Blunt chest trauma: a pictorial review

Poster No.:

C-2348

Congress:

ECR 2012

Type:

Educational Exhibit

Authors:

J. Palas , A. Matos , M. Ramalho ; Almada/PT, Lisboa/PT

Keywords:

Thorax, Lung, Mediastinum, CT, Contrast agent-intravenous,

Trauma

DOI:

10.1594/ecr2012/C-2348

1 1

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Learning objectives
To illustrate the spectrum of multidetector computed tomography (MDCT) findings in
thoracic blunt trauma evaluation.

Background
In the western countries, polytrauma is, according to some series, the third cause of
death, being the leading cause in young adults. Mortality rate occurs approximately in
20% of people who suffer blunt chest trauma and reaches 75%-80% when it is associated
to shock and brain trauma.
Traffic accidents represent the major source with approximately two thirds of the cases.
Imaging studies play an essential part of thoracic trauma care. The ideal imaging
technique has to reach the correct diagnosis as fast as possible, with a good accuracy in
detecting chest trauma lesions; therefore MDCT has become the gold standard imaging
technique in the emergency department.

Imaging findings OR Procedure details

MDCT is crucial in the diagnosis of pulmonary contusions, tracheobronchial lacerations,
pneumomediastinum, aortic injury, mediastinal hemorrhage, pneumo- and hemothoraces
and chest wall lesions, such as bone fractures, muscle hematomas and subcutaneous
emphysema.
Optimal assessment requires careful technique, including the use of intravenously
administered contrast material and multiplanar reconstructed images. Awareness of
potential pitfalls is critical.
In this exhibit, we illustrate a spectrum of characteristic CT findings of traumatic injuries
of lungs, mediastinum, pleural space and chest wall.
Lung parenchyma
Pulmonary contusion
Pulmonary contusion is seen in 30%-70% of patients with blunt chest trauma [1, 2].
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It is a focal parenchymal injury of the alveolar epithelium, with interstitial edema and
alveolar hemorrhage. They are produced at the time of injury, usually adjacent to the
area of trauma, although they can also occur on the opposite side of the lung (contusion
for backlash).
CT is very sensitive for diagnosis and quantification of the extent of pulmonary
contusions. The CT appearance of pulmonary contusions depends on the severity of
parenchymal injury. The "ground glass" pattern is seen when interstitial or partial alveolar
compromise occurs, resulting in a heterogeneous opacification (Fig.1).

Fig. 1: Bilateral lung contusions. A concomitant right-sided small pneumothorax is also

noted.
References: J. Palas; Radiology, Almada, PORTUGAL
When injury to the alveoli is severe, they are seen as poorly defined areas of
consolidation, with no air broncogram sign, as a result of bronchial obstruction caused by

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secretions or blood. Massive pulmonary contusion may lead to the development of adult
respiratory distress syndrome and/or pneumonia [2].
They might be associated with other lesions, such as chest wall contusions, fractures
in the overlying area of impact, hemothorax (Fig.2), pneumothorax or concomitant
lacerations.

Fig. 2: Right lung focus of contusion. Ipsilateral hemothorax is also depicted.

References: J. Palas; Radiology, Almada, PORTUGAL
Resolution is usually rapid; the lung often returns to normal within a week. Failure of
resolution usually suggests superimposed infection, atelectasis, aspiration pneumonia
(Fig.3) or a blood clot in a laceration.

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Fig. 3: Dependent bilateral lung condensations, with air broncogram sign, in a

polytraumatized patient suffering from aspiration pneumonia.
References: J. Palas; Radiology, Almada, PORTUGAL
Lung laceration
Lacerations in the pulmonary parenchyma are most commonly caused by penetrating
traumas such as stab wounds or bullet wounds. However, blunt chest injuries can also
produce substantial pulmonary lacerations [3].
Lung laceration refers to a traumatic disruption of alveolar spaces with formation of a
cavity filled with blood (hematoma), air (pneumatocele), or more frequently a combination
of them [1, 2] (Fig.4).

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Fig. 4: Multiple focus of lung laceration, some of them filled with air and blood
(pneumohematocele), others with air (pneumatocele) or blood (hematocele). Right
pneumothorax and bilateral lung focus of contusion are also seen.
References: J. Palas; Radiology, Almada, PORTUGAL
Single isolated lacerations are most common, but multiple lacerations may occur.
The resultant pneumatocele has a variable course; usually it resolves within one to three
weeks as a pulmonary parenchymal scar. Nevertheless it may persist for several weeks
[3].
Surgery is indicated in cases of large parenchymal destruction, bleeding from a major
vessel or bronchovascular fistula [4].
Mediastinal Trauma
Tracheobronchial laceration

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Blunt chest trauma causes an abrupt increase in intrathoracic airways pressure.

Tracheobronchial injuries occur in less than 1% of blunt chest trauma patients. Bronchial
tear is more cornmon than tracheal tear and occurs more often on the right side.
Approximately 85% of tracheal lacerations occur 2 cm above the carina, and are usually
longitudinal, being located at the cartilage - membranous junction.
Discontinuity of the tracheal or bronchial wall can rarely be seen, with air leaking around
the airway (Fig. 5).

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Fig. 5: Tracheal injury associated with pneumothorax, pneumomediastinum and

subcutaneous emphysema.
References: J. Palas; Radiology, Almada, PORTUGAL
Among the more prevalent, but less specific, indirect findings, we can see
pneumothoraces, pneumomediastinum, pneumoretroperitoneum, and subcutaneous
emphysema. More specific signs of tracheobronchial tear include collapsed lung
("fallen lung" sign), persistent pneumothorax after tube thoracostomy, and herniation or
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overdistention of an endotracheal cuff in an intubated patient. All of these findings can

be readily detected with MPR and 3D reconstructions using MDCT [1].
If a laceration is suspected and none can be detected on CT, it is essential to perform
a bronchoscopy to evaluate the site and extent of the injury, guide the placement of
the endotracheal tube and maintain the airway. Laryngotracheal breaks may need a
tracheotomy [4].
Repair of tracheobronchial lacerations is best performed as soon as possible in order to
avoid chronic pulmonary complications. Death is frequent from this type of injury [3].
Pneumomediastinum
The air may enter into the mediastinum after a tracheobronchial or esophageal rupture,
but mainly from alveolar rupture. It fills the interstitium and then reaches the hilum and
mediastinum, dissecting along the bronchovascular sheaths (Macklin effect).
Air in the mediastinum, under pressure, can produce cardiovascular embarrassment
which, if not treated immediately, may be fatal [3].
Esophageal Injury
Blunt trauma of the esophagus is rare, because it is well protected in the mediastinum.
The site of rupture may be anywhere from the cervical esophagus to the distal esophagogastric junction. When esophageal rupture occurs, it is a nearly fatal condition and the
associated mortality approaches 90%, being the cause of death almost always secondary
due to mediastinitis [3].
CT findings that may suggest traumatic esophageal perforation are: focal extraluminal
air collections at the site of tear, mediastinitis, hydropneumomediastinum, hematoma
of the mediastinal or esophageal wall and the escape of oral contrast material into the
mediastinal or pleural space [5].
Treatment of choice includes surgery and large antibiotic coverage [4].
Aortic Lesions
A lesion of the thoracic aorta is usually fatal being the most lethal of all injuries of the
chest blunt trauma (85% of cases). The wounds of the thoracic aorta typically occur in
the aortic isthmus, aortic arch and descending aorta at the level of diaphragm [6].

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CT allows visualization of mediastinal hemorrhage (Fig.6), aortic-contour deformity,

an intimal flap, a thrombus into the aortic lumen, a pseudoaneurysm (Fig.7), an
abrupt change in caliber of the descending aorta compared with the ascending aorta
(pseudocoarctation), and extravasation of contrast material (rare).

Fig. 6: Mediastinal hemorrhage

References: J. Palas; Radiology, Almada, PORTUGAL

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Fig. 7: Aortic pseudoaneurysm in the characteristic location, just distal to the left
subclavian artery
References: J. Palas; Radiology, Almada, PORTUGAL
The treatment of choice is surgical repair by resection of the affected area and insertion
of a prosthetic replacement. Encouraging results are being obtained with the use of
endovascular stents. Injuries in supraaortic vessels, pulmonary vessels and large venous
vessels (cava, azygos) may be associated with cardiac tamponade or hypovolemic shock
from massive hemorrhage. In these cases surgical treatment is also urgent [4].
Pneumopericardium

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Findings may include air around the heart that does not rise above the level of pericardial
reflection at the root of the great vessels (Fig. 8).

Fig. 8: Pneumopericardium and pneumomediastinum. Bilateral dependent opacities

were also noted.
References: J. Palas; Radiology, Almada, PORTUGAL
Hemopericardium
Rapid accumulation of blood in the pericardial space often causes cardiac tamponade.
Although it is a clinical diagnosis, CT findings include large pericardial blood effusion (Fig.
9), with dilation of the superior and inferior vena cava; reflux of contrast material into the
azygos vein and inferior vena cava; deformation and compression of cardiac chambers
and other intrapericardial structures and bulging of the interventricular septum [7].

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Fig. 9: Hemopericardium and bilateral hemothorax

References: J. Palas; Radiology, Almada, PORTUGAL
Injuries of the pleural space
Pneumothorax
Pneumothorax occurs in 30%-40% of cases of blunt chest trauma, being the second
most common injury. It is an abnormal collection of air in the pleural space between the
visceral and parietal pleura (Fig.10).

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Fig. 10: Left pneumothorax and hemothorax with a subtle subcutaneous emphysema
References: J. Palas; Radiology, Almada, PORTUGAL
It may be caused by broken alveoli due to a sudden increase of intrathoracic pressure,
by a mechanism of chest deceleration (with or without rib fractures), by broken
emphysematous bulla, by pulmonary laceration, by tracheobronchial injury or due to the
"Macklin effect" [8].
Tension pneumothorax develops when air enters the pleural space but cannot leave
and is under considerable pressure. It expands the ipsilateral hemithorax, collapses the

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associated lung, depresses the associated hemidiaphragm, displaces the mediastinum

to the opposite side, produces atelectasis in the contralateral lung and prevents adequate
diastolic filling of the heart. The cardiorespiratory embarrassment caused by tension
pneumothorax can be severe [3].
The treatment is pleural drainage. Surgery is indicated when it finds a persistent or
massive air leak and lack of lung reexpansion [4].
Hemothorax
Hemothorax is defined as a collection of blood in the pleural space, usually due to
lesions of lung parenchyma or pleura or abdominal injuries (liver and splenic injuries with
diaphragmatic rupture). It occurs in 30%-50% of patients who suffer blunt chest trauma
[2].
CT easily characterizes the pleural fluid and determines the value of attenuation (typically
has an attenuation of 35-70 Hounsfield Units). Blood can be seen in the pleural space
at different degrees of coagulation, giving rise to a layered appearance, called the
"hematocrit sign" (Fig.11).

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Fig. 11: The "hematocrit sign" in a right hemothorax.

References: J. Palas; Radiology, Almada, PORTUGAL
Most cases are resolved with placement of pleural drainage.
The combination of pneumothorax and hemothorax is common, causing a
hemopneumothorax (Fig.12) which has the same treatment [4].

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Fig. 12: Right hemo-pneumothorax

References: J. Palas; Radiology, Almada, PORTUGAL
Wall chest trauma
Rib Fractures

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Rib fractures are commonly identified on CT scans obtained following blunt chest trauma,
being observed in 80% of patients (1) (Fig.13).

Fig. 13: Rib fracture

References: J. Palas; Radiology, Almada, PORTUGAL
The most affected rib arches are 3 to 9. [2]. Flail chest is a traumatic condition in which
there are three or more contiguous ribs with fractures in two or more places, probably
requiring surgical treatment (Fig.14).

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Fig. 14: Multiple bilateral rib fractures

References: J. Palas; Radiology, Almada, PORTUGAL
CT can determine the site and number of fractures, as well as other associated injuries
(hemothorax, pneumothorax, subcutaneous emphysema, and pulmonary contusion).
Sternal Fractures
Sternal fractures have been reported in approximately 8% of blunt chest trauma patients.
Approximately 90% of such fractures are secondary to motor vehicle accident (due to
seat belt or air bag trauma) [2].
They usually involve the sternal body and manubrium (Fig.15), often associated to
mediastinal hematoma, lung, cardiac and spinal injury.

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Fig. 15: Sternum fracture at the level of the manubrium

References: J. Palas; Radiology, Almada, PORTUGAL
Coronal, sagittal and three-dimensional reconstructions (3D) often demonstrate sternal
and clavicular fractures and sternoclavicular dislocations better than axial images do.
Treatment is usually based on pain control and chest physiotherapy [4].
Shoulder Fracture

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They occur after high-impact trauma and have been associated with pulmonary
contusion, rib fractures, clavicle and scapula fractures (Fig.16) and arterial injuries
(subclavian, axillary or brachial).

Fig. 16: Right scapula fractures

References: J. Palas; Radiology, Almada, PORTUGAL
Thoracic Spine Fractures
Fractures of the thoracic spine occur in 3% of patients with blunt thoracic trauma; a high
percentage is associated with spinal cord injury. The most vulnerable site to fractures is
the thoracoabdominal junction involving the T9-T11 vertebral bodies.
Signs of vertebral body fractures on CT scans include disruption or fracture of the
vertebral body, pedicle, and/or spinous processes, paraspinal hematoma and confined
posterior mediastinum hematoma.
CT is the modality of choice in the evaluation of spine fractures. Reconstructed sagittal
and coronal multiplanar images are often useful.
Chest wall hematoma
Hematomas may be of arterial or venous origin (Fig. 17). Extrapleural hematomas are
commonly associated with rib fractures that injure the intercostal, internal mammary or
subclavian arteries [2].

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Fig. 17: Left anterior chest wall muscles hematoma

References: J. Palas; Radiology, Almada, PORTUGAL
Subcutaneous Emphysema
Air can spread through the fascial planes to the rest of the chest wall, abdomen, or even
into the head, neck and extremities (Fig.18).

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Fig. 18: Exuberant subcutaneous emphysema that dissects along the arms, neck,
chest and abdominal wall. A retropneumoperitoneu is also seen.
References: J. Palas; Radiology, Almada, PORTUGAL
Page 23 of 44

Most of the times it has a tracheobronchial tear origin, but it can also be a consequence
of esophageal rupture.
Traumatic pulmonary hernia
Lung herniation is a rare complication of blunt chest trauma. Herniation may occur
through an acquired abnormality when intrathoracic pressure increases with trauma.
The antero-lateral chest wall is more susceptible to traumatic lung herniation, because
of the minimal soft tissue support (intercostal muscles) compared to the posterior wall.
Supraclavicular hernias have also been reported.
When lung herniation is symptomatic, prompt surgical reduction is usually recommended
[2].
Diaphragm trauma
Approximately 8% of patients with chest or abdominal trauma have a traumatic rupture
of the diaphragm.
CT not only detects small diaphragmatic discontinuities, but also identifies the fat or the
involved viscera. Diaphragmatic rupture is more common on the left side (77-90%) than
on the right and the stomach is the most common abdominal viscus to become herniated
[1].
Sagittal and coronal reformations are superior to axial images in detecting diaphragmatic
rupture.
Treatment of these type of lesions is surgical [4].
Images for this section:

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Fig. 1: Bilateral lung contusions. A concomitant right-sided small pneumothorax is also

noted.

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Fig. 2: Right lung focus of contusion. Ipsilateral hemothorax is also depicted.

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Fig. 3: Dependent bilateral lung condensations, with air broncogram sign, in a

polytraumatized patient suffering from aspiration pneumonia.

Page 27 of 44

Fig. 4: Multiple focus of lung laceration, some of them filled with air and blood
(pneumohematocele), others with air (pneumatocele) or blood (hematocele). Right
pneumothorax and bilateral lung focus of contusion are also seen.

Page 28 of 44

Fig. 5: Tracheal injury associated with pneumothorax, pneumomediastinum and

subcutaneous emphysema.

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Fig. 6: Mediastinal hemorrhage

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Fig. 7: Aortic pseudoaneurysm in the characteristic location, just distal to the left
subclavian artery

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Fig. 8: Pneumopericardium and pneumomediastinum. Bilateral dependent opacities

were also noted.

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Fig. 9: Hemopericardium and bilateral hemothorax

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Fig. 10: Left pneumothorax and hemothorax with a subtle subcutaneous emphysema

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Fig. 11: The "hematocrit sign" in a right hemothorax.

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Fig. 12: Right hemo-pneumothorax

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Fig. 13: Rib fracture

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Fig. 14: Multiple bilateral rib fractures

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Fig. 15: Sternum fracture at the level of the manubrium

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Fig. 16: Right scapula fractures

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Fig. 17: Left anterior chest wall muscles hematoma

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Fig. 18: Exuberant subcutaneous emphysema that dissects along the arms, neck, chest
and abdominal wall. A retropneumoperitoneu is also seen.

Page 42 of 44

Conclusion
MDCT is the imaging modality of choice in the assessment of patients with clinical or
radiographic findings suggestive of thoracic lesions following blunt chest trauma. The
accuracy is improved with the use of intravenously contrast material and multiplanar
reconstructed images.

Personal Information
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