragm
• Less significant signs:
Indistinct diaphragm,
effusion, atelectasis

74. PENETRATING TRAUMA
Gun-shot wounds:
Caliber, weight, construction of bullet
Velocity
Tissue impacted
Knife wounds:
All low energy, small diameter wounds. Frequently,
superficial stab or slash.
Look for lung laceration, pneumothorax, hemothorax,
pneumomediastinum, abnormal contour of
mediastinum or heart.
Path of wound is straight.

76. CLICK HERE TO ADD TEXT PART 3
SPINAL TRAUMA

77. Objectives
• Clinical indication for each
imaging modality
• Identify anatomy of the spine
• Approach to spine radiography
interpretation
• Classification of spine injuries

78. Canadian C-Spine Rule for selective ordering of cervical spine imaging
Stiell, I. G et al. BMJ 2009;339:b4146

79. Who gets CT
GCS below 13 on initial assessment.
Has been intubated.
Plain film series is technically inadequate (for
example, desired view unavailable), suspicious or
definitely abnormal.
Continued clinical suspicion of injury despite a
normal X-ray.
The patient is being scanned for multi-region trauma.

80. Who gets MRI
Unexplained neurologic symptoms/signs
For visualizing soft tissues, neural elements and
unsuspected disk herniation
To differentiate cord edema, hemorrhage, and
infarction
To better characterize epidural hematoma

81. RADIOGRAPHY for primary cervical spine
screening
• Minimum standard views
– Lateral through C7
– AP
– Odontoid
• Supplementary views
• Bilateral obliques
– Swimmer’s
– Flex ion and extension

85. Lateral View
Base of the occiput should be visualized
Junction of C7-T1 must be visualized
A swimmer’s view taken with one arm extended over
the head can be helpful
AP view
Must include the spinous processes of all the cervical
vertebrae from C2 trough T1.
OM view
Must show relationship of the lateral masses of C1
and the odontoid process.

86. NNOORRMMAALL CCEERRVVIICCAALL SSPPIINNEE
1 = anterior vertebral line
2 = posterior vertebral line
3 = spinolaminar line
4 = posterior spinous line
RP

87. CCeerrvviiccaall SSppiinneess NNoorrmmss
PPrreeddeennttaall ssppaaccee • 3mm or less
(4-5mm in children)
CC22--CC33 ppsseeuuddoossuubblluuxxaattiioonn • 3mm or less
(4-5mm in children)
RReettrroopphhaarryynnggeeaall ssppaaccee • < 6mm at C2
• < 22mm at C6
• For children 1/2 to 2/3
vertebral body distance
anteroposteriorly
AAnngguullaattiioonn ooff ssppiinnaall ccoolluummnn aatt
aannyy ssiinnggllee iinntteerrssppaaccee lleevveell
• < 11 degrees
CCoorrdd ddiimmeennssiioonn • 10-13mm

88. Mechanism of Fractures
Hyperflexion Hyperextension Axial compression

89. Classification

90. Classification
Type of Injury Fractures Stability
Flexion Anterior subluxation
Unilateral facet dislocation
Bilateral facet dislocation
Wedge compression fracture
Flexion teardrop fracture
Clay Shoveler's fracture
Odontoid
stable or delayed instability
stable
unstable
stable
unstable
stable
unstable
Extension Hangman's fracture unstable
Compression Jefferson fracture
Burst fracture
unstable
stable

91. CT versus Radiography
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rreevveeaalleedd oonn CCTT
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92. So, which do you choose?
• Helical CT
– Faster?
– More Sensitive?
– Cost effective/more
expensive?
• Conventional Rad
– Slower?
– Less sensitive?
– Less expensive?

93. Blackmore et al (2001) Risk stratification
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94. Blackmore et al’s recommendation
CT should be considered aass TTHHEE PPRRIIMMAARRYY
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95. Case 1

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• Unilateral Facet Dislocation
Hyperflexion + rotation
Superior facet slides over inferior facet and becomes
locked
Anterior subluxation of superior vertebral body –25%
AP diameter
Stable injury
30% with associated neurologic deficit
MRI: disk extrusion leading to cord compression

100. Case (2)

103. Bilateral Facet Dislocation
Extreme hyperflexion
Anterior dislocation of articular masses (disruption of
posterior ligament complex,PLL,disk and ALL).
Complete dislocation: dislocated vertebra anteriorly
displaced ½ of AP diameter of vertebral body
Unstable ( high incidence of cord damage)

104. Case (3)

108. Case (4)

111. Flexion Tear Drop
Flexion+compression (MVA)
Teardrop fragment comes from the anteroinferior
aspect of the vertebral body
Larger posterior part displaced backward into the
spinal canal
Facets joints and interspinous distances usually
widened, disk space may be narrowed
70% of patients with neurologic injuries
Unstable fracture (complete disruption of ligaments
and anterior cord syndrome

112. Case (5)

113. Hangman’s fracture
Most common cervical spine fracture
Usually hyperextension
Unstable, however seldom associated with cord
injury (AP diameter of spinal canal greatest at C1/C2
level and # pedicles allow decompression)
Hangman’s + uni/bilateral facet dislocation: high rate
of neurologic complications

114. Case (6)

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117. Hyperextension injury
Widening of disk space anteriorly and narrowing
posteriorly
“open book”
Central cord injury= disproportionated weakness in
arms and normal strength in the legs
Injuries can be devastating, however are uncommon
hemorrhagic

118. Case (7)

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121. Extension Teardrop Fracture
ALL pulls bony fragment away from inferior aspect
of the vertebra because sudden extension
Fragment is true avulsion x fragment from flexion
teardrop (compression)
Lower cervical spine
Central cord syndrome (buckling of ligamenta flava
into spinal canal)
Stable in flexion; highly unstable in extension

122. Case (8)

124. Jefferson Fracture
Burst fracture of ring of C1
Axial loading in the occiput
No associated neuro deficts ( C1 ring is wide!)
> 2mm dislocation of lateral masses of C1 or
odontoid view is diagnostic, 1-2 mm is equivocal
( rotation of head?)
Predental space > 3 mm: disruption of transverse
ligament
1/3 associated with C2 fracture

125. Thoracic Spine Injuries
Rigid
Spinal canal narrower than cervical or lumbar spine
Large spinal cord diameter relative to canal
diameter increases the risk of cord injury
Injury, usually significant (complete), less common
than in other regions
Association between fractures of the thoracic spine
and severe pulmonary injuries, mediastinal
hemorrhage

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Compression fracture
Injury to anterior column due to anterior or lateral
flexion
Middle and posterior columns remain intact
X-ray - decreased height anterior vertebral body, post
body height normal
Amount of anterior compression usually less than
40% of post body height
Clinically - stable, cord injury rare

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• Unstable if:
– vertebral height > 50%
– Angulation more than 20
degrees
– Multiple adjacent Loss of
compression fractures

129. Burst
• Disruption of the middle column
• Mechanism- axial loading
• Varying degrees of retropulsion
into the
neural canal
• X-ray- spreading of post elements
• If post elements involved- 50%
have neuro
injury
• Neurologic injury more common in:
– Loss of vertebral ht > 50%
– Angulation > 20 deg
– Canal compromise more than 40%

130. Lumbar Spine Injury
• Lower lumbar spine is the
most mobile
• Isolated fractures of the
lower lumbar spine rarely
result in complete
neurologic injuries
• Injuries: complete cauda
equina lesion or isolated
nerve root injuries

131. Spinal cord injury (SCI)
Spinal cord injury
There are two types of
injury to the spinal cord:
• Non-hemorrhagic with
only high signal on MR
due to edema.
• Hemorrhagic with areas of
low signal intensity within
the area of edema.

132. • There is a strong correlation
between the length of the
spinal cord edema and the
clinical outcome.
• The most important factor
however is whether there is
hemorrhage, since
hemorrhagic spinal cord
injury has an extremely poor
outcome.

133. Midsagittal (a) T1-weighted and (b) T2-weighted MR images obtained in 45-
year-old man with acute traumatic C5 through C6 mild SCI after a fall show
the distances of the spinal canal and spinal cord at the injury site (Di and di,
respectively), one segment below the injury site (Db and db, respectively), and
one segment above the injury site (Da and da, respectively) used to (a)
estimate the MCC and (b) measure spinal canal compression.
©2007 by Radiological Society of North America

134. THANK YOU