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Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.

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The document outlines trauma imaging guidelines and techniques presented at the Assiut University Trauma Course in March 2010, emphasizing the critical role of timely imaging in trauma care. It discusses specific modalities such as skull radiography and CT scans for diagnosing head and chest injuries, while advocating against routine skull X-rays in pediatric cases. Additionally, it covers the diagnostic approach to spinal injuries and the importance of utilizing various imaging modalities based on clinical indications.

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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.
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).
Time is of the Essence in Trauma Time is the eenneemmyy ffoorr ttrraauummaa vviiccttiimmss TTrraauummaa ssuurrggeeoonnss aarree rruulleedd bbyy tthhee ““GGoollddeenn HHoouurr””..
CLICK HERE TO ADD TEXT PART (1) HEAD TRAUMA
“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).
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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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).
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.
Depressed fractures are often difficult to see. Look for increased or double density
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CLICK HERE TO ADD TEXT 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).
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.
CLICK Anatomic HPaEttRernEs Tof O ADD TEXT Traumatic Brain injury BBlloooodd: eeppiidduurraall,, ssuubbdduurraall,, ppaarreenncchhyymmaa,, vveennttrriiccuullaarr,, aanndd ssuubbaarraacchhnnooiidd.. DDiirreecctt iinnjjuurryy ttoo bbrraaiinn –– ffrroonnttaall lloobbee aanndd aanntteerriioorr tteemmppoorraall lloobbee.. SShheeeerriinngg iinnjjuurryy: ddeeffoorrmmaattiioonn ooff bbrraaiinn ccaauussiinngg ddiiffffuussee aaxxoonnaall iinnjjuurryy..
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Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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CLICK HERE TO ADD TEXT 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.
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.
CLICK HERE TO ADD TEXT 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.
Figure 1. Patient 2. Tong K A et al. Radiology 2003;227:332-339 ©2003 by Radiological Society of North America
Figure 2. Patient 4. Tong K A et al. Radiology 2003;227:332-339 ©2003 by Radiological Society of North America
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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PART 2 CHEST TRAUMA
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.
CLICK HERE TO ADD TEXT • Blunt • Penetrating Types of Chest trauma • Explosion Related Chemical Agent Related Biological Agent Related
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Trauma Chest Radiograph • Usually AP, often supine, frequently in poor inspiration. • So, a challenge to interpret.
CT Chest More sensitive and specific
CT Chest: Reformat The new MDCT scanners do awesome reformats without additional scanning.
Blunt chest trauma • Factures and dislocations • Air where it shouldn’t be • Hemothorax • Pulmonary contusion and laceration • Diaphragm injuries
Fractures and Dislocations • Spine • Ribs • Clavicles • Sternum • Shoulders
CLICK HERE TO ADD TEXT • Spine Injuries • Look for loss of alignment, fractures and paraspinal hematoma. • The findings may be very subtle.
CLICK HERE TO ADD TEXT • CT is the imaging modality of choice for evaluation of these injuries.
CLICK HERE TO ADD TEXT 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
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.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
CLICK HERE TO ADD TEXT Sterno-Clavicular Dislocations • Anterior: Not much of a problem. • Posterior: Less common; can injure great vessels or trachea.
Sterno-clavicle dislocation: CT Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
Shoulder Injuries Look particularly for dislocations and scapula fractures
Sternum Fractures • Not usually a problem. • Controversial association with myocardial injury.
AIR where it shouldn’t be • Pneumothorax • Pneumomediastinum • Subcutaneous emphysema • Systemic venous air embolism • Pneumopericardium • Pneumoperitoneum/retroperitoneum
PNEUMOTHORAX • Simple • Tension • Open
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.
Pneumothorax: Simple • Erect AP/PA view best • Visceral pleural line • No vessels or markings • Variable degree of lung collapse • No shift
PNEUMOTHORAX: Tension • Erect AP/PA view best. • Shift of mediastinum away from PTX side. • Depressed hemidiaphragm. • Degree of lung collapse is variable.
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.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
PNEUMOMEDIASTIUM • Usually from ruptured alveoli. • Can also be from trachea, bronchi, esophagus, bowel and neck injuries.
CLICK HERE PNEUMOMEDIASTIUM TO ADD TEXT Signs: • Linear paratracheal lucencies • Air along heart border • “V” sign at aortic-diaphragm junction • Continuous diaphragm sign
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Surgical Emphysema
Pneumopericardium Penetrating injuries
Pneumoperitoneum
Systemic venous air embolism
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
Traumatic aortic rupture
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
CT: Pulmonary laceration The tear in the lung can fill with blood or air.
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
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
CLICK HERE TO ADD TEXT PART 3 SPINAL TRAUMA
Objectives • Clinical indication for each imaging modality • Identify anatomy of the spine • Approach to spine radiography interpretation • Classification of spine injuries
Canadian C-Spine Rule for selective ordering of cervical spine imaging Stiell, I. G et al. BMJ 2009;339:b4146
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.
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
RADIOGRAPHY for primary cervical spine screening • Minimum standard views – Lateral through C7 – AP – Odontoid • Supplementary views • Bilateral obliques – Swimmer’s – Flex ion and extension
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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.
NNOORRMMAALL CCEERRVVIICCAALL SSPPIINNEE 1 = anterior vertebral line 2 = posterior vertebral line 3 = spinolaminar line 4 = posterior spinous line RP
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
Mechanism of Fractures Hyperflexion Hyperextension Axial compression
Classification
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
CT versus Radiography VVaannddeerrmmaarrkk ccllaaiimmeedd:: WWeellll ppoossiittiioonneedd aanndd ooppttiimmaallllyy eexxppoosseedd rraaddiiooggrraapphhss ddiisscclloossee 9955%% ooff cclliinniiccaallllyy ssiiggnniiffiiccaanntt CC--ssppiinnee ffrraaccttuurreess.. HHoowweevveerr –– tthheessee hhiigghh qquuaalliittyy ssttuuddiieess aarree oofftteenn iimmppoossssiibbllee ttoo oobbttaaiinn aanndd pptt’’ss aatt hhiigghheesstt rriisskk aarree mmoosstt lliikkeellyy ttoo hhaavvee tteecchhnniiccaallllyy ccoommpprroommiisseedd iimmaaggiinngg.. 1999966 NNuunneezz eett aall 4400%% ooff FFxx’’ss mmiisssseedd oonn rraadd llaatteerr rreevveeaalleedd oonn CCTT 1//33 hhaadd cclliinniiccaallllyy ssiiggnniiffiiccaanntt oorr uunnssttaabbllee FFxx’’ss
So, which do you choose? • Helical CT – Faster? – More Sensitive? – Cost effective/more expensive? • Conventional Rad – Slower? – Less sensitive? – Less expensive?
Blackmore et al (2001) Risk stratification HHiigghh ((ffrraaccttuurree rriisskk ooff 1111..22%%)) == sseevveerree hheeaadd iinnjjuurryy,, ffooccaall nneeuurroo ddeeffiicciittss,, >>5500 yyrrss ww// hhiigghh-eenneerrggyy mmeecchhaanniissmm ooff iinnjjuurryy.. MMooddeerraattee ((44..22%%))== >>5500 yyrrss ww// aa mmooddeerraattee-eenneerrggyy mmeecchhaanniissmm oorr <<5500 ww//hhiigghh eenneerrggyy.. LLooww ((22..11%%))== <<5500 ww// mmooddeerraattee eenneerrggyy mmeecchhaanniissmm ooff iinnjjuurryy..
Blackmore et al’s recommendation CT should be considered aass TTHHEE PPRRIIMMAARRYY cceerrvviiccaall ssppiinnee ssccrreeeenniinngg mmooddaalliittyy iinn sseelleecctteedd vviiccttiimmss ooff mmaajjoorr ttrraauummaa wwhhoo aarree eexxaammiinneedd iinn hhiigghh-vvoolluummee uurrbbaann EEDD’’ss..
Case 1
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Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
CLICK HERE TO ADD TEXT • 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
Case (2)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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)
Case (3)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Case (4)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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
Case (5)
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
Case (6)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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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
Case (7)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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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
Case (8)
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
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
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
Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.
CLICK HERE TO ADD TEXT 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
CLICK HERE TO ADD TEXT • Unstable if: – vertebral height > 50% – Angulation more than 20 degrees – Multiple adjacent Loss of compression fractures
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%
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
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.
• 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.
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
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Introduction to trauma imaging. Guidelines and highlights for different imaging techniques.

  • 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””..
  • 4. CLICK HERE TO ADD TEXT 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
  • 7. CLICK HERE TO ADD TEXT Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 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
  • 11. CLICK HERE TO ADD TEXT • Click Here To Add Text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 12. CLICK HERE TO ADD TEXT Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 13. CLICK HERE TO ADD TEXT
  • 14. CLICK HERE TO ADD TEXT
  • 15. CLICK HERE TO ADD TEXT 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 BBlloooodd: eeppiidduurraall,, ssuubbdduurraall,, ppaarreenncchhyymmaa,, vveennttrriiccuullaarr,, aanndd ssuubbaarraacchhnnooiidd.. DDiirreecctt iinnjjuurryy ttoo bbrraaiinn –– ffrroonnttaall lloobbee aanndd aanntteerriioorr tteemmppoorraall lloobbee.. SShheeeerriinngg iinnjjuurryy: ddeeffoorrmmaattiioonn ooff bbrraaiinn ccaauussiinngg ddiiffffuussee aaxxoonnaall iinnjjuurryy..
  • 18. CLICK HERE TO ADD TEXT
  • 20. CLICK HERE TO ADD TEXT • Click Here To Add Text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 21. CLICK HERE TO ADD TEXT 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.
  • 23. CLICK HERE TO ADD TEXT 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
  • 27. CLICK HERE TO ADD TEXT Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 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.
  • 30. CLICK HERE TO ADD TEXT • Blunt • Penetrating Types of Chest trauma • Explosion Related Chemical Agent Related Biological Agent Related
  • 31. CLICK HERE TO ADD TEXT
  • 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
  • 37. CLICK HERE TO ADD TEXT • Spine Injuries • Look for loss of alignment, fractures and paraspinal hematoma. • The findings may be very subtle.
  • 38. CLICK HERE TO ADD TEXT • CT is the imaging modality of choice for evaluation of these injuries.
  • 39. CLICK HERE TO ADD TEXT 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.
  • 42. CLICK HERE TO ADD TEXT Sterno-Clavicular Dislocations • Anterior: Not much of a problem. • Posterior: Less common; can injure great vessels or trachea.
  • 43. Sterno-clavicle dislocation: CT Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text. Click here to add text.
  • 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
  • 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
  • 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
  • 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 VVaannddeerrmmaarrkk ccllaaiimmeedd:: WWeellll ppoossiittiioonneedd aanndd ooppttiimmaallllyy eexxppoosseedd rraaddiiooggrraapphhss ddiisscclloossee 9955%% ooff cclliinniiccaallllyy ssiiggnniiffiiccaanntt CC--ssppiinnee ffrraaccttuurreess.. HHoowweevveerr –– tthheessee hhiigghh qquuaalliittyy ssttuuddiieess aarree oofftteenn iimmppoossssiibbllee ttoo oobbttaaiinn aanndd pptt’’ss aatt hhiigghheesstt rriisskk aarree mmoosstt lliikkeellyy ttoo hhaavvee tteecchhnniiccaallllyy ccoommpprroommiisseedd iimmaaggiinngg.. 1999966 NNuunneezz eett aall 4400%% ooff FFxx’’ss mmiisssseedd oonn rraadd llaatteerr rreevveeaalleedd oonn CCTT 1//33 hhaadd cclliinniiccaallllyy ssiiggnniiffiiccaanntt oorr uunnssttaabbllee FFxx’’ss
  • 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 HHiigghh ((ffrraaccttuurree rriisskk ooff 1111..22%%)) == sseevveerree hheeaadd iinnjjuurryy,, ffooccaall nneeuurroo ddeeffiicciittss,, >>5500 yyrrss ww// hhiigghh-eenneerrggyy mmeecchhaanniissmm ooff iinnjjuurryy.. MMooddeerraattee ((44..22%%))== >>5500 yyrrss ww// aa mmooddeerraattee-eenneerrggyy mmeecchhaanniissmm oorr <<5500 ww//hhiigghh eenneerrggyy.. LLooww ((22..11%%))== <<5500 ww// mmooddeerraattee eenneerrggyy mmeecchhaanniissmm ooff iinnjjuurryy..
  • 94. Blackmore et al’s recommendation CT should be considered aass TTHHEE PPRRIIMMAARRYY cceerrvviiccaall ssppiinnee ssccrreeeenniinngg mmooddaalliittyy iinn sseelleecctteedd vviiccttiimmss ooff mmaajjoorr ttrraauummaa wwhhoo aarree eexxaammiinneedd iinn hhiigghh-vvoolluummee uurrbbaann EEDD’’ss..
  • 96. CLICK HERE TO ADD TEXT
  • 97. CLICK HERE TO ADD TEXT
  • 99. CLICK HERE TO ADD TEXT • 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
  • 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)
  • 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
  • 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
  • 116. CLICK HERE TO ADD TEXT
  • 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
  • 120. CLICK HERE TO ADD TEXT
  • 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
  • 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
  • 127. CLICK HERE TO ADD TEXT 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
  • 128. CLICK HERE TO ADD TEXT • 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

Editor's Notes

  • #25: Figure 1. Patient 2. A, Transverse GRE (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) and, B, SW (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) MR images obtained in an 11-year-old boy who was injured in a motor vehicle accident. Small hemorrhagic shearing injuries (arrows in B), such as those commonly seen in the subcortical junction of gray and white matter, were often seen only on the SW MR images.
  • #26: Figure 2. Patient 4. A, C, Transverse GRE MR images (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) obtained at two different levels of the corpus callosum in a 14-year-old girl who was injured in a motor vehicle accident. B, D, Corresponding transverse SW MR images (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) obtained in the same girl show hemorrhagic shearing lesions with variable sizes and shapes in the corpus callosum. The smallest lesions (small arrow in B and D) are seen only on the SW MR images. The larger lesions (large arrow) are more visible on the SW MR images owing to greater hypointensity and are only slightly larger on these images than on the GRE MR images.
  • #27: Figure 3. Patient 2. A, Transverse GRE (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) and, B, transverse SW (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) MR images obtained in an 11-year-old boy who was injured in a motor vehicle accident. Brain stem lesions (small arrow) often were either poorly visualized or invisible on the GRE images compared with their appearance on the SW MR images. The mild increase in blooming artifact (large arrow) on the SW MR images also accentuates the magnetic susceptibility effects from the bones of the skull base.