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Title: Chest Wall, Lung, and Pleural Space Trauma Authors: Miller LA Journal: Radiologic Clinics of North America (2006) Key Points Chest radiographs are useful to identify chest trauma such as mediastinal hematoma, pneumothorax, pulmonary contusion, and bony trauma but can underestimate the severity of the injury. Computerized tomography (CT) is often more sensitive than routine chest x-ray and is a useful tool in the trauma patient. Multidetector CT (MDCT) adds high-quality multiplanar reformations that can be easily obtained and add to the diagnosis and management of these patients. Clinical Conclusions Blunt chest trauma can result in serious life-threatening injuries so a high index of suspicion coupled with careful use of imaging modalities is key to the early identification and treatment of these injuries. Section Highlights Pulmonary Trauma Pulmonary contusion is caused by chest wall compression against the lung, shearing of lung tissue across bony structures, puncture by rib fracture, or tearing from prior pleural adhesions; it is more evident on CT than radiograph. Figure 1-2 Pulmonary laceration is a traumatic disruption of the lung architecture that results in formation of a cavity that is filled with air or 1-3 blood and is also more readily seen on CT than radiography. Figure 3 Pleural Trauma Pneumothorax occurs in 30-40% of patients after blunt chest trauma, is more easily seen on CT than chest radiography, and may 4, 5 require treatment with chest tube placement if >20% or if tension pneumothorax develops. Figure 4-7 6 Hemothorax is seen approximately 50% of patients who sustain blunt chest trauma; CT is helpful in detecting the site of active bleeding. Figure 9-10 Skeletal Trauma 7, 8 Rib Fractures are the most common skeletal injury in blunt chest trauma, occurring in approximately 50% of patients; Flail chest occurs when there are at least two fracture sites on each of three or more consecutive rib and traumatic pulmonary herniation may occur as a result of severe blunt chest trauma. Figure 11-12 9 Sternal fracture occur in 3-8% of patients with blunt chest trauma, most commonly at the body or manubrium. Sternoclavicular dislocation are most commonly anterior with posterior dislocations being a cause of serious morbidity. Figure 13 Scapular fractures are typically related to high-velocity motor vehicle collisions and falls and most are treated non-operatively unless 10 the glenoid or scapular neck are involved. Scapulothoracic dissociation (STD) is a rare injury that most commonly results from motorcycle collision with the upper extremity appearing flaccid and pulseless as a result of subclavian or axillary artery and brachial plexus injury or avulsion. Figure 14 Key References 1. Shin M.S. and Ho K.J., Computed tomography evaluation of posttraumatic pulmonary pseudocysts. Clin Imaging, 1993. 17(3): p. 189-92. 2. Wagner R.B., Crawford W.O., Jr., and Schimpf P.P., Classification of parenchymal injuries of the lung. Radiology, 1988. 167(1): p. 77-82. 3. Trupka A., Waydhas C., Hallfeldt K.K., Nast-Kolb D., Pfeifer K.J., and Schweiberer L., Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma, 1997. 43(3): p. 405-11; discussion 411-2. 4. Weissberg D. and Refaely Y., Pneumothorax: experience with 1,199 patients. Chest, 2000. 117(5): p. 1279-85. 5. Pacanowski J.P., Waack M.L., Daley B.J., Hunter K.S., Clinton R., Diamond D.L., and Enderson B.L., Is routine roentgenography needed after closed tube thoracostomy removal? J Trauma, 2000. 48(4): p. 684-8. 6. Stark P., Pleura, in Radiology of thoracic trauma, P. Stark, Editor. 1993, Andover Medical Publishers: Boston. p. 54-72. 7. Tocino I. and Miller M.H., Computed tomography in blunt chest trauma. J Thorac Imaging, 1987. 2(3): p. 45-59. 8. DeLuca S.A., Rhea J.T., and O'Malley T.O., Radiographic evaluation of rib fractures. AJR Am J Roentgenol, 1982. 138(1): p. 91-2. 9. Athanassiadi K., Gerazounis M., Moustardas M., and Metaxas E., Sternal fractures: retrospective analysis of 100 cases. World J Surg, 2002. 26(10): p. 1243-6. 10. McGahan J.P., Rab G.T., and Dublin A., Fractures of the scapula. J Trauma, 1980. 20(10): p. 880-3.
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