Trauma Radiology Companion PDF

Trauma Radiology
C O M PA N I O N
Methods, Guidelines, and Imaging Fundamentals
SECOND EDITION
Martin L. Gunn, M.B.Ch.B., FRANZCR.

Assistant Professor of Radiology
University of Washington
Seattle, Washington
Joel A. Gross, M.S., M.D.

Associate Professor of Radiology
Director of Emergency Radiology
Seattle, Washington
Michelle M. Bittle, M.D.

Assistant Professor of Radiology
Seattle, Washington
Eric J. Stern, M.D.

Professor of Radiology
Adjunct Professor of Medicine
Adjunct Professor of Medical Education and Bioinformatics
Adjunct Professor of Global Health
Seattle, Washington
Bittle_FM.indd i 4/30/2011 4:01:19 PM

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Library of Congress Cataloging-in-Publication Data

Bittle, Michelle M.
Trauma radiology companion : methods, guidelines, and imaging fundamentals.
2nd ed. / Michelle M. Bittle, Joel A. Gross, Martin L. Gunn.
p. ; cm.
Rev. ed. of: Trauma radiology companion / edited by Eric J. Stern. c1997.
Includes bibliographical references and index.
ISBN 978-1-60831-378-5
1. Wounds and injuriesImaging. 2. Wounds and injuries--Diagnosis. I. Gross, Joel A. II. Gunn,
Martin L. III. Trauma radiology companion. IV. Title.
[DNLM: 1. Wounds and Injuriesradiography. 2. Diagnostic Imagingmethods. WO 700]
RD93.7.T734 2011
617.1'0754dc22
2011004309
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This second edition of Trauma Radiology Companion is dedicated
to the memory of Robert L. Bree, M.D.
Robert L. Bree, M.D., an internationally respected physician and professor of radiol-
ogy at the Harborview Medical Center, University of Washington, died in 2010 at
the age of 66. Dr. Bree earned his medical degree from the University of Michigan
in 1966. After 10 years at Beaumont Hospital in Detroit, Dr. Bree became a pro-
fessor of radiology and director of ultrasound at the University of Michigan Hospi-
tal. His dedication to the field of radiology and ultrasound, in particular, resulted
in many landmark articles and innovations in ultrasound imaging. He served as
chair of Radiology at the University of Missouri and continued to be a leader in Aca-
demic Radiology through research and teaching and as an examiner for the Ameri-
can Board of Radiology. In addition to being a tremendous academician, he was a
devoted family man and moved to Everett, Washington, to be closer to his family
and grandchildren and took a position with Radia Inc. Fortunately for Harborview
Medical Center and the University of Washington, he returned to academics and he
joined our staff in 2005.
While continuing academic pursuits at Harborview Medical Center, he devel-
oped a passion for utilization management and was instrumental in passing the
landmark 2009 Washington State legislation, Advanced Imaging Management,
designed to ensure appropriate utilization of imaging procedures and ultimately
reduce medical costs and unnecessary radiation.
Bittle_FM.indd iii 4/30/2011 4:01:21 PM

Contents
Contributors xii
Foreword xiv
Foreword to the First Edition xv
Preface xvi
1 Overview of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Epidemiology of Trauma 2
Ken F. Linnau
Blunt Trauma Resuscitation Imaging: The Radiologic ABCs 5

Michelle M. Bittle and Leila Bender
Trauma Severity Scoring 8

Ken F. Linnau
Medical-Legal Issues in Trauma and Emergency Radiology 11

Annemarie Relyea-Chew
Special Procedures in the Emergency Room 15

Charles A. Rohrmann
Gunshot Wounds 18
Zachary Ashwell and Michelle M. Bittle
Gunshot Wounds: Low-Velocity Bullet Injury 22

Gunshot Wounds: Shotgun Injury 24

Contrast Reactions and Extravasation 28

Martin L. Gunn
2 Brain and Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Cerebral Contusion 30
Robert B. Carr and Kathleen R. Fink
Diffuse Axonal Injury 32

Epidural Hematoma/Hyperacute Intracranial Hemorrhage 34

Acute Subdural Hematoma 36

Chronic Subdural Hematoma/Acute Rehemorrhage 38

Linear Skull Fracture 40

Depressed Skull Fracture 42
Delayed Posttraumatic Intracranial Hemorrhage 44

Kathleen R. Fink and Carrie Marder
iv
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Contents v
Child Abuse 46
Angelisa Paladin
Gunshot Wound to Head 48

Sung E. LoGerfo
Blunt Carotid and Vertebral Artery Injuries 50

Martin L. Gunn and Sung E. LoGerfo
Acute Intracranial Hemorrhage: Intraventricular Hemorrhage

and Traumatic Subarachnoid Hemorrhage 54
Herniation: Uncal 56
Sung E. LoGerfo
Herniation: Subfalcine 58
Sung E. LoGerfo
Herniation: Upward (Cerebellar Hemorrhage) 60

Sung E. LoGerfo
Diffuse Anoxic Changes 62

Sung E. LoGerfo
Cerebral Perfusion SPECT in Traumatic Brain Injury 64

David H. Lewis
Cerebral Blood Flow Imaging for Brain Death 66

David H. Lewis
Facial Trauma: Orbital Floor Fracture 68

Facial Trauma: Tripod Fracture 70

Facial Trauma: Le Fort Fracture 72

Cervical Spine Injury: Occipital Condyle Fractures 74

Ken F. Linnau
Cervical Spine Injury: Atlanto-Occipital Dissociation 76

Ken F. Linnau
Cervical Spine Injury: Jefferson Fracture 78

Ken F. Linnau
Cervical Spine Injury: Transverse Atlantal Ligament Injury 80

Ken F. Linnau
Cervical Spine Injury: Dens Fracture 82

Ken F. Linnau
Cervical Spine Injury: Traumatic Spondylolisthesis of the Axis 84

Ken F. Linnau
Cervical Spine Injury: Flexion-Teardrop Fracture (aka Hyperflexion

Injuries) 86
Quynh T. Nguyen
Lower Cervical Spine Injury: Unilateral Jumped Facet 88

Quynh T. Nguyen
Lower Cervical Spine Injury: Bilateral Jumped Facets 90

Quynh T. Nguyen
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vi Contents
Lower Cervical Spine Injury: Isolated Posterior Ligamentous Injury 92

Quynh T. Nguyen
Lower Cervical Spine Injury: Burst Fracture 94

Quynh T. Nguyen
Thoracic/Lumbar Spine Injury: Compression and Burst Fractures 96

Quynh T. Nguyen
Thoracic/Lumbar Spine Injury: Flexion-Distraction and Chance

Injuries 98
Quynh T. Nguyen
Thoracic/Lumbar Spine Injury: Hyperextension Injuries 100

Quynh T. Nguyen
Thoracic/Lumbar Spine Injury: Fracture-Dislocations 102

Quynh T. Nguyen
Radionuclide Detection of Cerebrospinal Fluid Leaks 104

David H. Lewis
3 Torso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Scapulothoracic Dissociation 106
Martin L. Gunn
Scapula Fracture 108

Eric J. Stern
Rib Fractures 110

Eric J. Stern
Sternoclavicular Dislocation 112

Martin L. Gunn
Sternal Fractures 114

Martin L. Gunn
Airway Rupture/Laceration 116

Eric J. Stern
Esophageal Rupture/Laceration 118

Martin L. Gunn
Esophageal Intubation with Gastric Perforation 120

Martin L. Gunn
Traumatic Aortic Injury: Overview 122

Martin L. Gunn
Traumatic Aortic Injury: Chest Radiography 124

Martin L. Gunn
Traumatic Aortic Injury: Minimal Aortic Injury 126

Martin L. Gunn
Traumatic Aortic Injury: Computed Tomography 128

Martin L. Gunn
Traumatic Aortic Injury: Endovascular Repair 132

Martin L. Gunn
Injury to the Great Vessels 136

Martin L. Gunn
Peripheral Vascular Trauma 138

Martin L. Gunn
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Contents vii
Myocardial Contusion 140

Martin L. Gunn and Christopher Ingraham
Cardiac Perforation and Rupture 142

Martin L. Gunn and Christopher Ingraham
Diaphragm Injury 144

Martin L. Gunn and Eric J. Stern
Pulmonary Contusion 148

Eric J. Stern
Pulmonary Laceration 150

Eric J. Stern
Pulmonary Laceration: Penetrating Injuries 154

Eric J. Stern
Pulmonary Laceration: Pulmonary Hematoma 156

Eric J. Stern
Lung Injury: Blast Effect 158

Eric J. Stern
Traumatic Pneumothorax 160

Ken F. Linnau
Intrathoracic Ectopic Air Collections 164

Eric J. Stern
Aspiration of Foreign Body 166

Eric J. Stern
Near-Drowning 168
Eric J. Stern
Intraperitoneal Fluid in Trauma 170

Leila Bender and Martin L. Gunn
Focused Assessment with Sonography for Trauma (FAST) 174

Martin L. Gunn
Extraperitoneal Fluid in Trauma 178

Intraperitoneal and Retroperitoneal Gas 180

Active Bleeding: Findings on CT Scan 182

Liver Injury: Acute 184

Leila Bender and Todd Kooy
Liver Injury: Follow-Up and Natural History 190

Biliary Injury 192

Splenic Trauma 196

Leila Bender and Michelle M. Bittle
Solid Organ Injury: Indications for Angiography 200

Matthew Kogut and Christopher Ingraham
Pancreatic Injury 204

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viii Contents
Gastrointestinal and Mesenteric Injury 206

Duodenal Injury 210

Colorectal Injury 212

Michelle M. Bittle
Adrenal Hemorrhage 214

Michelle M. Bittle
Renal Injuries 216

Joel A. Gross and John P. OBrien
Renal Injuries: Imaging 220

Joel A. Gross and John P. OBrien
Renal Injuries: Clinical Management Issues 226

John P. OBrien and Joel A. Gross
Renal Laceration with Urinary Extravasation 228

John P. OBrien and Joel A. Gross
Ureteral Injuries 230

Joel A. Gross and Lorenzo Mannelli
Bladder Injuries: Extraperitoneal Rupture 234

Lorenzo Mannelli and Joel A. Gross
Bladder Injuries: Intraperitoneal Rupture 240

Joel A. Gross and Lorenzo Mannelli
Urethral Injuries 244

Robert L. Bree
Anterior Urethral Laceration 248

Robert L. Bree
Imaging The Gravid Uterus 250

Claudia Sadro
Testicular Trauma 254

Robert L. Bree
4 Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Clavicle Fractures 256
Emily Albrecht
Acromioclavicular Joint Dislocation 258

Emily Albrecht
Shoulder Joint Dislocation 260

Emily Albrecht
Shoulder Dislocation: Posterior 264

Emily Albrecht
Proximal Humeral Fractures 266

Emily Albrecht
Humeral Shaft Fractures 268

Michelle M. Bittle and Michael McBain
Distal Humeral Fractures 270

Emily Albrecht
Humerus: Epicondyle Injury 272

Emily Albrecht
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Contents ix
Elbow Dislocation 274

Emily Albrecht
Radial Head Fractures 276

Emily Albrecht
Radius and Ulna Shaft Fractures 278

Michelle M. Bittle and Issac Reeve
Distal Radius and Ulna Fractures 280

Michelle M. Bittle and Issac Reeve
Carpal Fractures 284

Michelle M. Bittle and Brian Dontchos
Carpal Dislocations 288

Michelle M. Bittle and Brian Dontchos
Metacarpal Fractures 290

Emily Albrecht
Phalangeal Fractures 296

Emily Albrecht
5 Pelvis/Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Overview of Pelvic Fractures 300
Robert Nathan and Claire Sandstrom
Pelvic Apophyseal Avulsions 302

Lateral Compression Pelvic Injury 304

Anteroposterior Compression Pelvic Injury 306

Vertical Shear Pelvic Injury 308

Pelvic Ring Disruption and Arterial Injury 310

Sacral Fracture 312

Basic Acetabular Anatomy 314

Anterior Hip Dislocation 316

Posterior Hip Dislocation 318

Posterior Wall Acetabular Fracture 320

Transverse Acetabular Fracture 322

Both Column Acetabular Fracture 326

Intracapsular Femoral Neck Fracture 330

Michelle M. Bittle and Claudia Sadro
Occult Hip Fracture 332

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x Contents
Stress and Insufficiency Fractures of the Femoral Neck 334

Extracapsular Proximal Femur Fractures: Intertrochanteric

Femur Fracture 338
Extracapsular Proximal Femur Fractures: Subtrochanteric

Femur Fracture 340
Femoral Shaft Fracture 342

Supracondylar Fracture of the Femur 346

Patella Fracture 348

Michelle M. Bittle
Tibial Plateau Fracture 352

Michelle M. Bittle
Anterior Cruciate Ligament Avulsion Fracture 356

Michelle M. Bittle
Posterior Cruciate Ligament Avulsion Fracture 358

Michelle M. Bittle
Collateral Ligament Injuries of the Knee 360

Michelle M. Bittle
Anterior Cruciate Ligament Tear 362

Claudia Sadro
Meniscal Tears 364

Michelle M. Bittle and Alice S. Ha
Segond Fracture: Lateral Capsular Avulsion 366

Michelle M. Bittle
Patellar Dislocation 368

Michelle M. Bittle and Christopher Ingraham
Knee Dislocation 370

Tibial Stress Fracture 372

Tibial And Fibular Shaft Fractures 374

Tibial Plafond Fracture (Pilon Fracture) 376

Robert Nathan and Christopher Ingraham
Ankle Mortise Injuries: Classification 378

Calcaneal Fracture 384

Talus Fracture 388

Talar and Subtalar Dislocations 394

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Contents xi
Tarsal Navicular Fracture 396

Cuboid and Cuneiform Fractures 400

Tarsometatarsal (Lisfranc) Fracture Dislocation 402

Metatarsal Fracture 406

Toe Injuries and Lower Extremity Foreign Bodies 408

Index 411
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Contributors
Emily Albrecht, PA-C Alice S. Ha, M.D.

Teaching Associate Faculty, Radiology Assistant Professor of Radiology
University of Washington University of Washington
Seattle, Washington Seattle, Washington
Zachary Ashwell, B.S., M.S.M.E. Christopher Ingraham, M.D.

Medical Student Chief Radiology Resident
George Washington University University of Washington
Washington, District of Columbia Seattle, Washington
Leila Bender, M.D. Matthew Kogut, M.D.

Radiology Resident Assistant Professor of Radiology
Michelle M. Bittle, M.D. Todd Kooy, M.D.

Assistant Professor of Radiology Assistant Professor of Radiology
Robert L. Bree, M.D., M.H.S.A., F.A.C.R. David H. Lewis, M.D.

Professor of Radiology Associate Professor of Radiology
University of Washington Director of Nuclear Medicine
Seattle, Washington University of Washington
Seattle, Washington
Robert B. Carr, M.D.
Radiology Resident Ken F. Linnau, M.D., M.S.
University of Washington Assistant Professor of Radiology
Seattle, Washington
Brian Dontchos, M.D.
Radiology Resident Sung E. LoGerfo, M.D.
University of Washington Assistant Professor of Radiology
Seattle, Washington
Kathleen R. Fink, M.D.
Assistant Professor of Radiology Lorenzo Mannelli, M.D.
University of Washington Acting Instructor and Senior Fellow
Seattle, Washington Emergency Radiology
Joel A. Gross, M.S., M.D. Seattle, Washington
Associate Professor of Radiology
Director of Emergency Radiology Carrie Marder, M.D., Ph.D.
University of Washington Radiology Resident
Seattle, Washington
Assistant Professor of Radiology Michael McBain, B.S.
University of Washington Medical Student
Seattle, Washington
xii
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Contributors xiii
Robert Nathan, M.D., M.P.H. Charles A. Rohrmann, M.D.

Acting Assistant Professor of Radiology Professor of Radiology
Quynh T. Nguyen, PA-C, M.H.S. Claudia Sadro, M.D.

Teaching Associate Faculty, Radiology Assistant Professor of Radiology
John P. OBrien, M.D. Claire Sandstrom, M.D.

Acting Instructor and Senior Fellow Chief Radiology Resident
Emergency Radiology University of Washington
University of Washington Seattle, Washington
Seattle, Washington
Eric J. Stern, M.D.
Angelisa Paladin, M.D. Professor of Radiology
Associate Professor of Radiology Adjunct Professor of Medicine
Seattle Childrens Hospital Adjunct Professor of Medical Education and
University of Washington Bioinformatics
Seattle, Washington Adjunct Professor of Global Health
Issac Reeve, M.D. Seattle, Washington
Radiology Resident
Seattle, Washington
Annemarie Relyea-Chew, J.D., M.S.

Assistant Professor
Department of Radiology
Seattle, Washington
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Foreword
The evolution of trauma care of the past two decades has been almost entirely driven
by changes in imaging. The reliance on cross-sectional imaging, 3-D reconstruction,
angiography and embolization, and the expanded use of ultrasound have all signifi-
cantly and irrevocably altered the way clinicians care for the injured. This remark-
ably useful and complete compendium of trauma radiology should be read by not
only radiologists but also surgeons, emergency physicians, and other health care
providers who are called upon to make diagnoses and draft management plans in
the trauma patient. This book reflects an enviable practice pattern, that of clinicians
and radiologists forming a frontline partnership in the care of the injured patient.
The material presented is derived from a wealth of such firsthand experience and
clearly illustrates the subtlety, depth, and breadth of information that can be pro-
vided by such a partnership.
Gregory J. Jurkovich, M.D.

Chief of Trauma, Harborview Medical Center
Professor of Surgery
xiv
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Foreword to the First Edition
A critical component of the process of making a successful therapeutic decision

about a critically ill or severely injured patient is the rapid acquisition and interpre-
tation of radiographic images. The radiologist can be a full member of a physicians
group whose interference in critical illness can decrease mortality and diminish
morbidity. But sometimes missing is the insight required to properly conduct and
interpret imaging examinations in the trauma setting.
This book illustrates and underscores how radiologists can contribute to the
improvement of patient outcome. The contents announce the full engagement and
partnership of the radiologist into the integrity and urgency of the management of
the severely injured patient.
Michael K. Copass, M.D.
xv
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Preface
Harborview Medical Center is Washington States only Level 1 Trauma Center and
is the only such facility in four states (Washington, Alaska, Montana, and Idaho)
providing trauma and emergency coverage for nearly 25% of the geographical area
of the United States. Harborview Medical Center is one of the main teaching hospi-
tals of the University of Washington School of Medicine. Our unique position as the
only Level 1 Trauma Center for such a large area of the country provides our excep-
tional facility with a wealth of experience and diversity of case material.
The second edition of Trauma Radiology Companion serves as a timely educa-
tional resource for essential clinical and radiologic questions that arise when caring
for a trauma patient. New chapters include the use of CT angiography for diagnosis
of traumatic aortic injury, focused assessment with sonography in trauma (FAST),
and evaluating the pregnant trauma patient. In addition to radiographic evaluation
of the trauma patient, this book presents a general overview of trauma including
chapters on trauma epidemiology, radiology ABCs, review of trauma scoring sys-
tems, and medicolegal aspects of trauma imaging for the radiologist.
The intended audience for this book includes radiologists, radiology residents
and fellows, emergency medicine physicians, trauma surgeons, and other emer-
gency department care providers (nurses, physician assistants, nurse practitioners,
etc.) who need a quick, but thorough overview of imaging the trauma patient. The
second edition of Trauma Radiology Companion is an especially useful quick refer-
ence for the radiology and emergency medicine residents and fellows during their
call responsibilities.
Michelle M. Bittle, M.D.

Joel A. Gross, M.S., M.D.
Eric J. Stern, M.D.
xvi
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Bittle_Chap01.indd 1 4/15/2011 6:38:36 PM
CHAPTER
1 Overview of Trauma
EPIDEMIOLOGY OF TRAUMA
WHY WORRY ABOUT TRAUMA?

Trauma is common, expensive, and poorly understood.
HOW COMMON IS TRAUMA?

Magnitude
180,000 deaths per year in the United States are due to injury, 61 deaths/
100,000 persons (2007).
5 million injury deaths occur world wide each year (2000).
30 million nonfatal injuries occur per year in the United States, 9,800 injuries/
100,000 persons (2008).
Overall, trauma is the fifth most common cause of death.
Between 1 and 44 years of age, unintentional injury is the leading cause of death.
Injury, homicide, and suicide are first, second, and third most common causes of
death between the ages of 15 and 34.
Almost 50% of injury deaths occur in the most economically productive mem-
bers of the population.
HOW EXPENSIVE IS TRAUMA?

National total costs of injury requiring medical treatment per year are estimated
at $406 billion, including $80.2 billion medical care costs and $326 billion in pro-
ductivity losses (Finkelstein, 2006).
WHAT ARE THE MOST COMMON CAUSES OF TRAUMA-RELATED

DEATH IN THE UNITED STATES (2007)?
Motor vehicle crashes (MVCs) 23%
Suicide 17%
Poisoning 16%
2

Chapter 1 Overview of Trauma 3
Falls 12%
Homicide 7%
Motor Vehicle Crashes

44,000 annual deaths and >4 million nonfatal injuries (2007)
Men account for 70% of MVC trauma deaths.
In 60% of MVCs, blood alcohol concentration (BAC) is elevated.
Regional variation: highest risk in South and West (Alaska, Mississippi, New
Mexico, South Carolina, Alabama)
Seasonal variation is small:
Summer 30%
Fall 25%
Spring 25%
Winter 20%
Day of week and time of day variations:

Monday to Thursday, daytime fatalities higher
Friday to Sunday, nighttime fatalities higher
Homicides and Legal Intervention

19,000 annual deaths, 6.2/100,000 (2007)
Firearms used in 67% (85% handguns)
Strong variance by race and age group (Table 1.1)
Table 1.1 Homicide Fatalities by Ethnicity

Group Rate
Asian/Pacific Islanders 2.5/100,000
White 3.8/100,000
American Indian/Alaska Native 6.6/100,000
Black 22.6/100,000
Young black men (2029 y) 55.6/100,000
Suicides
35,000 annual deaths, 11.5/100,000 (2007)
15- to 44-year-olds are the largest group.
70% of suicides are white men.
WHAT CAN WE DO?

Injury Control Strategies
Education-persuasion (least effective)
Driver education (75% reduction in deaths of 16- to 17-year-old drivers would
reduce national fatalities by 600 to 700)

4 Chapter 1 Overview of Trauma
Change and enforce laws and regulations.

Require helmet use
Set and enforce speed limits
Prohibit drinking and driving
Automatic protection (most effective):

Crash avoidance (tail lights, redesign roads, antilock brakes)
Injury severity reduction (restraints and airbags)
SUGGESTED READING
http://www.cdc.gov/injury/. Accessed July 23, 2010.
Finklestein EA, Corso PS, Miller TR, et al. Incidence and economic burden of injuries in the
United States. New York, NY: Oxford University Press, 2006.
MacKenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev
2000;22:112119.

BLUNT TRAUMA RESUSCITATION IMAGING:

THE RADIOLOGIC ABCS
General Goal: Detect correctable causes of hypotension and hypoxemia.

Harborview Medical Center initial imaging protocol includes the following
portable radiographs:
Supine anteroposterior (AP) chest radiograph (CXR)
Supine AP pelvis
Cross table (horizontal-beam) lateral of the cervical spine
AIRWAY
Endotracheal Tube
Tube should be positioned centrally within tracheal lumen.
Tip position should be 5 to 7 cm above carina with neck in neutral position
(2 cm deeper with flexion, 2 cm shallower with extension).
Problems:
Iatrogenic injury. The balloon should be no more than 2.8 cm wide.
Dental trauma. Look for broken teeth or dental amalgam in the airways or
stomach on radiographs or CT. See Fig. 3.42.

Laryngotracheal laceration or perforation, typically at piriform fossa or crico-
thyroid junction
Tip is directed to the right with pneumomediastinum and subcutaneous
emphysema.
Mainstem bronchus intubation, most commonly right
Esophageal intubation (look for gastric distention). See case Esophageal Intu-
bation with Gastric Perforation, p. 118.
Tracheostomy Tube
Stoma usually at third tracheal cartilage ring
Tip should be several centimeters above carina.
Problems:
Partial or complete extubation
Posterior tube angulation leading to perforation of posterior tracheal mem-
brane and subsquent tracheoesophageal or tracheopleural fistula, or medias-

tinitis (especially if chronic indwelling nasogastric [NG] tube). Usually occurs
within 2 to 4 weeks post tracheostomy
Caveat: ALL tracheostomy patients have abnormal swallowing, and aspira-
tion pneumonitis needs to be differentiated from fistula.

Anterior tip angulation increases the risk of innominate artery erosion.

Subcutaneous emphysemaSmall amount is usual after tracheostomy; it should

NOT increase over time.
Postremoval complications
Stenosis, commonly 1 to 4 cm long segment 1.5 cm below the stoma; symp-
toms are unusual unless stenosis >50% to 75%

Tracheomalacia
Airway Obstruction
Mucous plugging and secretions
Aspiration of dental or foreign debris
BREATHING
Extrapulmonary and intrapulmonary causes of hypoxemia identifiable on CXR:
Hemothorax and pneumothorax
Lung parenchyma
Traumatic contusions and laceration
Aspiration
Atelectasis
Chest wall and diaphragm

Flail chest
Diaphragmatic hernia
CIRCULATION
Causes of hypotension identifiable on CXR:
Tension hemothorax and pneumothorax
Tension hemopericardium or pneumopericardium
Mediastinal hematoma
Causes of hypotension identifiable on pelvic XR:

Fractures of the pelvic ring
That increase potential intrapelvic volumeopen-book
Associated with major arterial lacerationsvertical shear, involvement of
sciatic notch
Persistent blood replacement requirements should lead to pelvic angiography
and embolization.
Causes of hypotension identifiable on cervical spine XR:
Fractures or subluxations associated with spinal shock
Craniocervical dissociation (atlanto-occipital dissociation)

SUMMARY
You should be able to reliably and immediately identify the following:
1. Endotracheal tube malpositions
2. Pneumothorax on a supine AP CXR
3. Tension (hemothorax, pneumothorax, pericardium)
4. Pulmonary parenchymal contusion, aspirations, etc.
5. Potential major diaphragmatic laceration
6. Flail chest
7. Abnormal mediastinum
8. Pelvic ring fractures
9. C-spine fractures and subluxations

TRAUMA SEVERITY SCORING
Characterization of injury severity is crucial to the scientific study of trauma. The

severity of a specific injury (e.g., blunt liver laceration) affects prognosis and guides
treatment. The consequence of multiple injuries accumulate in a nonarithmetic
manner and may result in outcomes worse than those expected from even the most
severe localized injury. A variety of trauma severity grading (scoring) schemes are
commonly used to estimate the magnitude of individual organ system (e.g., abdomen,
head and neck, etc.) and whole body (cumulative) injuries. Scoring systems can direct
patient triage to the most appropriate treatment center, enhance prospective recog-
nition of patients at increased risk of death, allow comparison of outcomes between
patients of similar injury severity, and promote collection of epidemiologic data.
Trauma severity scoring systems are of two broad types: physiologic and ana-
tomic. No current scoring system is optimal for all patient groups, and variation can
be considerable among the different systems. In general, systems that aggregate
information across multiple organ systems and/or combine physiologic and ana-
tomic data have the best predictive value for mortality and morbidity, and the least
variance.
PHYSIOLOGIC
Revised Trauma Score (RTS) is based on Glasgow Coma Scale (GCS, Table 1.2),
respiratory rate (RR) and systolic blood pressure (SBP). RTS is a simplification of
statistical tools used to predict mortality following injury and allows epidemiologic
comparisons.
RTS = (0.9368 GCS) + (0.2908 RR) + (0.7326 SBP), where GCS, SBP, and RR
are assigned integer values as shown in Table 1.3. A simplified version of RTS can be
used for prehospital triage to dedicated trauma centers.
Other physiologic scoring systems include APACHE II and SOFA.
ANATOMIC
Abbreviated Injury Scale (AIS) is a numerical method for grading injuries by severity,
which range from 1 (minor) to 6 (lethal). AIS ratings are consensus-derived, corre-
late with ICD-9, and can be collated into summary scores (e.g., Injury Severity Score
[ISS]). AIS guidelines are available at the Web site of the American Association for
the Surgery of Trauma.
ISS is a summary score for patients sustaining polytrauma obtained by summing
the squares of the three most severe AIS scores from the face, head and neck, chest,
abdomen and pelvis, extremities, and integument (Table 1.4).
For example, a patient sustaining a subarachnoid hemorrhage (AIS 2), pulmo-
nary laceration (AIS 3), and a comminuted femur fracture (AIS 3) would have an
ISS = (2)2 + (3)2 + (3)2 = 22.

Table 1.2 Glasgow Coma Scale (GCS) for Traumatic

Brain Injuries (TBI)
Scalar Assessment of Eye, Verbal, and Motor Responses
Eye Normal 4
To command 3
To pain 2
None 1
Verbal Oriented 5
Confused 4
Meaningless words 3
Grunts and sounds 2
None 1
Motor To command 6
Pain localization 5
Pain withdrawal 4
Flexion to pain 3
Extension to pain 2
None 1
GCS = Eye + Verbal + Motor
Normal 15
Mild impairment 1214
Moderate impairment 911
Severe impairment 8
Table 1.3 Revised Trauma Score (RTS)

Integer A Respiratory A Systolic Blood
Value for A GCS of Rate of Pressure of
4 1315 1029/min 90
3 912 >29/min 7689
2 68 69/min 5075
1 45 15/min 149
0 3 0/min 0

Table 1.4 Injury Severity Score (ISS)

ISS Probability of Survival (Blunt Trauma)
18 0.980
915 0.970
1624 0.875
2540 0.780
4149 0.600
5074 0.340
75 0.150
SUGGESTED READING
http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx. Accessed August 17,
2010.
Kilgo PD, Meredith JW, Osler TM. Injury severity scoring and outcomes research. In:
Feliciano DV, Mattox KL, Moore EE, eds. Trauma. New York, NY: McGraw-Hill Compa-
nies, 2008:1430.

MEDICAL-LEGAL ISSUES IN TRAUMA

AND EMERGENCY RADIOLOGY*
REGULATIONS AFFECTING DIAGNOSTIC IMAGING IN TRAUMA

Diagnostic imaging in the trauma and emergency setting is regulated by federal and
state statutes, and interpretive case law. The primary federal regulations include
those promulgated by the Department of Health and Human Services (HHS),1 Cen-
ters for Medicare and Medicaid (CMS),2 Emergency Medical Treatment and Labor
Act (EMTALA),3 Health Insurance Portability and Accountability Act (HIPAA),4
Patient Protection and Access to Care Act 2010 (PPACA),5 the Food and Drug
Administration (FDA),6 and Occupational Safety Health Administration (OSHA).7
Agencies such as The Joint Commission (TJC) focus on patient safety and account-
ability in their accreditation process.8 Regulation of imaging equipment occurs on a
state-by-state basiscombined with federal licensing, FDA oversight, and creden-
tialing by the American College of Radiology (ACR).9 The U.S. Department of Home-
land Security has identified radiology as having a primary role in caring for victims
of catastrophic events resulting from biological and nuclear terrorism.10
Each state, the District of Columbia, and entities under federal jurisdiction have
statutes and case law affecting diagnostic imaging that parallel federal regulations
or are unique to that jurisdiction. Many states have codified the standard of care to
which health care providers are expected to meet.11 In addition, individual jurisdic-
tions and institutions have provider or physician reporting requirements in cases of
child and intimate partner abuse, presence of communicable diseases, and evidence
of crimes (shootings, stabbings, sexual assault, illicit drugs). Radiologists practicing
in an emergency department (ED) should be familiar with the respective statutes
and reporting policies and anticipate becoming part of the evidence-gathering pro-
cess for subsequent legal proceedings.1214
MEDICO-LEGAL ISSUES ARISING FROM DIAGNOSTIC IMAGING

Medical-legal issues arising in diagnostic imaging in the trauma and emergency set-
ting are
Failure to diagnose
Noncommunication or miscommunication and documentation of urgent or
nonroutine findings
Resolution and communication of discrepant findings in preliminary, amended,
and/or finalized reports
*Current as of August 2010.

Change of shift (handoffs) of patients

Interpretation by on- or off -site radiologists versus interpretation by nonradiolo-
gists at the time of imaging in the ED.
The leading cause of malpractice actions against ED radiologists, and physicians
who interpret ED imaging, is failure to diagnose. Computed tomography (CT) is
used increasingly in trauma centers and the ED due to its high diagnostic accu-
racy; of CT studies in the United States, those performed of the head predominate.15
A significant limitation of CT is the delivery of high-dose radiation that may increase
risk of delayed, or even immediate injury to patients.16,17 Injuries resulting from
CT scan radiation have resulted in widely-publicized, multijurisdictional lawsuits
against manufacturers and providers.18,19 Radiologists and imaging providers should
follow ALARA principles (As Low As Reasonably Achievable) and encourage dose
reduction when appropriate.20
INFORMED CONSENT
An exception to the requirement of informed consent exists in the instance of the
emergent, unconscious patient with an immediate life-threatening condition.21,22
Difficulties arise when consent to treat is refused by conscious patients or those
incapable of consent, including minors and the medically incompetent. Patients who
are incompetent to consent may require a surrogate, mental health evaluation or
court ruling.23 In particular, radiologists performing interventional procedures and/
or with contrast should be familiar with the institution or facility-informed consent
policies and procedures, as well as applicable federal and state regulations. Lack
of informed consent may be claimed against emergency physicians if an adverse
event, such as a contrast reaction or extravasation, results in a harm about which
the patient was not informed. For example, the association between gadolinium-
based contrast and development of nephrogenic systemic fibrosis (NSF) in patients
with renal insufficiency has resulted in multijurisdictional litigation against provid-
ers and manufacturers.24,25
ELECTRONIC HEALTH RECORDS

Incentives under the federal Health Information Technology for Economic and Clin-
ical Health Act (HITECH) regulations compel providers nationwide to acquire and
use electronic medical record (EMR) or electronic health record (EHR) systems.26
Currently, there is no uniform standard for transmission, interpretation, and incor-
poration of outside diagnostic imaging into the medical records of patients who
are referred, self-refer, or are transferred to an ED or trauma center. Nevertheless,
more patients are transferred between facilities, and to EDs, accompanied by digi-
tized diagnostic imaging studies interpreted by an outside provider. Potential liabil-
ity issues arise when on-site ED radiologists must determine whether to accept or
reinterpret the outside images, or reimage ED patients who are present or are trans-
ferred with their prior studies.27

COMMUNICATION OF RESULTS
The legal obligations and standards for communication, reporting, and documen-
tation of radiology interpretation have evolved with the technology. Radiologists
practicing in the emergency and trauma setting are especially vulnerable to litiga-
tion resulting from errors in communication with peers and patients.28,29 The cur-
rent ACR Practice Guideline for Communication of Diagnostic Imaging Findings states
that in nonroutine and emergent clinical situations, the radiologist should expe-
dite the delivery of a diagnostic imaging report (preliminary or final) in a manner
that reasonably ensures timely receipt of findings.30,31 This is consistent with the
ACR Practice Guideline for radiologists providing coverage for diagnostic imaging
in EDs.30,31 All imaging facilities should have procedures and protocols in place for
timely communication of routine and nonroutine, or critical findings.
Included in the ACR Practice Guideline list of findings that may require non-
routine communication are those demonstrating need for immediate attention
(e.g., pneumothorax), those that are discrepant with a preceding or preliminary
interpretation of the same study and may adversely affect the patient, and
unexpected findings that over time could result in a serious, adverse outcome for
the patient.30,31 The presence of unexpected or incidental findings is more common
as advanced imaging modalities and interventional procedures are utilized in EDs
and trauma centers.32 Whether the radiologist is obliged to directly communicate
imaging findings to patients is an open debate; practices and policies vary. The
trend in case law and commentary would impose an ethical and legal duty on the
radiologist to directly communicate with patients.33,34 It is also clear that when a
physician-patient relationship does exist, it is the responsibility of the physician to
communicate findings directly and follow-up with that patient.
REFERENCES
1. Department of Health and Human Services: www.hhs.gov. Accessed February 1, 2011.
2. Centers for Medicare and Medicaid Services: www.cms.gov. Accessed February 1, 2011.
3. 42 U.S.C. 1395cc(1)(iii).
4. HHS: Office of Civil Rights: www.hhs.gov/ocr/privacy. Accessed February 1, 2011.
5. Patient Protection and Access to Care Act ( (P.L.) 111148 (124 Stat. 119 thru 124 Stat.
1025) ) and Health Care and Education Reconciliation Act of 2010) ( (P.L.) 111152 (124
Stat. 1029 thru 124 Stat. 1084) ).
6. Food and Drug Administration: www.fda.gov/radiation-emittingproducts. Accessed
February 1, 2011.
7. Occupational Health Safety Administration: www.osha.gov. Accessed February 1, 2011.
8. The Joint Commission: www.jointcommission.org. Accessed February 1, 2011.
9. American College of Radiology: www.ACR.org. Accessed February 1, 2011.
10. Burch H, Kitley CA, Naeem M. Department of Homeland Security national planning
scenerios: a spectrum of imaging findings to educate the radiologists. Emerg Radiol
2010;17:275284.
11. Lewis MH, Cohagan JA, Merenstein. The locality rule and the physicians dilemma: local
medical practices vs. the national standard of care. JAMA 2007;297:26332637.

12. Molina DK, Nichols JJ, DiDaio VJM. The sensitivity of computed tomography (CT) scans
in detecting trauma: are CT scans reliable enough for courtroom testimony? J Trauma
2007;63:625629.
13. Wilson TA. Gunshot injuries: what does a radiologist need to know? Radiographics
1999;19:13581368.
14. Kleinman PK. Diagnostic Imaging of Child Abuse. St. Louis, MO: Mosby-Year Book Inc.;
1998.
15. The 2007 National Hospital Ambulatory Medical Care Survey Emergency Department
Summary: www.cdc.gov/nchs/data/nhsr/nhsr026.pdf. Accessed August 2010.
16. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common
computed tomography examinations and the associated lifetime attributable risk of
cancer. Arc Intern Med 2009;169:20782086.
17. Brenner DJ, Hall EJ. Computed tomography an increasing source of radiation expo-
sure. N Engl J Med 2007;357:22772284.
18. After stroke scans, patients face serious health risks. www.nytimes.com/2010/08/01/
health/01radiation.html
19. FDA Makes Interim Recommendations to Address Concern of Excess Radiation Expo-
sure during CT Perfusion Imaging. December 7, 2009. http://www.fda.gov/Radiation-
EmittingProducts/default.htm. Accessed February 1, 2011.
20. Hendee RH, Becker GJ, Borgstede JP, et al. Addressing overutilization in medical imaging.
Radiology 2010;257:240245.
21. Berlin L. Informed consent. Am J Roentgenol 1997;169:1518.
22. Furrow BR, Greaney TL, Johnson SH, et al. Health Law. 5th ed. West Group, Aspen
Publishers; 2005:356412.
23. Eclavea RP, Martin LD. 53 Am Jur 2d Mentally Impaired Persons 111. 2010 West
Group.
24. Martin D. Nephrogenic system fibrosis: a radiologists practical perspective. Eur J Rad
2008;66:220224.
25. Dillman JR, Ellis JH, Cohan RH, et al. Frequency and severity of acute allergic-like reac-
tions to gadolinium-containing IV contrast in children and adults. Am J Roentgenol
2007;189:15331538.
26. American Recovery and Reinvestment Act (2009): Title XIII. Pub L. 1115.
27. Sung JC, Sodickson A, Ledbetter S. Outside CT imaging among emergency department
transfer patients. J Am Coll Radiol 2009;6:626632.
28. Berlin L. Standards for radiology interpretation and reporting in the emergency setting.
Pediatr Radiol 2008;38(Suppl 4):S639S644
29. West RW. Radiology malpractice in the emergency room setting. Emerg Radiol 2000;7:
1417.
30. American College of Radiology. ACR practice guideline for the communication of diag-
nostic imaging findings. In: Practice Guidelines and Technical Standards. Reston, VA:
American College of Radiology, 2005.
31. American College of Radiology. ACR practice guideline for radiologist coverage of imag-
ing performed in hospital emergency departments. In: Practice Guidelines and Technical
Standards. 2007: www.ACR.org. Accessed February 1, 2011.
32. Hall WB, Truitt SG, Scheunemann LP, et al. The prevalence of clinically relevant inciden-
tal findings on chest computed tomographic angiograms ordered to diagnose pulmo-
nary embolism. Arch Intern Med 2009;169:19611965.
33. Berlin L. Communicating results of all outpatient radiologic examinations directly to
patients: the time has come. Am J Roentgenol 2009;192:571573.
34. Berlin L. Communicating results of all radiologic examinations directly to patients: has
the time come? Am J Roentgenol 2007;189:12751282.

SPECIAL PROCEDURES IN THE EMERGENCY ROOM
URETHROGRAMS WITH FLUOROSCOPY

Standard Retrograde Urethrogram (RUG)
No transurethral catheter in place

Preliminary AP image
Position patient 45 degrees supine RPO; right obturator foramen should be closed.
Insert 8-Fr balloon catheter 2 cm (into fossa navicularis) and inflate with approx-
imately 2 mL of air (patient will report stretching sensation if awake).
Using a gloved hand, patient or technologist will hold penis laterally across thigh
with traction, pinching tip to retain balloon and contrast.
Gentle hand injection of 60% iodinated contrast with intermittent fluoroscopy
and captured images.
Pericatheter Retrograde Urethrogram (peri-cath RUG)
What to do if a Foley catheter has already been placed:

DO NOT REMOVE TRANSURETHRAL CATHETER!
Preliminary AP image
Position patient 45 degrees supine RPO; right obturator foramen should be closed.
Insert 8-Fr straight catheter (pediatric feeding tube) 5 cm along indwelling cath-
eter. Elastic band compression with clamp just proximal to the glans.
Catheter size should be small enough to easily pass along side of indwelling cath-
eter. DO NOT USE BALLOON CATHETER!
Using a gloved hand, patient or technologist will hold penis laterally across thigh
with traction, pinching tip to retain balloon and contrast.
Gentle hand injection of 60% iodinated contrast with intermittent fluoroscopy
and captured images.
Combined Retrograde and Antegrade (Voiding) Urethrography
Continue with injection after imaging the anterior urethra.

External sphincter spasm may be overcome by encouraging the patient to simulate
voiding: Relax your pelvic muscles as you would when you are passing urine.
Continue bladder filling to patient tolerance.
After discussion with ordering clinician, remove catheter and obtain RPO images
during voiding.

TRAUMA CYSTOGRAMS WITH FLUOROSCOPY

Inpatient with Foley Catheter in Place
Supplies: Cystografin 250 mL, two bottles; hemostats ( facilitate removing plastic
seals between Foley catheter and drainage tubing); adjustable IV pole.
Patient positioning: supine. Position central beam to midline at level of anterior
inferior iliac spines and collimate from umbilicus to inferior pubic symphysis.
Instill contrast under gravity until leakage (intraperitoneal of any amount or an
extraperitoneal collection larger than 2.0 cm in greatest dimension) or com-
plete filling (>450 mL instilled or intravesical pressure 40 cm H2O [40 cm above
the table]) is the best guarantee that adequate bladder distention has been
achieved.
Exam should be performed with fluoroscopy whenever possible. In addition to
intermittent fluoroscopy, static images should be obtained at 50 to 100 mL, 250
mL, 450 to 500 mL, or at whatever instilled volume produces an intravesical pres-
sure of at least 40 cm H2O.
Amount of instilled contrast should be included in your radiology report.
Reconnect Foley catheter to urine drainage catheter and reservoir. Gravity drain
the bladder and obtain radiograph with central beam centered in midline 1 inch
below anterior superior iliac spine (ASIS). (In apparently negative studies, this
is the MOST IMPORTANT film.)
FIGURE 1.1. Normal anatomy of the urethra. Anterior urethra: penile and bulbous. Posterior
urethra: membranous and prostatic. Asterisk denotes the anatomic divisions of the anterior
urethra.

TRAUMA ESOPHAGRAMS
For penetrating injuries suspected of transgressing midline structures of the tho-
racic inlet (Zone I of neck and torso) or mediastinum (Zone II of torso). The result
of this test is binary: leak or no leak. Other than location, characterization is not
necessary. Once a leak is demonstrated, the examination is terminated.
Supplies: Medium diameter (1618 Fr) nasogastric or feeding tube, or equivalent;
irrigation syringe 50 mL; 150 mL nonionic (water soluble) contrast (e.g., iohexol
300); 300 mL thin barium.
If patient is unable to cooperate fully, use one of the angiographic suites.
Patient position: generally, supine and supine obliques (LPO, RPO)
If patient can swallow, do not use an enteric tube.
If the patient is unable to cooperate, a tube esophagram is necessary. Tube posi-
tioning, hand injecting contrast and imaging: Position enteric (nasogastric or
orogastric) tube tip at junction of middle and distal thirds of esophagus and posi-
tion central beam through this point. Collimate vertically.
Suspend respiration, begin filming at four frames/s, and hand inject 50 mL of the
ionic contrast as fast as possible.
Reposition tub tip to junction of proximal and middle thirds of the esophagus
and repeat.
These two runs should image from proximal to distal esophageal sphincters.
Occasionally, a third run is necessary with the tube tip around T2 level. Injected
volume and vigor should be reduced (3040 mL, rapid injection).
Tube position (if used) should be determined by suspected site of injury.
If patient aspirates, switch to barium unless there is a gross leak at which time
the procedure is terminated.
Assuming no leak is shown with water soluble contrast, follow with barium.
Reposition or place an enteric tube into the stomach and aspirate as much of the
contrast as possible at termination of examination.

GUNSHOT WOUNDS
KEY FACTS
While the last century has shown marked decline in the overall death rate due
to injury, gunshot wounds continue to be a significant cause of morbidity and
mortality, second only to motor vehicle crashes.
In several states and the District of Columbia, the mortality rate for gunshot
wounds has exceeded that of motor vehicle accidents.
The nature and severity of gunshot injuries are dependent not only on the type
of weapon and projectile but also on the distance between the weapon and
the victim (range), muzzle velocity, trajectory within the body, and local tissue
properties.
The wounding potential of bullets fired from rifles and handguns, is notably
greater than that of shotgun pellets, due to their larger mass, impact velocity, and
the overall kinetic energy transferred to the tissue.
While tumble is unlikely, bullet yaw increases the presented area of a projectile
as it travels through the body. This results in a higher drag coefficient and subse-
quent energy transfer to the tissue, yielding a greater degree of tissue injury.
The objectives of imaging are to determine the path of the projectile(s) and to aid
in assessing which tissues have been injured and how severely they are injured.
Initial workup should always include conventional radiographs (two perpendicu-
lar views). CT scans are helpful for preoperative planning, when significant tis-
sue damage to the head, neck, or trunk is suspected. CT is rarely necessary in
extremity injuries. CTA or catheter angiography is essential whenever vascular
injury is suspected.
Careful evaluation of radiographs and CT images is generally more reliable than
clinical evaluation for determining both the direction of projectile travel and the
tissue(s) injured.

A. B.
FIGURE 1.2. Bullet injury to the head. (A) CT scan of the parietal bone shows beveling of
the inner table of the skull (straight arrows), typical of an entry wound. Note also the bone
and bullet fragments (curved white arrows) along the bullet track (within the brain) and the
outward driven bone fragments (open white arrow) within the scalp. (B) CT scan from a
more inferior level shows the major bullet fragment (large white arrow) that has come to rest
within the opposite hemisphere. Note that this large fragment can still be accurately local-
ized in spite of the starburst (beam hardening) artifact surrounding it. Because of this artifact,
bullet fragments are best seen using bone (wide) windows.

A.
FIGURE 1.3. High-velocity gunshot

injury. This patient was shot in the arm
by a hunting rifle. (A) An arm radio-
graph shows a shattered mid-humeral
shaft and multiple bullet fragments.
(B) An AP view of the lateral aspect of
the lower chest and upper abdomen
shows more metal fragments. This
patient had a severe liver injury. Note
the typical lead snowstorm created
by the soft-nosed high-velocity bullet.
The distribution of bullet and bone
fragments shows that the bullet was
traveling from lateral to medial.
B.

SUGGESTED READING
Dimaio VJM. Gunshot Wounds: Practical Aspects of Firearms, Ballistics and Forensic Techniques.
Boca Raton, FL: CRC Press, 1985:99162, 257265.
Jeffery AJ, Rutty GN, Robinson C, et al. Computed tomography of projectile injuries. Clin Radiol
2008;63:11601166.
Nance ML, Carr BG, Kallan MJ, et al. Variation in pediatric and adolescent firearm mortality
rates in rural and urban US countries. Pediatrics 2010;125:11121118.

GUNSHOT WOUNDS: LOW-VELOCITY BULLET INJURY
KEY FACTS
Gunshot wounds are characterized as low-velocity or high-velocity based on a
firearms muzzle velocity.
Low-velocity weapons have lower wounding potential than high-velocity
weapons. While close-range injuries with low-velocity bullets can be fatal,
medium- and long-range injuries are often superficial.
Projectiles from small caliber handguns and from airguns can travel long dis-
tances through subcutaneous tissue due to decreased resistance, but fail to pen-
etrate the fascia. This is particularly likely at medium to long range with an entry
wound at a shallow angle to the skin surface.
Low-velocity bullets commonly fail to penetrate the cranium. Despite this, intrac-
ranial injury can still be caused, especially with projectiles of large mass, capable
of inflicting a whiplash-type injury.
Because these projectiles can travel a long distance from the entry site, they may
not be included in the field of view of the initial radiographs. If a low-velocity
projectile is not found on initial radiographs and there is no exit wound, addi-
tional radiographs over a wider field of view should be obtained.

A. B.
FIGURE 1.4. (A) AP and (B) lateral views of the thigh show a nondeformed .22-caliber
bullet (open curved arrows) lying in the subcutaneous tissue anterior to the patella. The
entrance wound (solid arrows) was in the proximal thigh. Note that this low-velocity bullet
has traveled a long way through the subcutaneous tissue but has not breached bone, joint,
muscle, or even the fascia.
SUGGESTED READING
Bartlett CS. Clinical update: gunshot wound ballistics. Clin Orthopaed Relat Res 2003;408:
2857.
Inaba K, Barmparas G, Foster A, et al. Selective nonoperative management of torso gunshot
wounds: when is it safe to discharge? J Trauma 2010;68(6):13011304.
Ramirez RM, Cureton EL, Ereso AQ, et al. Single-contrast computed tomography for the
triage of patients with penetrating torso trauma. J Trauma 2009;67(3):583588.

GUNSHOT WOUNDS: SHOTGUN INJURY
KEY FACTS
Shotgun injuries differ from bullet wounds. The latter involve a single projectile
with each shot, while shotgun shells contain multiple, small, spherical, metal
pellets or shot.
Shotgun gauge measures the diameter of the barrel, with larger gauge represent-
ing a smaller bore diameter.
While older shotgun pellets were made of lead, Environmental Protection
Agency (EPA) regulations now require shotgun pellets to be made of steel. Steel
pellets are ferromagnetic and can move, causing additional damage if the patient
is exposed to a strong magnetic field. Magnetic resonance imaging may be con-
traindicated in such patients.
Steel pellets can usually be distinguished from lead pellets radiographically. Lead
shot tends to be deformed by impact with soft tissues and bone. Steel shot will
remain round.
Shotgun wadding, used to maximize muzzle velocity, can be expelled with the
shot, becoming a projectile itself, though it appears radiolucent on radiographs.
At close range, the combined mass of multiple pellets can act as a single projec-
tile, producing significantly greater soft tissue and bony injuries than a single
pellet. At longer range, shotgun pellets tend to produce superficial injuries that
are rarely life threatening.
As with bullet injuries, the severity of shotgun injuries varies with tissue type and
local anatomy.
Of particular concern are vascular injuries, as they can result in pellet
embolization.

A.
FIGURE 1.5. (A) AP and (B)

lateral radiographs of the pelvis
show multiple shotgun pellets,
primarily posteriorly and on the
left. These arose from a single
shotgun blast. Deformity of
several of the pellets confirms
that they are made of lead.
(continued )
B.

C.
FIGURE 1.5. (continued ) (C) PA and

(D) lateral chest radiographs show
two pellets in the right lung (curved
arrows). These pellets have embo-
lized to pulmonary vessels via the
inferior vena cava. Shotgun pellets
and bullet fragments can embolize
via arteries or veins to a wide vari-
ety of organs. Catastrophic arterial
pellet emboli can occur intracranially
following shotgun wounds to the
neck.
D.

SUGGESTED READING
Dougherty PJ, Vaidya R, Silverton CD, et al. Joint and long-bone gunshot injuries. J Bone Joint
Surg (Am) 2009;91:980997.
Dimaio VJM. Gunshot Wounds: Practical Aspects of Firearms, Ballistics and Forensic Techniques.
Boca Raton, FL: CRC Press, 1985:163226, 257265.
Sandler G, Merrett N, Buchan C, et al. Abdominal shotgun wound with pellet embolization
leading to bilateral lower limb amputation: case report and review of the literature of
missile emboli over the past 10 years. J Trauma 2009;67(6):E202E208.
Vayvada H, Menderes A, Yilmaz M, et al. Management of close-range, high-energy shotgun
and rifle wounds to the face. J Craniofac Surg 2005;16(5):794804.

CONTRAST REACTIONS AND EXTRAVASATION
KEY FACTS
Acute Adverse Reactions to Contrast Media
Risk of Repeat Reaction
Premedication is reserved for patients with a history of a prior moderate or

severe contrast reaction.
Adverse reactions occur with both iodinated and gadolinium-based contrast
media.
Always consider an alternate imaging test (e.g., nuclear medicine, ultrasound,
MR, noncontrast CT) that does not use iodinated intravenous contrast.
Evidence supporting the use of corticosteroid prophylaxis is inconclusive. One
study did show a reduction in the risk of a repeat reaction by 60%. Breakthrough
reactions (repeat reactions in premedicated patients) do occur, but the majority
of patients will not suffer one. Most breatkthrough reactions are similar in sever-
ity to the index (or first) reaction.
Patients with a history of moderate (diffuse urticaria, facial edema, mild brocho-
spasm) and severe (hypotension, overt bronchospasm, laryngeal edema, anaphy-
laxis) contrast reactions should be premedicated if iodinated contrast must be
administered.
Severe reactions to any other substance are associated with a higher risk of con-
trast reaction.
The presence of a physician skilled in airway management (e.g., anesthesiologist)
should be considered if the patient has a history of severe pulmonary or cardiac
complications of iodinated contrast agents.
Delayed reactions to contrast media occur 30 minutes to 7 days after contrast
injection. Common delayed reactions include cutaneous reactions (usually mac-
ular or maculopapular), nausea, vomiting, and pruritus without urticaria. They
tend to recur.
Premedication for Acute Adverse Reactions
Oral and intravenous steroid premedication are likely equally effective.

Ideally, steroids should be given at least 6 hours before contrast administration,
although this has not been empirically proven.
Avoid oral iodinated contrast if the patient has had a prior severe reaction to
intravenous iodinated contrast medium.
Premedication Regimens:
1. Prednisone 50 mg by mouth 13, 7, and 1 hour before intravenous contrast, plus
diphenhydramine 50 mg i.v., i.m., or po 1 hour before intravenous contrast.
Or
2. Methylprednisolone 32 mg by mouth 12 and 2 hours before intravenous
contrast. Diphenhydramine 50 mg may be added to this.

Or if the patient cannot take oral medication:

3. Hydrocortisone 200 mg intravenously 13, 7, and 1 hour before contrast.
In emergency situations:
4. Methylprednisolone 40 mg intravenously at 6 and 2 hours before the contrast
study plus diphenhydramine 50 mg intravenously 1 hour before the study.
CONTRAST EXTRAVASATION
Contrast extravasation is accidental extravascular injection of contrast media.
The risk of intravenous contrast extravasation with power injection is 1:100 to
1:1,000.
The most commonly reported severe injuries from low-osmolality contrast media
(LOCM) are compartment syndromes, skin ulceration, and tissue necrosis.
Severe injuries are extremely uncommon following LOCM extravasation (1: 442).
Treatment:
1. A radiologist should examine every patient who experiences contrast extravasation.
2. Elevate the affected extremity above the level of the heart.
3. Apply ice packs to the affected area for 10 minutes and then remove. Repeat ice
pack application as desired. Alternatively, warm compresses can be applied.
4. Hyaluronidase, corticosteroid injection, and tissue aspiration are likely ineffective.
5. For significant extravasations (e.g., >60 mL, or smaller extravasations in areas such
as the hand), the patient should be kept in the department for 2 to 4 hours and
released only after reevaluation by a physician. Clear instructions must accom-
pany the patient following discharge. A follow-up phone call by the department
is recommended.
6. Plastic surgery or orthopedic surgery should be consulted if the patient suffers
any of the following symptoms:
a. Skin blistering
b. Evidence of altered tissue perfusion (e.g., decreased capillary refill)
c. Signs of compartment syndrome
d. Increasing pain
e. Change in sensation of the limb distal to the site of the extravasation
SUGGESTED READING
American College of Radiology. ACR Manual on Contrast Media Version 7 (2010). http://
www.acr.org/secondarymainmenucategories/quality_safety/contrast_manual.aspx
Lasser EC, Berry CC, Mishkin MM, et al. Pretreatment with corticosteroids to prevent
adverse reactions to nonionic contrast media. Am J Roentgenol 1994;162:523526.
Wang CL, Cohan RH, Ellis JH, et al. Frequency, management, and outcome of extravasa-
tion of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology
2007;243:8087.

CHAPTER
2 Brain and Spine
CEREBRAL CONTUSION
KEY FACTS
There are two mechanisms for developing a cerebral contusion. The first is a
direct impact causing a depressed skull fracture with injury to the underlying
brain. The second is a rapid acceleration or deceleration injury.
The terms coup and contracoup may be used to denote injury at the site of
impact and opposite the site of impact, respectively.
The most common locations are
Adjacent to prominent calvarial interfaces with the brain, such as the inferior
frontal lobes, anterior and inferior temporal lobes, and occipital lobes
Adjacent to the falx cerebri and tentorium cerebelli
Pathologically, a contusion results from damage to vascular and neural struc-

tures. On computed tomography (CT), this region will demonstrate areas of
mixed high and low density due to the presence of hemorrhage and edema. Con-
tusions may be subtle at first but usually become more obvious over the course
of several days.
While CT is the imaging study of choice in the trauma setting, magnetic resonance
imaging (MRI) is more sensitive and accurate for the detection and characteriza-
tion of cerebral contusions. Susceptibility-weighted imaging is very sensitive to
the detection of blood products.
30

Chapter 2 Brain and Spine 31
A. B.
FIGURE 2.1. Axial unenhanced CT through the (A) inferior and (B) mid cerebrum. There
is significant right frontal soft tissue edema and fracture. Multiple hyperdense foci in the
underlying frontal lobe (white arrows) indicate parenchymal contusions. Similar findings in
the left temporal lobe (black arrow) indicate contracoup injury. Note also the parenchymal
hemorrhages in the basal ganglia and thalamus (white arrowheads) indicating shear injury.
Intraventricular hemorrhage is present within the fourth ventricle.
SUGGESTED READING
Alahmadi H, Vachhrajani S, Cusimano MD. The natural history of brain contusion: an
analysis of radiological and clinical progression. J Neurosurg 2010;112(5):11391145.

32 Chapter 2 Brain and Spine
DIFFUSE AXONAL INJURY
KEY FACTS
Diffuse axonal injury (DAI) is caused by rapid acceleration/deceleration injury to
the brain with multifocal axonal shearing. It is very common after severe brain
injury, and is the most common cause of posttraumatic vegetative state.
This injury typically occurs within the body and splenium of the corpus callosum,
parasagittal gray-white matter interface, dorsolateral brainstem, and internal
capsule.
The injury can be hemorrhagic or nonhemorrhagic, and each lesion usually mea-
sures 1 to 15 mm in size. CT may reveal foci of increased attenuation surrounded
by decreased attenuation at the common locations listed above. These represent
hemorrhagic lesions. The nonhemorrhagic lesions may be difficult to detect ini-
tially with CT.
MRI is far more sensitive in the detection of DAI. Look for areas of T2 signal pro-
longation, blooming on susceptibility-weighted imaging, and possible diffusion
restriction.

A. B.
C. D.
FIGURE 2.2. Axial unenhanced CT through the (A) lateral ventricles and (B) superior cere-
brum. C. Coronal FLAIR MRI through the corpus callosum. D. Axial susceptibility-weighted
(T2*) MRI through the superior cerebrum. There are parenchymal hemorrhages within the
corpus callosum and gray-white matter junctions of the frontal lobes (white arrows). The
FLAIR image reveals a greater extent of injury than seen with CT, with extensive nonhem-
orrhagic DAI within the corpus callosum (black arrow). T2* imaging is more sensitive than
CT at detecting small hemorrhagic lesions, with several additional lesions identified in this
case (black arrowheads).
SUGGESTED READING
Parizel PM, Ozsarlak O, Van Goethem JW, et al. Imaging findings in diffuse axonal injury
after closed head trauma. Eur Radiol 1998;8:960965.
Zheng WB, Liu GR, Li LP, et al. Prediction of recovery from a post-traumatic coma state by
diffusion-weighted imaging (DWI) in patients with diffuse axonal injury. Neuroradiology
2007;49(3):271279.

EPIDURAL HEMATOMA/HYPERACUTE
INTRACRANIAL HEMORRHAGE
KEY FACTS
The classic presentation of an acute epidural hematoma (EDH) is a lucid interval
after a blow to the head, followed by an acute deterioration in the level of con-
sciousness. This presentation may occur 50% of the time.
An EDH is usually due to disruption of a meningeal artery (90%), typically the
middle meningeal artery, with hemorrhage between the dura mater and inner
table of the skull. A venous EDH (10%) may result from laceration of a dural
venous sinus or vein and will be located adjacent to the injured vessel.
On CT, an acute EDH is biconvex, sharply demarcated, and hyperdense. It is
highly associated with adjacent skull fracture in adults but less strongly associ-
ated in children.
As opposed to subdural hematoma (SDH), an EDH will rarely cross suture lines
as these represent areas of dural anchoring. However, an EDH may form at the
vertex across the superior sagittal suture and is usually associated with adjacent
fracture and/or sutural diastasis.
Signs associated with a poorer prognosis include
EDH > 2 cm in thickness
central mixed densities within the collection suggesting ongoing hemorrhage
midline shift >1.5 cm
brainstem deformity
extensive associated injury.
Hyperacute hemorrhages, which are imaged within minutes to hours of the ini-
tial injury, contain unclotted as well as clotted blood. On CT, hyperacute hemor-
rhage will appear hypodense as opposed to the hyperdense appearance of acute
hemorrhage.

A.
B.
FIGURE 2.3. Axial unenhanced CT through the (A) cerebrum and (B) postcontrast axial
CT through the same level. There is a hyperdense lentiform extra-axial hemorrhage (black
arrowhead) with an overlying skull fracture (white arrowhead, inset). Areas of low attenu-
ation within the extra-axial collection represent hyperacute hemorrhage. On the postcon-
trast image, there is active extravasation (black arrow) adjacent to the region of hyperacute
hemorrhage, indicating ongoing bleeding. Also note the subfalcine herniation with leftward
displacement of the anterior cerebral arteries (white arrow).
SUGGESTED READING
Huisman TA, Tschirch FT. Epidural hematoma in children: do cranial sutures act as a barrier?
J Neuroradiol 2009;36(2):9397.

ACUTE SUBDURAL HEMATOMA
KEY FACTS
The subdural space is a potential space between the dura mater (superficial) and
the arachnoid (deeper).
A subdural hematoma (SDH) is caused by shearing of small bridging veins. These
veins are weakest where they cross the potential subdural space. A less common
mechanism for SDH is extension of a parenchymal hemorrhage into the subdural
space.
On CT, an acute (SDH) will appear crescentic and hyperdense. It will follow the
curvature of the calvarium. As opposed to an epidural hematoma (EDH), an SDH
may cross sutures but will not cross dural reflections (notably the midline falx
cerebri and the tentorium cerebelli). It can extend along the dural reflections, as
seen with a parafalcine SDH.
SDH may be classified as complicated (associated with brain injury) or simple
(unassociated with brain injury). A midline shift greater than expected for the
size of the SDH suggests associated brain contusion. A shift less than expected
suggests the presence of bilateral injury.
Mortality following a complicated SDH is over twice that associated with a sim-
ple SDH.
MRI can demonstrate a smaller SDH than can be seen with CT scan. This is rarely
necessary in the emergent situation.

A. B.
FIGURE 2.4. Axial unenhanced CT through the (A) temporal lobes and (B) bodies of the lat-
eral ventricles. There is a hyperdense left SDH with a crescentic shape (black arrowheads).
This is producing mass effect with subfalcine herniation beneath the free edges of the falx
cerebri (white arrows) and transtentorial herniation with medial displacement of the uncus
and parahippocampal gyrus (white arrowheads).
SUGGESTED READING
Petridis AK, Drner L, Doukas A, et al. Acute subdural hematoma in the elderly: clinical
and CT factors influencing the surgical treatment decision. Cen Eur Neurosurg
2009;70(2):7378.

CHRONIC SUBDURAL HEMATOMA/ACUTE REHEMORRHAGE
KEY FACTS
A subdural hematoma (SDH) is considered to be chronic when it has been pres-
ent for at least 3 weeks and is hypodense relative to brain on CT.
Between 1 and 3 weeks, a subacute SDH may be isodense to brain parenchyma
and difficult to identify if small.
The majority of patients with a chronic SDH have either no history of antecedent
trauma or a history of minor injury. Associated brain injuries are unusual.
Peak incidence of a chronic SDH is during the seventh decade and it is often
associated with underlying brain atrophy.
Imaging will be similar to a simple acute SDH, except that the attenuation will be
less than brain parenchyma.
Acute rehemorrhage into a chronic SDH can be seen on CT scan as a hyperdense
dependent component within a hypodense subdural collection. Alternatively,
the entire SDH can appear isodense when the hemoglobin of the acute bleed is
diluted by the fluid of the preexisting hypodense SDH.
MRI is more sensitive than CT in diagnosing chronic SDH. However, MRI is rarely
the first exam ordered in the emergent setting.

A. B.
FIGURE 2.5. Axial unenhanced CT through the (A) lateral ventricles and (B) superior
cerebrum. There are bilateral subdural collections containing layering mixed density mate-
rial on the left (black arrow) and a fluid-hematocrit level on the right (black arrowhead ). Note
the acute component on the right (white arrowhead ). Findings indicate chronic subdural
hematoma with acute rehemorrhage. There is diffuse sulcal effacement and mild rightward
subfalcine herniation.
SUGGESTED READING
Yokoyama K, Matsuki M, Shimano H, et al. Diffusion tensor imaging in chronic subdural
hematoma: correlation between clinical signs and fractional anisotropy in the pyramidal
tract. Am J Neuroradiol 2008;29:11591163.

LINEAR SKULL FRACTURE
KEY FACTS
An isolated linear skull fracture without underlying brain injury is rarely of clini-
cal concern.
The presence or absence of a skull fracture does not reliably correlate with the
presence of underlying brain injury. In adults, the majority of patients with intrac-
ranial injuries do not have a skull fracture.
A leptomeningeal cyst may rarely occur after a skull fracture. It is caused by tear-
ing of the dura with insinuation of the arachnoid within the fracture defect. Over
time, cerebrospinal fluid (CSF) pulsation may enlarge the fracture. This usually
occurs in young children.
Multiplanar reformats are often helpful for identifying fractures that are parallel
to the scan plane.
A. B.

C.
FIGURE 2.6. Axial unenhanced CT through the cerebrum in (A) bone window, (B) brain
window, and (C) a 3D reconstruction of the skull. There is a linear skull fracture in the left
parietal bone (black arrow). Note the normal lambdoid sutures (black arrowheads). There is a
small underlying epidural hematoma (EDH) (white arrow). 3D reconstructions better visual-
ize the fracture and clearly differentiate the fracture from the adjacent lambdoid suture.
SUGGESTED READING
Ringl H, Schernthaner R, Philipp MO, et al. Three-dimensional fracture visualisation of mul-
tidetector CT of the skull base in trauma patients: comparison of three reconstruction
algorithms. Eur Radiol 2009;19(10):24162424.

DEPRESSED SKULL FRACTURE
KEY FACTS
Depressed skull fractures are often associated with underlying brain injury, espe-
cially contusions.
It is important to measure the amount of skull depression.
Surgery to elevate the depressed bone fragments is usually indicated if there is
significant depression (>1 cm), neurological deficit related to underlying brain
injury, cerebrospinal fluid (CSF) leak, or an open fracture.
Open fractures and fractures extending through the paranasal sinuses confer a
higher risk of infection.
A. B.

C.
FIGURE 2.7. Axial unenhanced CT through the cerebrum in (A) bone window (B) brain
window and (C) sagittal CT venogram through the superior sagittal sinus. There is a commi-
nuted depressed skull fracture overlying the superior sagittal sinus. Also note the underly-
ing epidural hematoma (EDH) (black arrowhead) and subarachnoid hemorrhage (SAH) (black
arrow). The superior sagittal sinus is focally occluded due to injury (white arrowhead).
SUGGESTED READING
Smits M, Hunink M, van Rijssel H, et al. Outcome after complicated minor head injury.
Am J Neuroradiol 2008;29:506513.

DELAYED POSTTRAUMATIC INTRACRANIAL HEMORRHAGE
KEY FACTS
Delayed posttraumatic hemorrhage may complicate up to 4.5% of cases of
traumatic intracranial hemorrhage and refers to the development of paren-
chymal hemorrhage in brain parenchyma that initially appears uninjured. The
term also refers to enlargement or blossoming of small contusions into larger
hematomas.
Coagulopathy and injury severity are risk factors for progression of traumatic
brain injury, including delayed intracranial hemorrhage. Increased intracranial
pressure and clinical deterioration are also associated with delayed hemorrhage
or expanding hematoma.
Clinically, neurologic deterioration occurs after an asymptomatic interval of
hours to weeks. Most delayed hemorrhages appear in the first few hours, and
over 80% appear within 48 hours of injury.
The mechanism of delayed posttraumatic hemorrhage is not well understood,
but may involve small vessel injury or local release of thrombogenic mediators
causing small vessel occlusion with subsequent infarction and hemorrhage.

A. B.
FIGURE 2.8. Axial unenhanced CT through basal ganglia at (A) admission and (B) 18 hours
later in a 61-year-old woman after a motor vehicle crash. Initial CT (A) demonstrates a large
left parietal subgaleal hematoma and small right acute subdural hematoma (white arrows).
Delayed imaging (B) demonstrates development of a right temporal parenchymal hema-
toma with a fluid level, indicating hyperacute bleeding (black arrowhead).
SUGGESTED READING
Alvarez-Sabin J, Turon A, Lozano-Sanchez M, et al. Delayed posttraumatic hemorrhage.
Spat-apoplexie. Stroke 1995;26:15311535.
LeRoux P, Haglund M, Hope A, et al. Delayed traumatic intracranial hemorrhage: an analysis
of risk factors. J Neurosurg 1991;74:348.
Lipper MH, Kishore PRS, Girevendulis AK, et al. Delayed intracranial hematoma in patients
with severe head injury. Radiology 1979;133:645649.
Wang MC, Linnau KF, Tirschewell DL, et al. Utility of repeat head computed tomography
after blunt head trauma: a systematic review. J Trauma 2006;61:226233.

CHILD ABUSE
KEY FACTS
Ten percent of injuries in children under 2 years of age are due to nonaccidental
trauma.
Injury typically occurs from shaking the child, which produces a whiplash motion
of the childs head on its neck. Retinal hemorrhages are found in 65% to 100%
of abused children with head injury. Skull fractures are more common than in
nonabused children.
Diagnosis of child abuse based on cranial abnormalities requires documentation
of injury of different ages.
Head trauma is the leading cause of morbidity and mortality in the abused child,
especially under the age of 2 years.
CT scan of the head is the initial imaging study when a child presents with acute
neurologic symptoms. It is the best study to evaluate for acute hemorrhage. In
most cases, MRI will better demonstrate the extent of injury, help in stratification
for neurologic outcomes, differentiate ages of injuries, and confirm evidence of
repeated injury.
Intracranial injuries commonly seen on CT include subdural hematoma (SDH),
intracerebral shear injury, or parenchymal hematoma. In these children, it is
common for an SDH to extend into the interhemispheric fissure. (See also acute
SDH, intraparenchymal hemorrhage, shear injury.)
Outcome is poor: Mortality is 7% to 30%, severe cognitive or neurologic deficits
are 30% to 50%, and 30% will have full recovery.

A. B.
FIGURE 2.9. A. Axial noncontrast CT of the brain in a 9-week-old with first-time seizure
demonstrates hemorrhage along the tentorium cerebelli and posterior falx (arrow) and
increased density bifrontotemporal subdural collections. B. Axial T2 Flair in the same child
demonstrates subdural hematomas along the frontotemporal lobes bilaterally (arrows) with
extension into the anterior interhemispheric fissure.
SUGGESTED READING
Ball WS Jr. Nonaccidental craniocerebral trauma (child abuse): MR imaging. Radiology
1989;173(3): 609610.
Foerster BR, Petrou M, Lin D, et al. Neuroimaging evaluation of non-accidental head trauma
with correlation to clinical outcomes: a review. J Pediatr 2009;154:573577.
Merten DF, Carpenter DL. Radiologic imaging of inflicted injury in the child abuse syndrome.
Pediatr Clin North Am 1990;34:815837.

GUNSHOT WOUND TO HEAD
KEY FACTS
Severity of the intracranial injury from a gunshot wound depends upon the tra-
jectory, velocity, and size of the bullet. Civilian injuries tend to be caused by lower
velocity, smaller projectiles than those used in military situations.
Cerebral contusion and hemorrhage may occur at a distance from the bullet
track and are thought to be due to displacement of brain against the skull at the
time of bullet passage.
Outcome following a gunshot injury correlates with the level of consciousness at
surgery. Mortality in decerebrate patients is 94% to 97%.
Linear skull fractures are present in 70% of cranial gunshot injuries.
Extent of the injury is best defined with CT/CTA scan. Injury to brain, location of
bullet fragments, trajectory of the bullet, and associated fractures can be deter-
mined. There is little role for routine radiographs.
Identification of bullet fragments versus calcium or hemorrhage may require a
combination of window widths and levels: brain (width = 80, level = 30), blood
(width = 150, level = 60), and bone (width = 4,000, level = 500).
Metal bullet fragments will frequently show beam-hardening streak artifact and may
obscure critical anatomic structures such as vessels, nerves, and venous sinuses.
Cerebral angiography may be indicated if there is clinical need for endovascu-
lar treatment to treat a pseudoaneurysm, cavernous carotid fistula, or actively
bleeding vessel.
A. B.
FIGURE 2.10. Gunshot wound to head. Showing the path of the bullet. A. Axial noncontrast
CT scan at the level of the basal ganglia and (B) higher frontoparietal region demonstrates
a small metal fragment (white arrow) along the bullet tract entering from the left temporal
region and passing through the basal ganglia (arrowhead). There is a large quantity of intra-
ventricular blood. The exit wound (black arrow) shows characteristic outward beveling of the
calvarium. (continued)

C. D.
FIGURE 2.10. (continued ) C. Thin-slab MIP demonstrates active vascular extravasation

(arrow ) from a middle cerebral artery (MCA) branch that has herniated through the defect.
D. Delayed postcontrast axial CT demonstrates active bleeding in the sylvian fissure from a
left MCA branch and a large volume of accumulated contrast in the right scalp dressing.
SUGGESTED READING
Nagib MG, Rockswold GL, Sherman RS. Civilian gunshot wounds to the brain: prognosis
and management. Neurosurgery 1986;18:533537.
Stone JA, Sloane HW, Yu JS, et al. Gunshot wounds of the brain: influence of ballistics and
predictors of outcome by computed tomography. Emerg Radiol 1997;4(3):140149.

BLUNT CAROTID AND VERTEBRAL ARTERY INJURIES
KEY FACTS
Blunt cerebrovascular injuries (BCVI) are uncommon, but are likely under
diagnosed.
They may lead to major neurological deficits (such as stroke) and death. Mortality
rates are 17% to 38% for carotid artery injury and 8% to 18% for vertebral artery
injury.
Many lesions may be initially asymptomatic but are potentially treatable.
Traumatic dissection of the internal carotid artery is usually the result of a decel-
eration injury, often associated with other cranial injuries. Deficits following dis-
section of the carotid artery or vertebral artery reflect ischemic changes in neural
structures supplied by the vessel. With carotid artery dissection, this includes an
incomplete Horner syndrome and various stroke syndromes. Extensive infarcts
occur in less than 8% of patients.
The mechanism of injury is felt to be a sudden stretching of the artery. This might
occur if the neck is hyperextended and flexed to the side opposite the injured
vessel.
Fractures of the cervical spine, especially if they involve the transverse foramen
where the vertebral artery is located, can result in vertebral artery injuries.
Spontaneous dissection of the internal carotid artery may be a manifestation of
unrecognized trauma.
A. B.
FIGURE 2.11. Acute internal carotid dissection on CTA and MRI. A. Axial CTA scan at the
skull base shows arrows pointing to narrowed ICAs bilaterally and surrounded eccentrically
by a cuff of isodense soft tissue. B. Axial PD FS MR image at the skull base shows hyperin-
tense T2 signal eccentrically surrounding narrowed ICA flow voids bilaterally. The eccentric
hyperintense T2 signal represents intramural hematoma due to acute carotid dissections.

Indications for Imaging of Suspected Blunt Cerebrovascular Injury

Hemorrhage of potential arterial origin
Expanding cervical hematoma
Carotid Bruit in patients <50 y
Cerebral infarction on CT or MRI
Unexplained central or lateralizing neurological deficit, TIA, or Horner
syndrome
Near hanging resulting in cerebral anoxia
Direct blow to the neck (e.g. clothesline type injury)
Blunt trauma patients presenting with epistaxis from a suspected arterial
source
Other patients with significant blunt head or neck trauma, if one or more of the
following are present
Glasgow coma scale (GCS) 6
Petrous bone fracture involving the carotid canal
Diffuse axonal injury
Cervical spine subluxation
Fracture of C1, C2, or C3
Fracture through the transverse foramen
Le Fort II or III facial fractures
Complex mandible fractures
Pediatric trauma patients should be evaluated using the same criteria as the adult
population.
Biffl Grading System for Blunt Cerebrovascular Carotid and Vertebral

Artery Injuries
I Luminal irregularity or dissection; <25% luminal narrowing
II Dissection, intramural hematoma, thrombus, or raised intimal flap
with >25% luminal narrowing
III Pseudoaneurysm
IV Occlusion
V Transection with extravasation
Diagnosis can be made with catheter angiography, magnetic resonance angiog-

raphy, or CT angiography. Catheter angiography is currently the gold standard;
however, this is an evolving area.

A. B.
FIGURE 2.12. A 52-year-old man who fell. CT of the head demonstrated a right temporal
bone fracture (not shown here). (A) Axial contrast-enhanced CTA and (B) oblique thin-slab
MIP of the neck demonstrates a focal filling defect in the left vertebral artery at the level of
C3 (arrow ), consistent with a Biffl IItype injury. A subsequent angiogram demonstrated
resolution of the injury.

A. B.
FIGURE 2.13. A 39-year-old man who fell 15 feet onto his head. (A) Axial CTA of the head
with (B) coronal thin-slab MIP of the carotid artery demonstrates active extravasation into
the suprasellar cistern from the right internal carotid artery (arrow ), in keeping with a right
ICA transection (Biffl V). There is global hypoperfusion of the brain with reduced gray-white
matter differentiation on brain windows. The black arrowheads indicate a markedly com-
minuted skull fracture.
SUGGESTED READING
Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid and vertebral arterial injuries. World J Surg
2001;25:10361043.
Bousson V, Levy C, Brunereau L, et al. Dissections of the internal carotid artery: three-
dimensional time-of-flight MR angiography and MR imaging features. Am J Roentgenol
1999;173:139143.
Bromberg WJ, Collier B, Diebel L, et al. Blunt Cerebrovascular Injury: Practice Management
Guidelines. Chicago, IL: Eastern Association for the Surgery of Trauma (EAST), 2007:49.
Vertinsky AT, Schwartz NE, Fischbein NJ, et al. Comparison of multidetector CT angiogra-
phy and MR imaging of cervical artery dissection. Am J Neuroradiol 2008;29:17531760.

ACUTE INTRACRANIAL HEMORRHAGE: INTRAVENTRICULAR

HEMORRHAGE AND TRAUMATIC SUBARACHNOID HEMORRHAGE
KEY FACTS
Intraventricular Hemorrhage
Intraventricular hemorrhage occurs by contiguous extension from an intracere-
bral hematoma, shearing of subependymal veins, or reflux of subarachnoid blood
via the outlet foramina of the fourth ventricle.
Possible etiologies of the underlying hemorrhage include trauma, hypertension,
vascular malformation, aneurysm, etc.
Blood will layer in the dependent portions of the ventricles, usually the occipital
horns of the lateral ventricles.
Hydrocephalus may occur due to obstruction of CSF flow, especially at the aque-
duct of Sylvius.
Clinical outcome is related to the patients neurological status at admission,
associated injuries, and the cause of hemorrhage rather than the mere presence
of intraventricular hemorrhage.
Traumatic Subarachnoid Hemorrhage

Traumatic subarachnoid hemorrhage (tSAH) is a frequent occurrence in patients
with major head injury. It is associated with an increased age at presentation.
Traumatic injury to the brain results in stretching, tearing, and laceration of the
blood vessels coursing within the subarachnoid space. Blood enters the suba-
rachnoid space and mixes with the CSF.
Hemorrhage can accumulate in the brain cisterns, fissures, and cerebral sulci.
CT is considered the first choice examination for detection of SAH. Sensitivity
varies with the scanner used, interval after bleeding, and amount of hemor-
rhage.
MR sequences that are used for detecting acute SAH include FLAIR (where blood
appears hyperintense in the subarachnoid spaces), gradient echo, and especially
susceptibility-weighted images.
Traumatic subarachnoid hemorrhage is associated with adverse outcomes
beyond those expected from the associated intracranial injuries (e.g., subdural
hematomas and parenchymal damage).
tSAH is an indicator of more severe mechanical forces and intracranial deforma-
tion during the initial injury.

A. B.
FIGURE 2.14. Axial unenhanced CT through the (A) occipital horns and (B) bodies of the
lateral ventricles. There is hyperdense hemorrhage in the lateral ventricles (white arrows).
Note how the blood layers dependently within the occipital horns. Additionally, there is an
intraparenchymal hemorrhage in the left deep white matter (white arrowhead) consistent
with shear injury (diffuse axonal injury [DAI]).
A. B.
FIGURE 2.15. Traumatic subarachnoid hemorrhage. Axial unenhanced CT through the

superior cerebrum (A and B). There is hyperdense hemorrhage within the frontal sulci bilat-
erally (arrowheads ), consistent with SAH.
SUGGESTED READING
Servadei F, Murray GD, Teasdale GM, et al. Traumatic subarachnoid hemorrhage: demo-
graphic and clinical study of 750 patients from the European brain injury consor-
tium survey of head injuries. Neurosurgery 2002;50(2):261267; discussion 267269.
Wu Z, Li S, Lei J, et al. Evaluation of traumatic subarachnoid hemorrhage using susceptibility-
weighted imaging. Am J Neuroradiol 2010;31:1302310.

HERNIATION: UNCAL
KEY FACTS
The uncus lies in the medial temporal lobe and forms the lateral margin of the
suprasellar cistern. Lying in close relation to the uncus is the third nerve and
posterior cerebral artery.
Uncal herniation occurs when a space-occupying mass in the brain causes dis-
placement of the uncus medially. Initially, there is compression of the third nerve;
later there can be compression of the posterior cerebral artery and the inter-
nal carotid artery. When unilateral, the mass is frequently in the temporal lobe.
When bilateral, there may be bilateral temporal lobe injury or diffuse cerebral
swelling.
The patient will present with a fixed, dilated pupil ipsilateral to the side of the
lesion due to stretching of the ipsilateral oculomotor nerve.
Other complications of uncal herniation arise from compression of the brain-
stem and of the ipsilateral posterior cerebral and carotid arteries and can result
in infarction.
Choice of imaging modality depends upon the acuity of the presentation. Sudden
deterioration in the patients level of consciousness or suspicion of hemorrhage
suggests CT scan.
On axial images, whether CT or MRI, uncal herniation will be noted as medial
and downward displacement of the uncus with effacement of the ipsilateral
ambient cistern and flattening of the ipsilateral cerebral peduncle. Compression
of the contralateral peduncle against the free margin of the falx may occur.
Subfalcine herniation is also usually present.
A patient with severe untreated uncal herniation may progress to infarction of
the involved hemisphere.

A. B.
FIGURE 2.16. A. Axial CT scan through the level of the midbrain shows the right uncus
is displaced leftward (arrows on A and B), basal cisterns are effaced, and the midbrain is
flattened. B. Axial CT scan slightly superior shows complete effacement of the perimesen-
cephalic cisterns and enlarged left lateral ventricle (trapped) due to the leftward shift of
the brain.
SUGGESTED READING
Gean AD. Imaging of Head Trauma. New York, NY: Raven Press, 1994:107124.
Laine FJ, Shedden AI, Dunn MM, et al. Acquired intracranial herniations: MR imaging find-
ings. Am J Roentgenol 1995;165:967973.

HERNIATION: SUBFALCINE
KEY FACTS
Subfalcine herniation occurs when the cingulate sulcus is displaced across mid-
line inferior to the falx and superior to the corpus callosum. Typically, there is a
frontal or parietal intracranial mass.
Similar to other intracranial processes, CT scan is the study of choice if there is
acute deterioration in the patients level of consciousness or if there is a suspicion
of intracranial hemorrhage. MRI would be indicated if the history suggested a
more indolent process.
CT demonstration of subfalcine herniation can include shift of the third ventricle,
pineal gland, of the anterior cerebral arteries, and of the internal cerebral veins.
The falx commonly does not shift.
Infarct from compression of vascular structures is unusual in subfalcine hernia-
tion without uncal herniation.
Treatment of the underlying mass will allow resolution of herniation.

A. B.
FIGURE 2.17. A. Axial CT scan showing large right subdural hematoma (SDH). The anterior
arrow points to the cingulate gyrus displaced under the falx and left of midline, and the
posterior arrow shows that the posterior third ventricle and pineal are displaced to the left.
The left lateral ventricle is enlarged (trapped). B. Coronal CTA shows cingulate gyrus and
branches of the ACA (top arrows) displaced under falx and left of midline. Bottom arrow
demonstrates marked midline shift with right ACA displaced leftward.
SUGGESTED READING
Gean AD. Imaging of Head Trauma. New York, NY: Raven Press, 1994:107124.
Laine FJ, Shedden AI, Dunn MM, et al. Acquired intracranial herniations: MR imaging
findings. Am J Roentgenol 1995;165:967973.

HERNIATION: UPWARD (CEREBELLAR HEMORRHAGE)
KEY FACTS
Upward herniation occurs when a mass in the posterior fossa displaces the ante-
rior superior vermis upward into the tentorial incisura. Cerebellar tonsillar her-
niation can also be present. Acute processes such as traumatic or nontraumatic
hemorrhage or a more chronic process, such as a tumor can be causative.
The common causes of spontaneous, nontraumatic cerebellar hemorrhage
include hypertension, vascular malformations, neoplasm, and aneurysm.
Patients will have signs of brainstem compression, including coma, reactive
miotic pupils, and, when more severe, decerebrate posturing.
CT scan signs of upward herniation include flattening of the quadrigeminal plate
cistern with effacement of ambient and superior cerebellar cisterns, posterior
effacement of the midbrain, compression of the fourth ventricle, increased soft
tissues visualized within the tentorial incisura, and hydrocephalus involving the
lateral and third ventricles.
A. B.
FIGURE 2.18. A. Axial noncontrast CT scan through the posterior fossa. The large hemor-
rhage in the vermis and right cerebellar hemisphere displaces the fourth ventricle forward
and to the left (arrow). The prepontine and cerebellopontine angle cisterns are compro-
mised. B. Axial CT section obtained more superiorly shows effacement of the quadrigemi-
nal plate cistern and tentorial incisura, flattening of the collicular plate, and dilatation of both
temporal horns. This latter finding suggests hydrocephalus.

FIGURE 2.19. Axial CT scan in a patient with a large right transcompartmental venous
extradural hematoma shows right upward transtentorial herniation through the tentorial inci-
sura with effacement of posterior midbrain, quadrigeminal cistern, and aquaduct (arrows).
SUGGESTED READING
Laine FJ, Shedden AI, Dunn MM, et al. Acquired intracranial herniations: MR imaging find-
ings. Am J Roentgenol 1995;165:967973.
Osborne AG, Heaston DK, Wing SD. Diagnosis of transcending transtentorial herniation.
Am J Roentgenol 1978;130:755760.

DIFFUSE ANOXIC CHANGES
KEY FACTS
Diffuse global ischemia occurs when there is reduced supply of oxygen to the
brain. Causes of severe cerebral anoxia from trauma include strangulation,
choking, drowning, smoke inhalation, crushing injuries to the airways, and cir-
culatory shock.
Within the first 24 hours the gray matter/white matter interfaces may be difficult
to identify (loss of gray/white differentiation) on CT scan. This can be seen in the
cortex and in the basal ganglia. Diffuse cerebral swelling may not be clearly seen,
but if present will demonstrate effacement of the cerebral sulci and cisterns.
On noncontrast CT scan, it is important to window correctly using a narrow
window width and level (stroke window) to help differentiate the loss of gray
and white matter. When present on noncontrast CT scans, the reversal sign,
or reversal of gray matter attenuation relative to white matter attenuation, indi-
cates poor prognosis.
In severe cases of cerebral edema due to diffuse anoxic injury, the CT scan may
mimic subarachnoid hemorrhage (SAH) called pseudo-SAH and is thought to
be due to venous distension in the cerebral vessels related to elevated intrac-
ranial pressure and decreased venous return, which stands out against the low
attenuation edematous brain.
MR imaging using T2-weighted sequences (diffusion-weighted imaging [DWI]
and FLAIR) with corresponding ADC map can identify anoxic injury earlier than
CT. DWI will show hyperintense T2 signal in the cortex and deep gray nuclei and
show corresponding low ADC signal (restricted diffusion) indicating cytotoxic
edema or irreversible cell death. In the subacute period FLAIR will show hyper-
intense signal.
Although the CT scan appearance suggests the possibility of diffuse cerebral isch-
emia, it does not indicate brain death. Currently identification of brain death by
imaging requires demonstration of absent intracranial blood flow on a Techne-
tium-99 pertechnetate brain scan. Alternatively, diagnosis of brain death is made
with electroencephalography.

A. B.
C. D.
FIGURE 2.20. A. Axial CT scan at the level of the lateral ventricles. Cortical gray matter
and white matter are of similar density, sulci are effaced, and the central ventricles are
compressed bilaterally in this patient with diffuse anoxic changes. B. Axial noncontrast
CT scan more inferiorly demonstrates similar loss of gray white matter differentiation, dif-
fuse edema, and hyperdense vessels. This latter appearance mimics SAH (pseudo-SAH).
C and D. Axial DWI and ADC MR images on a different patient with anoxic injury shows
abnormal hyperintense T2 signal throughout the cortex with corresponding low ADC signal
(restricted diffusion) indicating diffuse infarction of the cortex.
SUGGESTED READING
Kavanagh EC. The reversal sign. Radiology 2007;245:914915.
Moore MJ, Vagal AS, Strub WM, et al. Reducing the gray zone: imaging spectrum of hypoper-
fusion and hypoxic brain injury in adults. Emerg Radiol 2010;17:123130.
Yuzawa H, Higano S, Mugikura S, et al. Pseudo-subarachnoid hemorrhage found in patients
with postresuscitation encephalopathy: characteristics of CT findings and clinical
importance. Am J Neuroradiol 2008;29:15441549.

CEREBRAL PERFUSION SPECT IN TRAUMATIC BRAIN INJURY
KEY FACTS
Blunt and penetrating head trauma strongly affect regional cerebral perfusion.
Posttraumatic SAH is associated with onset of vasospasm in 25% to 40% of patients.
Cerebral perfusion SPECT often shows more, larger, and earlier lesions than those
seen on CT or MRI after head injury.
Some of these lesions are contracoup phenomena, while others include diaschi-
sis ( functional disconnection of a region of brain distant from a known injury).
Cerebral SPECT detects the effects of vasospasm on tissue perfusion in patients
with SAH.
Absolute lack of blood flow to a large zone of brain reflects irreversible injury.
Hyperemic conditions due to dysregulated, increased blood flow after head injury
can be shown with SPECT.
If the patient is injected during a seizure, the scan will usually show increased
blood flow at the site responsible for the ictus. Therefore, it is important to note
the status of the patient at the time of injection.
After a mild to moderate head injury, a normal SPECT exam is predictive of a
good outcome.
FIGURE 2.21. Cerebral perfusion transaxial SPECT with Technetium-99m exametazime in

a patient with gunshot wound to head. Transcranial Doppler showed vasospasm in both
middle cerebral artery territories. SPECT exam showed bullet trajectory but no effect of
vasospasm on middle cerebral artery (MCA) territorial blood flow.

FIGURE 2.22. Cerebral perfusion SPECT after dural repair and craniotomy following gun-
shot wound to head. Cerebral angiogram showed right internal carotid artery occlusion.
Transaxial SPECT images show severe, large, absolute defect encompassing entire right
middle cerebral artery territory.
Functional brain imaging with SPECT in chronic mild traumatic brain injury
with cognitive fatigue suggests a partially disrupted network between the frontal
lobes and cerebellum.
SUGGESTED READING
Abdel-Dayem HM, Sadek SA, Kouris K, et al. Changes in cerebral perfusion after acute head
injury: comparison of CT with Tc-99m HM-PAO SPECT. Radiology 1987;165:221226.
Hattori N, Swan Foster M, Stobbe GA, et al. Differential SPECT scan activation patterns
associated with PASAT performance may indicate fronto-cerebellar dissociation in
chronic mild traumatic brain injury. J Nucl Med 2009;50(7):10541061.
Lewis DH. Functional brain imaging with cerebral perfusion SPECT in cerebrovascular
disease epilepsy and trauma. Neurosurg Clin North Am 1997;8(3):337344.
Roper SN, Mena I, King WA, et al. An analysis of cerebral blood flow in acute closed-head
injury using Technetium-99 m HMPAO SPECT and computed tomography. J Nucl Med
1991;34:16841687.

CEREBRAL BLOOD FLOW IMAGING FOR BRAIN DEATH
KEY FACTS
Total lack of brain blood flow, including cerebrum and infratentorial brain, is
required for Nuclear Medicine corroboration of brain death in the United States.
Scans can be done by a portable camera (if available) at the bedside or patient
would be needed to be transported to Nuclear Medicine Clinic. Scans include
dynamic and static images of the patients head.
Use of a cerebral perfusion radiopharmaceutical, such as Technetium-99m
HMPAO or Technetium-99m ECD, is preferred because an agent such as these
will cross the blood-brain barrier.
Other agents, such as Technetium-99m DTPA and Technetium-99m glucohep-
tonate, may be used but these tracers require an adequate bolus, proper camera
timing, and they do not cross the blood-brain barrier.
The brain scan can aid in resource utilization and management and the defini-
tion of organ donation status.
The presence of venous sinuses on the images has no impact on interpretation if
a cerebral perfusion radiopharmaceutical (HMPAO or ECD) is used.
For corroboration of the clinical assessment of brain death, electroencephalog-
raphy may also be used; however, it takes longer to accomplish, and flat-line
readings may be difficult to obtain because of artifacts.
It is wise to check for interfering medications or conditions that may hamper the
neurologic exam for brain death, such as barbiturates and hypothermia, before
commencing the radionuclide scan.
The mechanism for interruption of cerebral blood flow in brain death due to
traumatic brain injury usually involves an elevation of intracranial pressure that
exceeds cerebral perfusion pressure.

FIGURE 2.23. Anterior and lateral planar static images of patient with Grade V subarach-
noid hemorrhage (SAH) with Technetium-99m exametazime. Images show lack of uptake in
brain parenchyma, transverse sinuses are seen in the lateral image. This image shows total
lack of cerebral blood flow compatible with brain death.
FIGURE 2.24. Anterior and lateral planar static Technetium-99m HMPAO images show
presence of uptake in the cerebellum. Although, this is clearly a catastrophic event with no
chance of recovery, the presence of some uptake in the posterior fossa (arrow) makes this
study not compatible with total cessation of all brain blood flow.
SUGGESTED READING
Idea RJ, Lewis DH. Trauma cases of Harborview Medical Center. Timely diagnosis of brain
death in an emergency trauma center. Am J Roentgenol 1994;163(4):927928.
Reid RH, Gulenchyn KY, Ballinger JR. Clinical use of Technetium-99m HMPAO for determi-
nation of brain death. J Nucl Med 1989;30(10):16211626.

FACIAL TRAUMA: ORBITAL FLOOR FRACTURE
KEY FACTS
Orbital floor or blow-out fractures occur following an anterior impact to the
orbit. This increases the pressure within the orbit, resulting in failure of the thin,
poorly supported bone of the orbital floor.
Complications of orbital blowout fractures include entrapment of the inferior
rectus muscle with limitation of upward gaze, late enophthalmos, and direct
injury to the soft tissues of the orbit. If the fracture passes through the infraor-
bital canal, the patient may have decreased sensation in the ipsilateral midface
(V2 distribution).
Thin-slice CT with multiplanar reformats is the preferred method of evaluating
orbital floor fractures. The coronal images are particularly helpful. Look for dis-
placement of bone fragments inferiorly within the maxillary antrum. There may
also be herniation of the orbital fat and inferior rectus muscle through the frac-
ture defect.
Also look for retrobulbar hematoma (hemorrhage posterior to the globe). This
can increase the pressure within the orbit and lead to ischemia of the globe or
optic nerve.
Nondisplaced fractures may be difficult to detect. A clue to their presence is a
small amount of extraconal gas just above the orbital floor.

FIGURE 2.25. Coronal unenhanced CT through the orbits demonstrates bilateral orbital
floor fractures. There is herniation of the right inferior rectus muscle and orbital fat through
the fracture defect (white arrow). Also notice the bone fragment on the right side displaced
into the maxillary sinus. Additional findings include a fracture of the left medial orbital wall
and hemorrhage within both maxillary sinuses.
SUGGESTED READING
Kubal WS. Imaging of orbital trauma. RadioGraphics 2008;28:17291739.

FACIAL TRAUMA: TRIPOD FRACTURE
KEY FACTS
A tripod fracture has been referred to by many names, including trimalar and
zygomaticomaxillary complex (ZMC) fracture. Quadripod or tetrapod fracture
is a more accurate term than tripod fracture, as it involves all four zygomatic
articulations.
There are fractures through the zygomatic arch and in the region of the sphe-
nozygomatic suture (lateral orbit), frontozygomatic suture (lateral orbit), and
zygomaticomaxillary suture (orbital floor).
There may be associated infraorbital nerve trauma or intraorbital injury, with the
lateral rectus muscle particularly prone to injury.
Thin-slice CT with multiplanar reformats is the preferred method of evaluation.
In addition to describing the sites of fracture, it is important to describe the
degree of rotation about the sphenozygomatic suture.
A.

B.
FIGURE 2.26. (A) Axial unenhanced CT through the face and (B) 3D volume-rendered
reconstruction of the face. There are fractures through all four sutures of the zygomatic
bone. The fracture through the sphenozygomatic suture involves the lateral orbital wall
(black arrowhead). The 3D reconstruction demonstrates fractures through the frontozygo-
matic suture, zygomaticomaxillary suture, and zygomatic arch (black arrows).
SUGGESTED READING
Go JL, Vu VN, Lee KJ, et al. Orbital trauma. Neuroimaging Clin N Am 2002;12:311324.

FACIAL TRAUMA: LE FORT FRACTURE
KEY FACTS
Midface fractures are commonly classified as Le Fort I, II, or III fractures. By defi-
nition, all Le Fort fractures involve the pterygoid plates of the sphenoid bones.
A Le Fort I fracture is also known as a floating palate. The fracture passes horizon-
tally from the inferior aspect of the nasal aperture posteriorly. It passes through
the walls of the maxillary sinus.
A Le Fort II fracture is pyramidal in shape. It involves the nasal bridge near the
nasofrontal suture and extends inferolaterally through the inferior orbital floor. It
extends posteriorly through the maxilla to the pterygoid plates.
A Le Fort III fracture is also known as craniofacial dissociation. It involves the
medial and lateral orbital walls and extends laterally through the zygomatic arch.
It essentially separates the bones of the face from the bones of the skull.
Le Fort fractures can be unilateral or bilateral. There can also be a combination
of Le Fort fractures in the same patient, such as a Le Fort I on the right side and
a Le Fort III on the left side.
Thin-slice CT with multiplanar reformats is the preferred modality for evaluation.
Closely inspect the pterygoid plates, as they must be involved in the Le Fort
injuries. Fracture through the pterygoid plates in the absence of a Le Fort injury is
unusual.
FIGURE 2.27. Le Fort fracture types. I, II, and III show bilateral Le Fort type I, II, and III
fracture lines respectively. The fracture lines are shown in gray.

A.
B.
FIGURE 2.28. A. Axial unenhanced CT through the face and (B) 3D volume-rendered
reconstruction of the face. There are fractures through the walls of both maxillary sinuses
(white arrows). The fractures extend posteriorly to involve the pterygoid plates bilaterally
(black arrows). This pattern is consistent with a Le Fort I injury. The 3D reconstructed image
demonstrates separation of the palate from the rest of the face (black arrows).
SUGGESTED READING
Hopper R, Salemy S, Sze R. Diagnosis of midface fractures with CT: what the surgeon needs
to know. Radiographics 2006;26:783793.
Rhea J, Novelline R. How to simplify the CT diagnosis of Le Fort fractures. Am J Roentgenol
2005;184:17001705.

CERVICAL SPINE INJURY: OCCIPITAL CONDYLE FRACTURES
KEY FACTS
The occipital condyles articulate with the superior facets of C1, and owing to
their anatomic and ligamentous properties, the occipital condyles function as
the superior-most portion of the cervical spine.
The intrinsic ligaments lie within the spinal canal and provide most of the liga-
mentous stability between the skull base and C1. The paired alar ligaments con-
nect the tip of the dens with the occipital condyles.
Occipital condyle fractures have historically often been radiographically occult
and therefore thought to be rare injuries. Widespread use of computed tomogra-
phy (CT) has led to increased recognition of this injury, with a reported incidence
between 4% and 19%.
Occipital condyle fractures are commonly missed by less experienced radiolo-
gists and should be evaluated for on every CT of the head and cervical spine.
Occipital condyle fractures are potentially unstable. Symptoms range from pain
and posterior neck tenderness to significant neurological deficits.
Concomitant head injuries often confound the clinical examination.
Lower cranial nerve palsies occur in up to 1/3 of occipital condyle fractures. The
12th cranial nerve is at particular risk due to the course of the hypoglossal canal
through the condyles.
Anderson and Montesano proposed a classification for occipital condyle frac-
tures, incorporating possible mechanism of injury and potential for instability
(Table 2.1). Predictive validity and reliability of this classification have not been
tested.
Isolated occipital condyle fractures are usually treated conservatively with hard
collar or halo vest. Surgical intervention is rare.
Conventional radiographs are insensitive in detection of occipital condyle frac-
tures. Prominence of the prevertebral soft tissues (retropharyngeal hematoma) is
often the only radiographic clue. CT is the imaging modality of choice. Occipital
condyle fractures are often seen on the inferior axial images of head CTs and are
readily appreciated on coronal reformations of the craniocervical junction from
cervical spine CTs.
Table 2.1 Anderson and Montesano Classification of Occipital

Condyle Fractures
Proposed Mechanism Stability
Type I Axial load Usually stable
Type II Extension of linear basilar skull fracture Stable
Type III Avulsion of the alar ligament Potentially unstable

A. B.
FIGURE 2.29. A 35-year-old man was hit by

a car. A. Axial CT image shows a moderately
displaced fracture of the right occipital condyle
(black arrows). Fracture orientation suggests
avulsion of the right alar ligament (type III).
B. Axial CT image caudal to (A) shows small
avulsion fragment (white arrows ) of the left
occipital condyle (type III). C. Coronal CT ref-
ormation readily depicts right (black arrow) and
left (white arrow) occipital condyle avulsion
fractures. The injury was treated conservatively
C.
with a Miami-J collar.
SUGGESTED READING
Goradia D, Blackmore CC, Talner LB, et al. Predicting radiology resident errors in diagnosis
of cervical spine fractures. Acad Radiol 2005;12:888893.
Karam YR, Traynelis VC. Occipital condyle fractures. Neurosurgery 2010;66:5659.

CERVICAL SPINE INJURY: ATLANTO-OCCIPITAL DISSOCIATION
KEY FACTS
Atlanto-occipital dissociation (AOD) has been described in 8% to 19% of fatal
automobile accidents. However, survivors are seen with increasing frequency,
probably as a result of improved emergency care in the field.
Patients who survive may have cranial nerve deficits, quadriparesis, hemiparesis,
paraparesis, or lesser degrees of brainstem injury.
Separation of the cranium in relation to the atlas can occur anteriorly, posteri-
orly, or longitudinally. Radiologic diagnostic criteria need to evaluate all three
possibilities.
Diagnosis on a lateral radiograph of the head and cervical spine can be difficult
because appropriate landmarks must be seen and their relationships appreci-
ated. Plain film diagnosis requires a high index of suspicion. CT diagnosis is usu-
ally straight forward.
Normal measurements on a lateral radiograph as defined by Harris et al. are
Vertical Basion-Dens distance (Basion-Dens Interval, BDI): 12 mm
Basion 12 mm anterior or <4 mm posterior to the posterior C2 line (Basion
Axial Interval, BAI)

Other published criteria such as the Powers ratio and Lees X are less reliable
than these measurements.
Measurements greater than these normal values are diagnostic of AOD.
Diagnosis is often more apparent on sagittal and coronal CT reformations than
on axial CT images. Measurements derived from radiographs have been adapted
for multidetector row CT (MDCT).

A. B.
C. D.
FIGURE 2.30. A 10-year-old girl hit by car while crossing the street. A. Lateral radiograph
shows soft tissue swelling. The BDI is 18 mm. The occipital condyles are displaced ante-
riorly and superiorly (black arrow) in relation to the C1 lateral mass/tip of the dens (white
arrow). B. Axial CT image at the level of the tip of the dens: Absence of the occipital con-
dyles medial to the lateral mass of C1 (white arrows) suggests widening of the occipitoat-
lantal joint space. Parasagittal CT reformations show widening and anterior displacement of
the right (C, black arrow) and left (D, black arrow) occipital condyle in relation to the lateral
mass of C1.
SUGGESTED READING
Chang W, Alexander MT, Mirvis SE. Diagnostic determinants of craniocervical distraction
injury in adults. Am J Roentgenol 2009;192:5258.
Garrett M, Consiglieri G, Kakarla UK, et al. Occipitoatlantal dislocation. Neurosurgery
2010;66:4855.
Harris JH Jr, Carson GC, Wagner LK, et al. Radiologic diagnosis of traumatic occipitoverte-
bral dissociation: comparison of three methods of detecting occipitovertebral relation-
ships on lateral radiographs of supine subjects. Am J Roentgenol 1994;162:887892.

CERVICAL SPINE INJURY: JEFFERSON FRACTURE
KEY FACTS
The Jefferson fracture is a burst fracture of the ring of C1 resulting from an acute
axial load. Although originally described as a four-part disruption of the ring of
C1, the term is also used for three-part fractures involving the lamina and lateral
masses.
Patients frequently have neck pain without neurologic dysfunction.
Conventional radiographic diagnosis is best made with an open-mouth view of
the upper cervical spine. This demonstrates spreading of the lateral masses of C1.
Combined outward spreading of both lateral masses of C1 by more than 7 mm on
the open-mouth projection suggests injury to the transverse ligament.
Diagnosis can also be suggested from a lateral radiograph if the fractures through
the laminae of C1 are visible. This is a less reliable sign.
Axial CT scan reliably demonstrates the fractures throughout the ring of C1 and
the extent of displacement. Sagittal or coronal reconstructions show associated
injury to the dens or to the atlanto-occipital joints, but are less useful in defin-
ing the extent of injury to the ring of C1 (see Dens Fracture, Atlanto-occipital
dissociation).

A.
B.
FIGURE 2.31. A. Odontoid projection radiograph shows splaying of the lateral masses
of C1 (double-headed arrows). If the sum of left and right lateral mass overhang (black
arrows) exceeds 7 mm, instability is more likely. B. Axial CT image through the ring of C1
shows a three-part injury (arrows), two fractures in the anterior arch and fracture of the right
posterior arch.
SUGGESTED READING
Kakarla UK, Chang SW, Theodore N, et al. Atlas fractures. Neurosurgery 2010;66(3 Suppl):
6067.

CERVICAL SPINE INJURY: TRANSVERSE ATLANTAL

LIGAMENT INJURY
KEY FACTS
The transverse atlantal ligament arises from the lateral masses of C1 and main-
tains the relationship of the dens with the anterior ring of C1.
The majority of patients with injury of the transverse atlantal ligament will have
a normal neurologic examination.
Other nontraumatic processes that can affect stability of the transverse atlantal
ligament include rheumatoid arthritis, ankylosing spondylitis, and Down syn-
drome.
Using conventional radiographs, the distance between the dorsal surface of the
ring of C1 and the anterior surface of the dens (Atlanto-Dental Interval [ADI] )
should be no more than 3 mm in adults and no more than 5 mm in children.
CT scan can suggest instability of the transverse ligament from disruption of its
attachment to the ring of C1. Injury to the tissue of the ligament is not seen,
although other fractures can be appreciated.
Direct visualization of the ligaments and widening of the joint space anterior to
the dens is best evaluated with MRI.

A. B.
C. D.
FIGURE 2.32. A and B. T2-weighted axial MR images at C1-2 show disruption of the trans-
verse ligament (white arrow), which is normally of low signal intensity. There is widening of
the anterior atlantoaxial joint space (white arrowhead). C and D. Fluid sensitive axial STIR
images at the same level show abnormally high signal in the area of the disrupted trans-
verse ligament (black arrow). High signal is noted between the dorsal surface of the anterior
ring of C1 and the anterior surface of the dens (black arrowhead).
SUGGESTED READING
Kakarla UK, Chang SW, Theodore N, et al. Atlas fractures. Neurosurgery 2010;66:6067.

CERVICAL SPINE INJURY: DENS FRACTURE
KEY FACTS
Fractures of the dens are classified by location according to the system of
Anderson and dAlonzo.
Fracture Type Location

Type I Involves the tip of the dens (rare)
Type II Limited to the base of the dens (most common)
Type III Extends into the body of C2
Axis (C2) fractures comprise 7% to 17% of cervical spine fractures in many series.
In one series, 40% of axis fractures were associated with head injury and 18%
were associated with other cervical spine injuries.
Dens fractures are potentially unstable. Symptoms range from pain and neck
stiffness to myelopathy.
Most common cervical spine fractures in elderly patients are type II and III dens
fractures.
Predictors of healing of a dens fracture include displacement of the dens less
than 6 mm and patient age less than 50 years. Type III fractures have a higher rate
of healing than type II fractures.
Conventional radiographic diagnosis of a dens fracture requires a good open
mouth and a lateral projection of the upper cervical spine. This will show frac-
tures and displacement of the dens.
If CT scanning is obtained, axial, sagittal, and coronal reformations are required
to assess the caliber of the ring of C1, the width of the predental space, and asso-
ciated injuries. Type II fractures, which lie in an axial plane, may be inappar-
ent with routine axial imaging and be visualized only with sagittal or coronal
reformations.

A. B.
C. D.
FIGURE 2.33. A 20-year-old man involved in motor vehicle crash. A. Odontoid projection
radiograph shows fracture line extending from the base of the dens into the body of C2
(black arrowhead), suggestive of type III dens fracture. B. The lateral radiograph shows corti-
cal disruption with mild displacement (small black arrows). C. Coronal CT reformation clearly
demonstrates type III dens fracture (white arrow). D. Anterior displacement of the dens is
easily appreciated on sagittal CT reformation (white arrowheads).
SUGGESTED READING
Lomoschitz FM, Blackmore CC, Mirza SK, et al. Cervical spine injuries in patients 65 years
old and older: epidemiologic analysis regarding the effects of age and injury mechanism
on distribution, type, and stability of injuries. Am J Roentgenol 2002;178:573577.
Pryputniewicz DM, Hadley MN. Axis fractures. Neurosurgery 2010;66(3 Suppl):6882.

CERVICAL SPINE INJURY: TRAUMATIC

SPONDYLOLISTHESIS OF THE AXIS
KEY FACTS
Traumatic spondylolisthesis of C2, also known as a hangmans fracture, is most
commonly due to acute hyperextension of the head on the neck.
Neurologic sequelae are uncommon. In general, the spinal canal is expanded
without injury to spinal cord or nerve roots.
Fractures are bilateral through the pars interarticularis of C2. This is the portion
of the lamina lying between the articulating facet and the laminar arch. At times
the fracture line may be displaced more anteriorly into the vertebral body of C2.
Diagnosis using conventional radiographs is best made with a lateral projection.
With CT scan, the fracture may be diagnosed on axial images, but will be better
appreciated and understood using sagittal images.
Most cases of traumatic spondylolisthesis are treated with halo-vest immobiliza-
tion and the Effendi classification assists in treatment decisions.
The risk of vascular injury increases with the degree of displacement. CTA should
be considered to evaluate the major vessels of the neck after trauma.

A. B.
C. D.
FIGURE 2.34. A 21-year-old man drove his car into a tree. A. Lateral radiograph shows
fractures through the pars interarticularis of C2. Anterolisthesis of the vertebral body of
C2 and concern for a perched facet (arrow) suggest an Effendi type III fracture. B. Median
sagittal CT reformation confirms 12 mm anterolisthesis (double headed arrow) of C2 on C3,
putting the patient at risk for vascular injury. C. Right parasagittal CT reformation shows the
fractured inferior facet of C2 perched anterior to the superior facet of C3 (double arrow). D.
Axial image from CTA of the neck shows traumatic occlusion of the right vertebral artery at
the level of C2-3 (black arrowhead).
SUGGESTED READING
Pryputniewicz DM, Hadley MN. Axis fractures. Neurosurgery 2010;66:6882.

CERVICAL SPINE INJURY: FLEXION-TEARDROP FRACTURE

(AKA HYPERFLEXION INJURIES)
KEY FACTS
The teardrop fracture is a loosely used term often referring to any fracture with
a triangular fragment arising from the anterior aspect of a vertebral body. The
flexion teardrop fracture should be distinguished from the hyperextension tear-
drop avulsion fracture, which is caused by avulsion of the anterior-inferior corner
of the vertebral body where the anterior longitudinal ligament inserts (usually
C2). Radiographically, the extension teardrop fragment differs from the classic
flexion teardrop, in that the fragment is usually smaller and has a longer axial
width than vertical height.
The Flexion-Teardrop fracture is the most severe of cervical spine injuries with
extreme flexion along with vertical axial compression forces. It can result from
head-on motor vehicle collisions or diving into shallow water.
There is complete disruption of both the anterior and posterior ligamentous
(and/or bony) structures making it highly unstable.
On a lateral radiograph, there is a triangular-shaped fracture fragment arising
from the anterior-inferior corner of the vertebral body that resembles a teardrop
dripping from the vertebral body. The posterior aspect of the vertebral body at
this level is often displaced into the spinal canal.
On axial CT images, there is a classic pattern of coronal split fracture of the body,
usually accompanied by a sagittal component, forming a + or T configuration.
Due to the coronally oriented fracture and the disruption of both the anterior
and posterior ligamentous structures, the floating posterior fragment of the
vertebral body displaces backward into the spinal canal. In addition, there may
be a sagittal split component to the fracture. If this occurs, sagittal split compo-
nent involves both the vertebral body and the posterior neural arch.
Soft tissue components of spinal injury are better diagnosed using MRI. Cord
edema and hemorrhage are common resulting in severe neurologic deficits, usu-
ally a complete spinal cord injury with loss of both motor and sensory function
(ASIA A). There is disruption of the ligamentous complexes.

A. B.
*
*
C. D.
FIGURE 2.35. A. Midline sagittal CT with a classic triangular shape fracture of the anterior/
inferior vertebral body (arrow ). B. Axial CT with a classic coronal and sagittal split frac-
ture (giving a + or T pattern of fracture of the vertebral body). There is disruption of
the posterior bony and ligamentous complex as well making this a highly unstable injury.
Because of the coronal split fracture, the floating posterior body retropulses into the
cord. C. Midsagittal MR (STIR) shows the extensive cord edema (arrow ) as well as the
precervical and posterior soft tissue edema (asterisks). D. Axial MR (MPGR) sequence
demonstrates the extensive hemorrhage within the grey matter of the cord.
SUGGESTED READING
Kim K, Chen H, Russell E, et al. Flexion teardrop fracture of the cervical spine: radiographic
characteristics. Am J Roentgenol 1989;152:319326.
Pech P, Kilgore DP, Pojunas KW, et al. Cervical spine fractures: CT detection. Radiology
1985;157:117120.

LOWER CERVICAL SPINE INJURY: UNILATERAL JUMPED FACET
KEY FACTS
Unilateral facet override occurs from a combination of hyperflexion and rotation
of the cervical spine.
Patients may present with root dysfunction (radiculopathy), minimal neurologic
deficit, or spinal cord dysfunction.
A perched facet is a vertebral facet joint whose inferior articular process appears
to sit perched on the anterior-superior aspect of the vertebral facet below.
A jumped facet is a vertebral facet joint that is dislocated; the inferior articular
facet at one level lies anterior to the superior aspect of the vertebral facet below.
Diagnosis is made using AP and lateral conventional radiographs. On the lateral
projection, there is approximately 25% of anterolisthesis. On the AP projection
the affected spinous process will be out of alignment relative to the normal levels
above and below the level of injury.
Conventional radiographs and CT are used to identify patients with injuries. CT
scanning is used to define the full extent of the fracture and to identify other
levels of injury.
With CT scan, the overriding facet is best seen on sagittal reformations. If the
injury has not been reduced, there is a reversal of the facet joint on axial plane
images with the round nonarticulating portions of the articular processes abut-
ting each other, rather than the flat articular surfaces. There is rotation of the
affected vertebral body relative to the normal levels above and below. If the injury
has been reduced, careful observation for abnormal diastasis of the facet joint
must be noted.
FIGURE 2.36. Sagittal CT showing the inferior

articular process of the facet perched on top
of the superior articular process of the level
below (arrow ). This is a highly unstable injury
as this perched facet can easily slip anteriorly
and become a jumped facet.

A. B.
C. D.
FIGURE 2.37. Unilateral jumped facet. A. Lateral radiograph shows 25% anterolisthesis of
C3-4 and offset of one of the facets (arrow ). B. Oblique radiograph with patients head turned
to his left nicely demonstrates the jumped C3-4 facet joint (arrow ). C. CT with sagittal refor-
mation shows the facet has jumped with the inferior articular process of C3 anterior to the
superior articular process of C4 (arrow ). A small fracture fragment from the inferior facet of
C3 is noted adjacent to the superior facet of C4. D. Axial CT shows the reverse orientation of
the right C3-4 facet joint (arrow ) compared to the left. A small fragment of the right inferior
facet of C3 is noted articulating with the superior facet of C4.
SUGGESTED READING
Andreshak JL, Dekutoski MB. Management of unilateral facet dislocations: a review of the
literature. Orthopedics 1997;20(10):917926.
Gehweiler JA Jr, Osborne RL Jr, Becker RF. The Radiology of Vertebral Trauma. Philadelphia,
PA: WB Saunders, 1980:239252.

LOWER CERVICAL SPINE INJURY: BILATERAL JUMPED FACETS
KEY FACTS
This injury occurs with flexion and distraction forces. The flexion forces are usu-
ally anterior to the spinal column or in the anterior column of the vertebrae and
distraction forces are in the posterior column. There is disruption of ligaments
and dislocation of the facet joints (jumped or locked facets).
A jumped facet is a vertebral facet joint that is dislocated; the inferior articular
facet of the superior vertebra lies anterior to the superior articular facet of the
inferior vertebra.
Patients present with a range of neurologic dysfunction ranging from complete
spinal cord injury to no spinal cord injury.
Lateral radiograph shows 50% or greater anterolisthesis. There may be associ-
ated fractures.
Ligamentous injury is detected indirectly by noting widening of disc spaces, unroof-
ing of the facet joints and widening of the interspinous space between spinous
processes.
Initial management in spinal dislocation is reduction under fluoroscopy. This can
precede detailed imaging studies such as MRI.
CT is used to identify the extent of osseous injury as well as postreduction align-
ment. Fractures can be missed on routine radiographs.
On MRI, cervical disc herniation is found in conjunction with bilateral facet dis-
location in 2% to 30% of cases, depending upon the series.
In the acute setting, perched facets with a normal neurologic exam are more
unstable injuries as they can become jumped with minimal movement resulting
in the more devastating bilateral jumped facets. Immediate spine consult and
reduction is crucial.
A. B.

C. D.
E. F.
FIGURE 2.38. A. Lateral radiograph shows 50% C4-5 anterolisthesis with jumped fac-
ets (arrow ). B. Midsagittal CT again shows the 50% C4-5 anterolisthesis with the left
(C) and right parasagittal (D) reformations showing both C4 inferior articular processes
have jumped anterior to the C5 superior articular processes. E. Axial CT demonstrates
reverse orientation of bilateral C4-5 facet joints as well as a bony retropulsion into the canal.
F. Midsagittal MR (STIR) demonstrates complete disruption of all columns of the spine
including the anterior longitudinal ligament (arrow ), disc, posterior longitudinal ligament,
interspinous ligaments, and the facet joints. In addition, there is extensive cord contusion
with focal hemorrhage within the cord (arrowhead ).
SUGGESTED READING
Acheson MB, Livingston RR, Richardson ML, et al. High resolution CT scanning in evaluations
of cervical spine trauma: a comparison with plain film examination. Am J Roentgenol
1987;148:11791185.
Bucholz RW. Rockwood and Green, 7th ed. Lippincott Williams & Wilkins, 2009.

LOWER CERVICAL SPINE INJURY: ISOLATED POSTERIOR

LIGAMENTOUS INJURY
KEY FACTS
Hyperflexion of the cervical spine results in distractive forces to the posterior
column; it usually occurs in motor vehicle collisions (MVC), and sports injuries.
Lateral radiographs show widening of the interspinous distance, suggestive of
supraspinous and interspinous ligament tears.
Further flexion can disrupt the ligamentous capsule surrounding the facet joints,
leading to perched or jumped facets.
Findings may be subtle if the injury spontaneously reduces when the patient lies
supine or is placed in a collar prior to radiographic evaluation.
May not be associated with a fracture.
If the injury is unrecognized and untreated, it can lead to a chronic kyphotic
deformity of the cervical spine.

A. B.
FIGURE 2.39. A. Lateral radiograph with widen-

ing of the C5-6 spinous processes and unroof-
ing of the facet joints relative to the levels above
and below (distance 2 is longer than 1 or 3).
B. Midline CT sagittal reformation shows widening
of the distance between the C5 and C6 spinous
processes (right arrow ), an indirect sign of ligamen-
tous injury. In addition, there is anterolisthesis of
C5 on C6 (left arrow) C. Midline sagittal MR (STIR)
shows abnormal high T2 signal in the C5-6 inters-
pinous ligament (arrow).
C.
SUGGESTED READING
Benedetti P, Fahr L, Kuhns L, et al. MR imaging findings in spinal ligamentous injury. A picto-
rial essay. Am J Roentgenol 2000;175:661665.
Rihn J, Fisher C, Harrop J, et al. Assessment of the posterior ligamentous complex following
acute cervical trauma. J Bone Joint Surg (Am) 2010;92:583589.

LOWER CERVICAL SPINE INJURY: BURST FRACTURE
KEY FACTS
Burst fractures occur following a direct axial load on the spine. In the lower cervi-
cal spine the vertebral bodies are comminuted with height loss. Bone fragments
may be displaced anteriorly, laterally, and/or posteriorly into the spinal canal.
Burst fractures involve failure of at least the anterior and middle columns.
True burst fractures of the cervical spine are rare. Due to the mobility of the neck,
there is usually a subsequent flexion, extension, or lateral bending force, usually
leading to a flexion-teardrop injury (see above).
On lateral projection, there is height loss of the vertebral body.
On CT, there is height loss with or without bony retropulsion into the canal. It
is essential to distinguish between a burst and a much more unstable flexion-
teardrop fracture.
In a neurologically normal patient, a lower cervical burst fracture is usually
treated with traction (if the posterior longitudinal ligament is intact) and exter-
nal bracing. Alternatively, if there is a neurological deficit, an anterior corpec-
tomy and spine fusion is performed.

A. B.
FIGURE 2.40. A. Lateral radiograph showing height

loss involving the anterior and posterior parts of the
C7 vertebral body (arrow )an axial load mechanism.
B. Axial CT showing anterior and middle column
involvement with 40% anterior to posterior canal
narrowing (arrow ). C. CT with sagittal reformation
again demonstrates C7 height loss involving both
the anterior and middle columns (posterior column
was intact).
C.
SUGGESTED READING
Dvorak MF, Fisher CG, Fehlings MG, et al. The surgical approach to subaxial cervical spine
injuries: an evidence-based algorithm based on the SLIC classification system. Spine
2007;32(23):26202629.

THORACIC/LUMBAR SPINE INJURY: COMPRESSION

AND BURST FRACTURES
KEY FACTS
Compression and burst fractures are the result of axial load on the spinal column.
Mechanisms of injury predominantly include fall and motor vehicle collisions,
but they may occur with minimal trauma in the osteoporotic population.
The three-column concept of thoracic and lumbar spine stability introduced by
Denis is frequently used (see Table 2.2).
There is disruption of the anterior column (compression fracture); the anterior
and middle columns (two-column burst) or the anterior, middle and posterior
column (three-column burst).
Similar to other spine injuries, diagnosis is initially made using conventional
radiographs.
On CT, the overall alignment, percentage of vertebral body height loss, and per-
centage of canal compromise and integrity of the posterior bony (and ligamen-
tous) structures needs to be assessed and reported.
Table 2.2 Three Column Concept of Spine Stabilitya,b

Anterior column Anterior longitudinal ligament
Anterior part of intervertebral disk
Anterior 2/3 of vertebral bodya
Middle column Posterior 1/3 of vertebral bodya
Posterior part of intervertebral disk
Posterior longitudinal ligament
Posterior column Posterior elements (pedicles, facets, laminae, spinous
processes)
Posterior ligaments (supraspinous, interspinous,
ligamentum flavum)
a
Sources (and Denis own work) vary, some defining the anterior column as the anterior 1/2
and some defining the anterior column as the anterior 2/3 of the vertebral body.
b
Other, more recent means of assessing spine stability include the Thoracolumbar Injury
Classification and Severity Score (TLICS). This system includes injury morphology, posterior
ligamentous complex integrity, and neurological status.

A. B.
FIGURE 2.41. A. Axial CT demonstrates a burst fracture. There is 80% canal compromise
from bony retropulsion (arrow ) and widening of the facet joints. B. Midsagittal CT of the
same injury showing normal alignment but with 50% height loss and again the extensive
bony retropulsion into the canal.
SUGGESTED READING
Denis F. The three-column spine and its significance in the classification of acute thora-
columbar spinal injuries. Spine 1983;8:817831.

THORACIC/LUMBAR SPINE INJURY: FLEXION-DISTRACTION

AND CHANCE INJURIES
KEY FACTS
These injuries are associated with automobile lap belts and a rear seat position.
The lap belt, resting on the anterior abdominal wall, acts as the fulcrum of injury.
In a motor vehicle accident, the flexion fracture is due to axial load associated
with rapid deceleration followed by distraction of the posterior column as the
torso folds over the lap belt.
In flexion-distraction injuries, the fulcrum of flexion is in the vertebral body result-
ing in anterior compression of the vertebral body and height loss. It is crucial to
identify the posterior column ligamentous injury as this is the component that
makes this injury require operative management.
In Chance injuries, the fulcrum of flexion is ANTERIOR to the spinal column, hence
all three columns of the spine fail in distraction ( from a posterior to anterior direc-
tion). Chance injuries can be ligamentous, bony, or a combination of the two.
On conventional radiographs, the key is to identify distraction of the posterior
column structures (i.e., widening of the spinous processes).
Axial plane fractures are a hallmark of distraction forces. Since these axial plane
injuries are difficult to recognize on axial plane CT images, sagittal and coronal
plane reformations are necessary to best identify these injuries.
The majority of these injuries occur at the thoracolumbar junction and greater
than 50% are associated with small bowel or colon injuries.
A. B.
FIGURE 2.42. A and B. Flexion-distraction injury. AP and lateral radiographs demonstrate the
abnormal widening between the T11 and T12 spinous processes (double arrow ), best seen on
the AP view, indicating a ligamentous injury. Lateral radiograph shows the T12 wedge defor-
mity, which may be misdiagnosed as simply a compression fracture rather than an unstable
flexion-distraction injury seen here. (continued )

C. D.
FIGURE 2.42. (continued ) C. Axial CT shows the body fracture due to compressive forces
and partially empty facets due to distractive forces to the posterior column. D. Sagittal CT
again demonstrates hallmark features of flexion-distraction injuries: anterior column com-
pression (arrow ) and posterior column distraction (double arrow ).
FIGURE 2.43. Chance fracture. Midsagittal

CT shows an axial plane fracture through the
body and spinous process (arrow ) without
compression of the vertebral body indicat-
ing a Chance injury (in this case, primarily
a bony Chance). The compressive forces in
Chance injuries are ANTERIOR to the spine
so that the spinal column fails in distractive
forces from a posterior to anterior direction.
SUGGESTED READING
Anderson PA, Rivara FP, Maier RV, et al. The epidemiology of seatbelt-associated injuries.
J Trauma 1991;31:6067.
Rihn JA, Yang N, Fisher C, et al. Using magnetic resonance imaging to accurately assess
injury to the posterior ligamentous comples of the spine: a prospective comparison of
the surgeon and radiologist. J Neurosurg Spine 2010;12(4):391396.

THORACIC/LUMBAR SPINE INJURY:

HYPEREXTENSION INJURIES
KEY FACTS
Mechanisms of injury include falls backward or motor vehicle accidents.
Characterized radiographically by widening of the intervertebral disk space ante-
riorly. Additional features may include retrolisthesis, impaction fractures of the
middle and posterior columns, and anterior inferior endplate corner fractures.
Patients with a fused spine (e.g., diffuse idiopathic skeletal hyperostosis [DISH] or
ankylosing spondylitis [AS]) are particularly subject to this injury.
There is distraction of the anterior column. This may continue in an anterior to
posterior direction to involve the middle and posterior columns of the spine (a
reverse flexion/distraction or Chance injury). It can result in dislocation of the
spinal column if there is a shear force component. The fracture plane is predomi-
nantly axial in orientation.
In patient with underlying fused vertebral bodies, maintaining reduction of the
fracture using an external brace is difficult. The spine acts like a long bone; the
fracture results in two long lever arms.
On CT, the diagnosis may be subtle on axial reconstructions if it lies in the axial
plane, and is better identified on sagittal and coronal reformats.
Because of the difficult nature of identifying these injuries in the severely fused
or osteoporotic patient, screening MR with sagittal STIR sequences is of great
utility.

A. B.
FIGURE 2.44. A. Axial CT can be limited in these

injuries, as injuries are frequently oriented in or near
the axial plane. In this example, the anterior aspect
of the vertebral body is not visible. Sagittal and coro-
nal reformats are required to exclude these injuries.
B. Sagittal CT shows distraction of the anterior col-
umn of this ankylosed spine (arrow ) in this case,
from AS. Hyperextension-distraction forces occur
in an anterior to posterior direction, the reverse of
a Chance injury. C. Coronal CT shows disruption of
the spinal column (arrows )with a free floating cal-
cified disc (arrowhead ).
C.
SUGGESTED READING
Hendrix RW, Melany M, Miller F, et al. Fracture of the spine in patients with ankylosis
due to diffuse skeletal hyperostosis: Clinical and imaging findings. Am J Roentgenol
1994;162:899904.

THORACIC/LUMBAR SPINE INJURY: FRACTURE-DISLOCATIONS
KEY FACTS
A fracture-dislocation of the thoracolumbar spine is an unstable injury involving
bone and soft tissue in which one vertebra is dislocated from the adjacent vertebra.
Shear or rotational injuries to all three columns of the spine are due to high forces.
They most commonly arise following motor vehicle collisions (MVCs) and falls
from height.
Initial mechanism may be axial load, flexion/distraction, or hyperextension,
but if the end result is traumatic spinal column malalignment, it is a fracture-
dislocation.
Majority of these injuries occur at thoracolumbar junction due to the relative
immobility of the thoracic spine compared to the lumbar spine; injury can occur
to the cord, the conus medularis, the cauda equina, or a combination.
Three patterns of thoracolumbar facet dislocation have been described: anterior
subluxation with anterior facet dislocation, lateral subluxation with lateral facet
dislocation, and acute kyphosis with superior subluxation of the facets.
Axial CT signs include the empty or naked facet (see Fig. 2.46) and the double
vertebra (two vertebral bodies on one axial slice) signs. A small fracture of the
anterosuperior or anteroinferior margin of a vertebral body is often caused by
avulsion of the adjacent anterior longitudinal ligament.
Associated with a high rate of complete neurological deficit; >90% of patients
with a fracture-dislocation above T10 will be paraplegic and 60% below T10
A. B.
FIGURE 2.45. A woman who was hit by a pipe, with resulting traumatic spinal malalignment
and paralysis. A. Lateral radiograph demonstrates loss of the T7-8 interspace and overlap
between the adjacent inferior endplates (arrow ) with a kyphotic deformity at that level. B. The
fracture-dislocation is better demonstrated on the AP radiograph, where there is significant
left lateral translation of T7 on T8 (arrow ). There is a paraspinal hematoma (arrowhead ).

A. B.
C. D.
FIGURE 2.46. Thoracic fracture-dislocation with bilateral jumped facets following a motor
vehicle collision. A. Bedside chest radiograph demonstrates widening of the inters-
pinous distance between T10 and T11 (double arrows) and a small paraspinal hematoma
(arrowhead). B. Axial CT demonstrates the vertebral body fracture and bilateral naked
superior facets (white arrows) at T11 due to loss of articulation of the T10 inferior facet.
C. Midsagittal CT reformation demonstrates anterolisthesis of T10 on T11, an avulsion frac-
ture of the anterosuperior endplate of T11 narrowing of the spinal canal and widening of the
interspinous distance. D. Parasagittal reformation demonstrates a jumped facet joint.
In general, most require surgical treatment for decompression and stabilization

to prevent further deformity and to allow early mobilization and rehabilitation.
SUGGESTED READING
Gharib A, Postel G, Mirza S, et al. A thoracic spine translation injury with lateral facet dislo-
cation. Am J Roentgenol 2002;178:1450.

RADIONUCLIDE DETECTION OF CEREBROSPINAL FLUID LEAKS
KEY FACTS
Radionuclide techniques are the most sensitive imaging tests for CSF leak
detection.
Scans integrate activity over time to detect and localize extraneuraxial radionu-
clide activity that is indicative of leak.
The radionuclide is instilled into the subarachnoid space usually via lumbar
puncture.
The preferred agent for CSF leak studies is Indium-111 DTPA because of its long
half-life, but other radiotracers such as Technetium-99m DTPA can be used as
long as sterility and apyrogenicity are assured.
Cotton pledgets may be placed in the nose, ears, or wounds, for example, and
then measured in a well counter for assay of radioactivity.
If the leak could arise from an unusual location, using single-photon tomography
may aid in detection and localization.
Abdominal images are obtained to evaluate for swallowed activity.
The major complication of CSF leaks is infection.
Once the leak is detected by the radionuclide study, other detailed imaging stud-
ies, such as CT myelography, may yield further localization.

FIGURE 2.47. Posterior planar images of a

patient injected with Indium-111 DTPA via cer-
vical puncture show extravasation of radionu-
clide (A, arrow) to the bottom left of the CSF
column (above the left kidney). B. Delayed
image shows subtle accumulation of radio-
nuclide in the left hemithorax. The patient had
sustained a gunshot wound to the chest with
thoracic cord injury. Thoracostomy tube on left
had shown high rate of drainage.
A.
B.
SUGGESTED READING
Lewis DH, Graham MM. Benefit of tomography in scintigraphic localization of cerebrospinal
fluid leak. J Nucl Med 1991;32:21492151.
Lewis DH, Manchanda V. Central nervous system scintigraphy. In: Brant WE, Helms CA, eds.
Fundamentals of Diagnostic Radiology, 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006:14721486.

CHAPTER
3 Torso
SCAPULOTHORACIC DISSOCIATION
KEY FACTS
Scapulothoracic dissociation is a rare but devastating injury characterized by a
complete loss of the scapulothoracic articulation, and lateral displacement of the
scapula, with intact skin.
It results from severe traction forces to the shoulder girdle.
Injuries may include acromioclavicular joint separation, clavicle fractures, stern-
oclavicular joint (SCJ) separation, and muscular injuries to the deltoid, pectoralis
minor, rhomboids, levator scapulae, trapezius, and latissimus dorsi.
Brachial plexus and subclavian vascular injuries are the rule.
Because most patients with this injury are involved in high-speed motor vehicle
accidents, there is a high prevalence of other severe injuries.
Radiography
The important chest radiographic feature on a nonrotated film is a laterally dis-
placed scapula.
Check the scapulothoracic ratio (STR).
Medial angle of the scapula (abnormal:normal 1.23) on a nonrotated
anterior-posterior chest radiograph

Medial margin of the glenoid (abnormal:normal 1.15)
Other clues to the diagnosis are the following:

Fracture of the clavicle with lateral displacement of several centimeters of the
distal fragment
Acromioclavicular separation
Sternoclavicular fracture
Apicolateral pleural cap
Axillary or superior mediastinal hematoma
Catheter or CT Angiography
Scapulothoracic dissociation is associated with vascular injuries in 88% of patients.
106

Chapter 3 Torso 107
FIGURE 3.1. Supine AP

chest radiograph in a 50-year-
old man who was struck by
a car while riding his bicycle.
The scapulothoracic ratio,
measured from the medial
borders of the scapula to the
midline (double arrows), mea-
sures 1.5. Additional signs
supportive of scapulotho-
racic dissociation include a
large apicolateral pleural cap
(white asterisk) and superior
mediastinal hematoma.
FIGURE 3.2. Coronal maxi-

mum intensity projection
(MIP) of a contrast-enhanced
computed tomography (CT)
angiogram of the chest in a
42-year-old man involved in a
motorcycle collision. There is
an abrupt cutoff of the right
axillary artery (white arrow)
with active arterial contrast
extravasation (black arrow).
The patient was taken imme-
diately to the operating
room and his axillary artery
repaired with a graft.
The vascular injuries associated with scapulothoracic dissociation are poten-

tially limb or life threatening.
Emergency subclavian angiography (or CTA) is essential to assess the nature of
arterial injuries to the limb in affected patients.
Magnetic Resonance Imaging
MRI of the brachial plexus should be performed to evaluate neurological defects.
This imaging is usually not obtained acutely.
Findings that indicate brachial plexus injury include nerve root avulsion and
pseudomeningoceles.
SUGGESTED READING
Brucker PU, Gruen GS, Kaufmann RA. Scapulothoracic dissociation: evaluation and man-
agement. Injury 2005;36:11471155.
Ridpath CA, Nork S, Linnau K, et al. Scapulothoracic dissociation: are there reliable chest
radiographic findings? Emerg Radiol 2001;8:304307.

108 Chapter 3 Torso
SCAPULA FRACTURE
KEY FACTS
Adequate radiographic evaluation of the scapula can be difficult, as much of the
bone is often obscured by the chest on AP radiographs. AP and lateral views in
the scapular plane (Grashey and Y views) are the minimum acceptable. Axil-
lary views may be helpful in clarifying displacement and deformity.
On chest radiographs, a useful indication of fracture is the scapular X sign. The
X is formed from the crossing of the projected lines of the supraspinatous and
infraspinatous fossa. A break in the X is a reliable sign of fracture.
Adequate assessment of fracture morphology often requires CT. If surgical repair
is planned, CT becomes an important part of the preoperative workup. Three-
dimensional reconstructions are useful for surgical planning.
The presence or absence of displacement, comminution, or articular involve-
ment should always be determined. Intra-articular extension is often the decid-
ing factor between surgical and conservative management.
Displaced acromial, glenoid, and severely displaced body and neck fractures will
usually require surgical repair.
In patients suffering polytrauma, other injuries are commonly associated with
scapular fractures, including severe and life-threatening injuries in remote loca-
tions (such as the skull, abdomen, and pelvis), as well as major injuries to the
adjacent chest and axilla.
Rib fractures, pneumothorax, hemothorax, and lung contusion are frequently
associated injuries. Clavicle fractures are often found with glenoid injuries. Inju-
ries to the brachial plexus and axillary vessels are infrequent, but when they do
occur, they have a poor prognosis.
Ninety percent of patients with both scapular and rib fractures will also have a
pneumothorax.
The severity of the other injuries often determines the management of a scapular
fracture. Surgical repair may be delayed or ruled out in the face of life-threatening
injuries elsewhere.

Chapter 3 Torso 109
A. B.
FIGURE 3.3. This patient fractured his scapula

during a motor vehicle accident. The AP radio-
graph (A) shows the comminuted fracture of
the scapula (curved arrows) extending through
the glenoid fossa. CT scan through the central
glenoid (B) shows the inferior portion of the
glenoid (arrow) displaced medially. A second,
more superior, CT scan slice (C) shows the
superior portion of the glenoid (arrow), with
the coracoid process (open arrow), en face,
because it is rotated 90 degrees away from the
humeral head.
C.
FIGURE 3.4. Frontal chest radiograph

from a middle-aged man involved in a
motor vehicle crash shows a fracture
of the left scapula (arrows). Note the
scapular X-sign, with a break in the X
shape formed by the infrascapular and
suprascapular fossa, when compared
with the normal right side (arrow-
head).
SUGGESTED READING
Collins J. Chest wall trauma. J Thorac Imag 2000;15(2):112119.

110 Chapter 3 Torso
RIB FRACTURES
KEY FACTS
Rib fractures usually follow blunt trauma to the chest, but are also seen after
vigorous coughing.
They usually occur in the lower ten ribs, laterally, away from the protection of the
overlying chest wall musculature.
Isolated first rib fractures can occur secondarily to whiplash injuries, and as a
sports-related injury in those sports with violent overhead throwing motions, for
example, baseball or lacrosse. This is an avulsion fracture at the insertion of the
scalene muscles on the first rib. Previously infrequently identified on radiographs,
first and second rib injuries are now frequently encountered on CT scans.
Lower rib fractures are associated with increased risk of injury to the liver and
spleen.
Nondisplaced rib fractures can be hard to visualize acutely on the chest radio-
graph, especially anterior fractures, often only revealing themselves as callous
forms at the fracture site 10 to 14 days after injury. Rib cartilage fractures or sepa-
rations are not radiographically evident.
Specific radiographic examination of the ribs, with oblique positioning of the
patient, is more accurate than the chest radiograph in detecting subtle rib
fractures.
Serious intrathoracic complications associated with rib fractures include pneu-
mothorax (see Fig. 3.39), hemothorax, pulmonary contusion (see Fig. 3.30), pul-
monary laceration (see Fig. 3.34), and secondarily, atelectasis, and pneumonia.
Indirect radiographic findings, such as extrapleural hematoma, increase the yield
of a directed search for rib fracture.
Flail Chest
The most common definition for a flail chest is 3 or more contiguous ribs with
segmental fractures (i.e., fractured in 2 or more places).
Flail chest is a marker of high kinetic energy absorption, but is not necessarily a
marker for great vessel, tracheobronchial, or diaphragmatic injuries.
Flail chest is highly associated with pulmonary contusion or laceration, pneu-
mothorax, and hemothorax, especially with increasing number of rib fractures.
It is also associated with clavicular and scapular fractures.
Patients with flail chest may require prolonged mechanical ventilation due to
acute respiratory failure. Newer management approaches include surgical fixa-
tion of ribs to allow more rapid recovery.

Chapter 3 Torso 111
A. B.
FIGURE 3.5. A. AP chest radiograph in a 57-year-old man involved in a high speed motor
vehicle collision shows multiple left posterior rib fractures (white arrows) and a large left
pulmonary contusion. B. Volume-rendered posterior oblique view shows six segmental left
rib fractures (labeled 3 to 8 inclusive in the interspace above each rib). The remaining ribs
are fractured in one location. This patient did not undergo internal fixation, but required a
prolonged period of mechanical ventilation in intensive care.
FIGURE 3.6. CT scan through the

upper abdomen from any patient
involved in a motor vehicle crash
shows a fracture through the cos-
tal cartilage of a left lower rib near
the junction with the lower sternum
(arrows). These types of fractures are
typically not evident by chest radio-
graph. Note the surrounding soft tissue
hematoma. These lower rib fractures
are frequently associated with upper
abdominal visceral injuries; note the
small hepatic laceration (arrowhead).
There was also an associated splenic
laceration.
SUGGESTED READING
Collins J. Chest wall trauma. J Thorac Imag 2000;15(2):112119.

112 Chapter 3 Torso
STERNOCLAVICULAR DISLOCATION
KEY FACTS
Sternoclavicular joint (SCJ) dislocation usually results when significant lateral
force is applied to the shoulder, which travels along the long axis of the clavicle
to the SCJ.
Depending on the angle of the clavicle with respect to the sternum at the time
force is applied, either an anterior or posterior dislocation will occur.
The relationship of the clavicle to the manubrium is used to classify SCJ disloca-
tion into anterior and posterior dislocation.
In children and young adults, Salter Harris I or II fractures through the physeal
plate of the medical clavicle typically occur.
Radiologic findings can be subtle because there is only minimal displacement of
the clavicle on the AP radiograph. Look for the following:
Lateral displacement of the proximal end of the clavicle
Apparent asymmetry in clavicular head height
Although specific oblique (serendipity and Hobbs) views can be obtained to diag-
nose SCJ dislocation, interpretation is challenging.
Ultrasound can be performed to diagnose SCJ dislocation.
CT is the imaging method of choice, especially in the multitrauma patient.
Anterior Sternoclavicular Dislocation
Anterior dislocation is more common than posterior dislocation (9:1).
It is usually treated with closed reduction.
Posterior Sternoclavicular Dislocation
Proximity of the clavicle to critical thoracic outlet structures can lead to severe or
life-threatening complications, such as impingement on or injury to the trachea,
esophageal injury, pneumothorax, laceration of underlying great vessels, and bra-
chial plexus injury.
When posterior SCJ dislocation is suspected, consider CT angiography with con-
tralateral (or lower limb) venous contrast injection.
FIGURE 3.7. Anterior sternoclavicular disloca-
tion. Anterior-oblique volume-rendered recon-
struction of a contrast-enhanced CT of the chest
in a 42-year-old woman pedestrian struck by a car.
The left clavicular head (white arrow) is anteriorly
dislocated in comparison with the manubrium,
compared to the right. The exact relationship
between the manubrium and the clavicle is not
always apparent on any single axial or multipla-
nar reformat image but is well demonstrated on
volume-rendered reconstructions.

Chapter 3 Torso 113
A. B.
C.
FIGURE 3.8. Posterior SCJ fracture-dislocation with vascular injury in a 20-year-old man
involved in a high-speed motor vehicle collision. A. AP chest radiograph demonstrates a
mediastinal hematoma, with widening of the right paratracheal stripe, and obscuration of
the aortic contour (white arrows). A diagnosis of SCJ dislocation cannot be made. B. Axial
contrast CT angiogram. Asymmetric widening of the right sternoclavicular joint (black arrow)
associated with a small avulsion fracture of the medial clavicular head is clearly shown. In
addition, there is mediastinal hematoma (asterisk) and a filling defect in the brachiocephalic
artery (white arrow). C. Catheter angiogram of the aortic arch and branch vessels demon-
strates pseudoaneurysms of the brachiocephalic artery (black arrowheads). The intraluminal
thrombus is also visible (small white arrow).
SUGGESTED READING
Jaggard MK, Gupte CM, Gulati V, et al. A comprehensive review of trauma and disruption
to the sternoclavicular joint with the proposal of a new classification system. J Trauma
2009;66:576584.

114 Chapter 3 Torso
STERNAL FRACTURES
KEY FACTS
Sternal fractures occur in about 3% to 7% of blunt chest trauma, and their rate is
higher with seat-belt (but not airbag) use. Insufficiency fractures of the sternum
also occur, especially in females with osteoporosis and in patients on long-term
steroids.
When caused by direct impact, fractures classically occur at the site of impact.
Pain and tenderness of the sternum are the most common patient complaints.
Simple sternal fractures are usually benign and do not require special treatment
or an expensive workup.
Sternal body fractures are most common, but more energy is required to frac-
ture the manubrium, and these have a greater association with intrathoracic and
upper mediastinal (especially great vessel) injuries.
Depressed, segmental sternal fractures have an increased association with myo-
cardial injury, including hemopericardium.
The fracture pattern is usually transverse or oblique.
Sternal fractures are associated with injuries to the head, limbs, spine, heart, and
lung.
When a sternal fracture is suspected, a 12-lead ECG should be performed to
examine for arrythmias, conduction disturbances, and myocardial injury.
The outcome of patients with an isolated sternal fracture and a normal ECG is
excellent.
Radiography
Frontal chest radiographs usually do not show sternal fractures.
Oblique or lateral chest radiographs may show sternal fractures. Because sternal
fractures can be impacted or overriding, they can appear on oblique views as
linear bands of increased density (not lucent).
Ultrasound
Ultrasound has a similar sensitivity for sternal fractures as plain radiography.
Chest CT
Chest CT is not generally indicated in most patients.
CT is the gold-standard examination for sternal fractures. As most fractures are
transverse, the CT should be performed with coronal oblique and sagittal refor-
mations, angled to the plane of the sternum.
Performing CT of the chest with intravenous contrast improves assessment of
associated great vessel injury and hemopericardium.

Chapter 3 Torso 115
FIGURE 3.9. Lateral radiograph of the chest in a

46-year-old man involved in a motor vehicle colli-
sion. He had a large anterior chest contusion and a
palpable sternal deformity. Transverse fracture of the
sternal body with significant overlap of the fracture
fragments (arrows).
A. B.
FIGURE 3.10. CT of the chest in a 91-year-old man who was a restrained passenger in a
high-speed motor vehicle collision. A. Transverse sternal fracture (white arrow) with signifi-
cant anterior mediastinal hematoma (asterisk). Note how the anterior mediastinal hema-
toma does not extend to the aorta or great vessels. The small black arrow shows an area
of misregistration in the ascending aorta due to cardiac pulsation. B. On the axial image,
the fracture is clearly visible, but more subtle (white arrow). The presence of an isolated
retrosternal anterior mediastinal hematoma strongly suggests a sternal fracture, and spe-
cific sagittal and oblique coronal reformats of the sternum may be necessary to detect the
fracture. A left anterior rib fracture is also present (small black arrow).
SUGGESTED READING
Restrepo CS, Martinez S, Lemos DF, et al. Imaging appearances of the sternum and sterno-
clavicular joints. Radiographics 2009;29:839859.

116 Chapter 3 Torso
AIRWAY RUPTURE/LACERATION
KEY FACTS
Cervical Trachea
These injuries usually occur secondary to a direct blow, causing the so-called
clothesline injury, but most frequently in motor vehicle crashes against the steer-
ing wheel.
There is a range of injury severity from membranous rupture, to cartilage ring
fracture, to cricothyroid dislocation.
Direct laryngoscopy and open exploration are indicated for severe injuries.
CT scanning is a useful modality for lesser injuries; look for abnormal air collec-
tions, cartilage fractures, and arytenoid dislocations.
Intrathoracic Trachea
Airway disruptions can be due to both blunt and penetrating injuries, though are
very infrequent after blunt chest trauma.
The clinical picture is not uniform; hence the correct diagnosis can be delayed
or evasive.
Patients typically exhibit cough, significant soft tissue emphysema, pneumo-
mediastinum, pneumothorax, hemoptysis, increasing respiratory distress, and
hypoxia within a few hours of the injury.
The most common sites of injury are the main bronchi (right > left); 75% occur
within 2 cm of the tracheal carina.
Tracheobronchial rupture from blunt trauma is usually single and transverse, but
a minority may have longitudinal or complex tears.
Associated injuries include rupture of the great vessels.
While often suspected radiographically, the diagnosis is usually confirmed endo-
scopically/bronchoscopically.
Imaging shows the following:
Extensive soft tissue emphysema
Pneumomediastinum
Pneumothorax that fails to reexpand with chest tube drainage
CT scans can often show the disruption directly.
With tracheal lacerations, mediastinal air collections will predominate. If
bronchial, and >2 cm from the tracheal carina, recalcitrant pneumothorax

will predominate. Within 2 cm of the tracheal carina, heterotopic air collec-
tions will be mixed.
A rare, but pathognomonic chest radiographic finding is the so-called fallen
lung sign. After a complete laceration of a main bronchus, the lung collapses, or
falls, down into the dependent pleural space.

Chapter 3 Torso 117
FIGURE 3.11. CT scan through the upper chest from a patient involved in a motor vehicle
crash shows a pneumomediastinum (arrowhead) resulting from a tracheal laceration. Note
the endotracheal tube balloon cuff distorting the normal round shape of the trachea. The
tear of the posterior membrane of the trachea, at its junction with the tracheal cartilage,
allows the balloon to bulge posteriorly and to the right (arrow).
SUGGESTED READING
Sangster GP, Gonzlez-Beicos A, Carbo AI, et al. Blunt traumatic injuries of the lung paren-
chyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer
tomography imaging findings. Emerg Radiol 2007;14(5):297310.

118 Chapter 3 Torso
ESOPHAGEAL RUPTURE/LACERATION
KEY FACTS
Causes of esophageal rupture include iatrogenic injury (usually from endoscopic
instrumentation and/or balloon dilation), spontaneous rupture (Boerhaave syn-
drome), trauma, and neoplasms.
Boerhaave syndrome usually occurs after vomiting or vigorous retching, often
after heavy food intake. The tear is most commonly located in the posterolateral
aspect of the distal esophagus, just proximal to the gastroesophageal junction.
Symptoms include severe substernal chest pain, followed rapidly by signs of sep-
sis secondary to mediastinitis.
Chest radiographs are nonspecific and usually show a wide mediastinum and
left pleural effusion or hydropneumothorax. Pneumomediastinum is another
common, nonspecific finding. Occasionally, one can see the V-sign of Naclerio,
where pneumomediastinum extends to and reflects the parietal pleura off the
left hemidiaphragm yielding a lucent V.
Injuries from blunt trauma are extremely rare, accounting for 1% of cases of
pneumomediastinum following blunt trauma. They are usually associated with
pneumomediastinum or pneumoperitoneum. They typically affect the phrenic
ampulla and cervical esophagus.
Penetrating injuries to the esophagus and central airways should always be
strongly suspected in cases of transmediastinal injury but these injuries can
result from entry wounds anywhere in the chest.
Esophageal rupture can also be seen in blast injuries.
In penetrating injuries of the supraclavicular esophagus, the trachea is injured in
half of cases (and vice versa).
Delay in diagnosing esophageal rupture doubles patient mortality every 6 hours;
>85% mortality if the delay is >24 hours.
Mediastinitis and abscess formation can result from an esophageal laceration.
Esophagram technique is described in Chapter 1. For esophagographic diagnosis
of esophageal rupture, use water-soluble iodinated contrast in the left anterior
oblique (LAO) position. If this is normal, follow with thin barium solution in the
supine and supine oblique (LPO, RPO) positions (see case Special Procedures in
the Emergency Room, p. 17, Chapter 1).

Chapter 3 Torso 119
A. B.
FIGURE 3.12. Esophageal perforation from pen-

etrating injury. A 23-year-old woman who swal-
lowed a pen. A. Plain chest radiograph reveals
a ballpoint pen in the stomach (black arrow). B.
Owing to severe pain, a CT of the chest was
performed. This demonstrates extensive medi-
astinal gas (asterisk) and bilateral pneumotho-
races. There is a defect in the left lateral wall
of the esophagus (arrow), where the lumen
appears to extend to the edge of the aorta.
C. An esophagram demonstrates leakage of
contrast at this level (black arrow).
C.
SUGGESTED READING
Bjerke HS. Penetrating and blunt injuries of the esophagus. Chest Surg Clin N Am 1994;4:
811818.
Dissanaike S, Shalhub S, Jurkovich GJ. The evaluation of pneumomediastinum in blunt
trauma patients. J Trauma 2008;65:13401345.

120 Chapter 3 Torso
ESOPHAGEAL INTUBATION WITH GASTRIC PERFORATION
KEY FACTS
Unrecognized esophageal malposition is an uncommon (1%) but potentially
catastrophic complication of attempted endotracheal intubation.
Esophageal intubation is suggested or diagnosed on chest radiographs by show-
ing the following:
Projection of any part of the endotracheal tube outside of the airway
An enlarged tracheal balloon cuff (transverse diameter >2.8 cm)
New extrapulmonary gas collections (marked gastric dilation, pneumoperito-
neum, pneumomediastinum)
Distal prolapse of the tracheal balloon (distal margin <1.2 cm proximal to
endotracheal tube tip)

Chest radiographs should be obtained routinely to verify correct endotracheal
tube position.
Gastric rupture and pneumoperitoneum following esophageal intubation and
ventilation are rare, usually occurring during cardiopulmonary resuscitation.

Chapter 3 Torso 121
FIGURE 3.13. AP chest radiograph from an 80-year-old-woman after accidental esophageal

intubation shows a large pneumoperitoneum resulting from gastric rupture. Note the endo-
tracheal balloon cuff projecting beyond the tracheal air column (arrows). (From Song JK,
Stern EJ, Beaty CD. Gastric perforation: a complication of inadvertent esophageal intuba-
tion. AJR Am J Roentgenol 1995 Jun;164(6):1386, with permission.)
SUGGESTED READING
Brunel W, Coleman DL, Schwartz DE, et al. Assessment of routine chest roentgenograms
and the physical examination to confirm endotracheal tube position. Chest 1989;96:
10431045.

122 Chapter 3 Torso
TRAUMATIC AORTIC INJURY: OVERVIEW
KEY FACTS
Blunt thoracic aortic injury (BTAI) accounts for 10% to 20% of fatalities in motor
vehicle collisions; up to 80% of these victims die at the accident scene. Survival
is estimated to be 60% to 80% for those patients who reach hospital alive. Hence,
prompt detection is critical.
Sudden deceleration is usually the cause. High-speed motor vehicle collisions
(both head-on and side impact) are the most common cause, followed by falls
and crush injuries.
Multiple mechanisms of injury have been proposed to account for the spectrum
of injury pattern. These include the deceleration shear force theory, where iner-
tial forces during deceleration cause shearing of the aorta at its points of fixation,
especially the ligamentum arteriosum. Other mechanisms include an osseous
pinch mechanism caused by pinching between the anterior chest wall and the
spine, longitudinal stretching of the aorta, and a water-hammer effect.
BTAI is principally a disease of adults and children >10 years of age. It is extremely
rare in children <10.
Of patients arriving in hospital, the vast majority of injuries occur at the level
of the aortic isthmus (80%90%), origins of the great vessels (4%10%), the dia-
phragmatic hiatus (1%3%), and aortic root (1%4%).
Untreated, 30% of patients will die within the first 24 hours after arriving in
hospital.
Minimal aortic injuries are injuries that represent 10% to 25% of BTAI. They
typically appear as small intimal irregularities without pseudoaneurysms and
respond well to noninvasive management.
Penetrating thoracic aortic injury is usually the result of gunshot and knife inju-
ries. Its mortality rate prior to arrival in hospital is high, up to 90%
Unlike blunt aortic injury, penetrating thoracic aortic injuries typically involve
the ascending aorta, arch, and less commonly affect the descending aorta.
Arterial embolization should be considered when gunshot wounds without an
exit wound are encountered. If the missile enters the aorta distal to the great ves-
sels, embolization to the lower extremity is likely. If it enters proximal to the great
vessels, embolization to the brain and upper extremity should be considered.
Abdominal aortic injuries are rare. They are associated with distraction injuries
of the thoracolumbar spine, retroperitoneal injuries (pancreas, renal), and bowel
injuries. They have been managed successfully with endovascular repair.

Chapter 3 Torso 123
FIGURE 3.14. Posterior projection

of a volume-rendered reconstruc-
tion of a contrast-enhanced CTA of
the thoracic aorta demonstrating a
typical pseudoaneurysm (asterisk)
that arises in the region of the aor-
tic isthmus. Nearly 90% of blunt
thoracic aortic injuries arise in this
location.
FIGURE 3.15. Coronal thin-slab maxi-

mum intensity projection of a CTA of the
abdomen demonstrating an infrarenal
abdominal aortic injury in a young man
involved in a motor vehicle collision. The
proximal and distal intimo-medial flaps
(black arrows) demonstrate the typical FIGURE 3.16. 3D volume-rendered
appearance for a stretch type injury. CTA following endovascular repair.
Although the flaps covered the origins The patient had a full recovery from
of the common iliac arteries, the man his abdominal aortic injury.
had normal lower extremity pulses.
SUGGESTED READING
Neschis DG, Scalea TM, Flinn WR, et al. Blunt aortic injury. N Engl J Med 2008;359:
17081716.

124 Chapter 3 Torso
TRAUMATIC AORTIC INJURY: CHEST RADIOGRAPHY
KEY FACTS
There are many chest radiographic signs used to detect mediastinal hematoma;
no individual sign is specific for acute traumatic aortic injury (ATAI). The mecha-
nism of injury and clinical suspicion are still very important factors. The basic
premise is that 99% of ATAI are associated with mediastinal hematoma. Well-
recognized chest radiographic signs of mediastinal hematoma, and thus indi-
rectly ATAI, include the following:
Abnormal aortic contour
Aortopulmonary window opacification
Deviation of trachea, nasogastric tube, or endotracheal tube to the right
Abnormal left paraspinal stripe
Left apical pleural cap
Thickened right paratracheal stripe
Depression of left main bronchus
Left hemothorax
Mediastinal widening on the chest radiograph (>8 cm at the level of the aortic
arch on an erect radiograph) has fair sensitivity for traumatic aortic injury (92%).
However, by itself, it is not that useful, with a specificity of only 10%. Mediasti-
nal widening can result from magnification and distortion of the mediastinal
contour inherent in the portable supine chest radiograph. It can also be due to
atherosclerosis, mediastinal lipomatosis, pulmonary atelectasis, or pleural effu-
sions abutting the mediastinum or mediastinal lymph adenopathy. Hence, using
mediastinal width, without the signs listed above, to determine the presence or
absence of aortic injury is strongly discouraged.
Chest radiography is not useful for the assessment of mediastinal hematoma in
young children (<10 years of age) due to thymic silhouette and extremely low
incidence of aortic injury.
The negative predictive value of a normal chest radiograph is 98%; in other words,
it virtually excludes the presence of aortic injury. However, in high-risk patients
undergoing CT for other reasons, CT of the thorax should be considered.
Coned-down views of the mediastinum likely increase the specificity of radiogra-
phy for aortic injury compared to a standard supine radiograph.

Chapter 3 Torso 125
FIGURE 3.17. Abnormal

mediastinum in a 19-year-old
man who drove his pickup
at high speed into a fence.
Although the mediastinum
was not widened, the tho-
racic aorta is not clearly
seen. There is a left apical
pleural cap (black arrow-
head). A left pulmonary con-
tusion (asterisk) is present.
No rib fractures are evident.
The absence of fractures to
the thoracic cage is not an
uncommon finding in young
patients with thoracic aortic
injury.
FIGURE 3.18. Coronal mul-

tiplanar reconstruction of a
CTA of the aorta in the same
patient. Although there was
only a small quantity of peri-
aortic hematoma, there is
a pseudoaneurysm of the
aortic isthmus (white arrow).
The pulmonary contusion is
also seen (asterisk).
SUGGESTED READING
Barker DE, Crabtree JD Jr, White JE, et al. Mediastinal evaluation utilizing the reverse Tren-
delenburg radiograph. Am Surg 1999;65(5):484489.
Gundry SR, Burney RE, Mackenzie JR, et al. Assessment of mediastinal widening associated
with traumatic rupture of the aorta. J Trauma 1983;23(4):293299.
Ho RT, Blackmore CC, Bloch RD, et al. Can we rely on mediastinal widening on chest radi-
ography to identify subjects with aortic injury? Emerg Radiol 2002;9(4):183187. [Epub
2002 Aug 14.]

126 Chapter 3 Torso
TRAUMATIC AORTIC INJURY: MINIMAL AORTIC INJURY
KEY FACTS
Minimal aortic injury (MAI) is a minor injury to the thoracic aorta resulting from
blunt trauma. MAI has been increasingly recognized since CT became the stan-
dard modality to assess for thoracic aortic injury.
They appear as small intimal tears or intraluminal filling defects in the aorta,
most commonly in the region of the aortic isthmus and descending thoracic
aorta.
Intimal injuries are typically smaller than 1 cm in size, but can be larger.
MAI is usually associated with absence of periaortic hematoma, or at most a
small amount of periaortic hematoma.
These injuries are typically not seen with catheter angiography, although they have
been described with MRI, echocardiography and intra-vascular ultrasound.
Occasionally, they are associated with small infarcts in the organs supplied by
arteries distal to the injury, such as in the kidneys and spleen.
Minimal aortic injury is usually treated noninvasively. Beta blockade and antico-
agulation (if possible) with follow-up CT are the mainstays of management. The
lesion usually resolves on follow-up CT.
In addition, intramural hematoma of the aorta can result from blunt trauma and
can be managed noninvasively.

Chapter 3 Torso 127
FIGURE 3.19. Small intimal injury

demonstrated on CTA (aka mini-
mal aortic injury) in a 28-year-old
man involved in a fall from a bridge.
The intraluminal filling defect in the
distal descending thoracic aorta
(white arrow) is likely due to throm-
bus attached to a small intimal tear.
Note the absence of periaortic
hematoma. Follow-up CTA seven
days following the injury demon-
strated complete resolution.
SUGGESTED READING
Malhotra AK, Fabian TC, Croce MA, et al. Minimal aortic injury: a lesion associated with
advancing diagnostic techniques. J Trauma 2001;51(6):10421048.

128 Chapter 3 Torso
TRAUMATIC AORTIC INJURY: COMPUTED TOMOGRAPHY
KEY FACTS
CTA of the chest is now considered the gold standard for the detection of
blunt thoracic aortic injury (BTAI) and accordingly has supplanted catheter
angiography. The sensitivity, negative predictive value, and accuracy all approach
100% when mutlidetector row CT scanners are used.
CTA should be considered in any adult with a mechanism that puts them at high
risk of BTAI, those with an abnormal or indeterminate mediastinum on chest
radiography, and in patients undergoing a trauma pan-scan.
If possible, the contrast injection should be through the right arm to avoid streak
artifact from dense contrast in the left brachiocephalic vein. Bolus triggering or
a timing bolus is usually used to ensure that the helical acquisition occurs at
peak aortic enhancement, although many centers continue to use a fixed con-
trast delay when CTA of the thoracic aorta is combined with CTA of other body
regions.
Using modern multidetector computed tomography (MDCT) scanners, near-
isotrophic reconstructions allow the display of the aorta in multiple planes. For
optimal assessment of the branch vessel origins, and aortic isthmus, it is criti-
cal not only to obtain multiplanar reformats but also to evaluate them in every
case.
In most circumstances, cardiac gating is not used. However, cardiac gating can
be used in specific cases where cardiac motion and pulsation artifact cause diag-
nostic uncertainty on an initial scan, especially around the aortic root.
Classically, the CT signs of BTAI are termed indirect (simply periaortic hema-
toma) and direct (visualization of the aortic injury.)
Blood that is separated from the aorta by a fat plane should not be considered
periaortic blood. This is usually due to fractures of adjacent structures (e.g., ster-
num, spine) or injuries to small mediastinal vessels.
The presence of periaortic blood should prompt a thorough examination of the
aorta and branch vessels in multiple planes. If no aortic injury is observed in a
high-quality CTA, the patient is extremely unlikely to have an aortic injury, and
follow-up catheter angiography is unlikely to be of value.
Direct signs of aortic injury include the following:
Pseudoaneurysm
Intimal flap
Intraluminal filling defect
Pseudocoarctation (abrupt narrowing in the aortic caliber)
Active contrast extravasation

Chapter 3 Torso 129
Once the diagnosis is established by the presence of direct signs on MDCT, no

further diagnostic testing is usually necessary.
Retrocrural periaortic blood seen on the upper extent of an abdominal CT should
prompt a chest CTA of the patient at risk for BTAI.
Cardiac pulsation artifacts are common at the aortic root and ascending aorta.
These usually have quite indistinct margins and project beyond the aortic wall,
in comparison to aortic injuries, which are usually sharply defined and project
into the aortic lumen. In addition, pulsation artifacts are usually accompanied
by a similar appearing artifact in the main pulmonary artery at the same level. If
a question persists about an injury at this level, electrocardiograph-gated CTA or
transesophageal echocardiography should be considered.
FIGURE 3.20. Acute aortic transection on CT. Sagittal thin-slab maximum intensity
projection in a 41-year-old woman involved in a high-speed motor vehicle collision. Typical
appearing pseudoaneurysm arising from the undersurface of the aorta in the region of the
aortic isthmus (white arrow). Note the acute angles the pseudoaneurysm makes with the
aorta, a feature that is valuable in discriminating the injury from the smooth, obtuse angles
made by the ductus diverticulum, a common anatomic variant.

130 Chapter 3 Torso
A.
B.
FIGURE 3.21. A. Axial CT demonstrates the beret sign (arrow) arising from the anterior
surface of the aorta (A). The beret is the pseudoaneurym hanging over the aortic lumen.
A small quantity of periaortic blood surrounds the aorta. B. Supine chest radiograph in the
same woman. The mediastinum is not grossly widened (7 cm at the aortic arch) although
there is a left apical pleural cap (black arrowhead) and loss of the aortopulmonary window
(black arrow). Rotation of the film limits assessment, not uncommon in the trauma setting.

Chapter 3 Torso 131
FIGURE 3.22. Catheter angiogram of the aorta demonstrating a large traumatic transection
(pseudoaneurysm) of the aortic isthmus in a 23-year-old man who was involved in a motor
vehicle collision (black arrow).
SUGGESTED READING
Sammer M, Wang E, Blackmore CC, et al. Indeterminate CT angiography in blunt thoracic
trauma: is CT angiography enough? Am J Roentgenol 2007;189(3):603608.
Steenburg SD, Ravenel JG, Ikonomidis JS, et al. Acute traumatic aortic injury: imaging evalu-
ation and management. Radiology 2008;248(3):748762.

132 Chapter 3 Torso
TRAUMATIC AORTIC INJURY: ENDOVASCULAR REPAIR
KEY FACTS
Traditionally, repair of blunt thoracic aortic injury (BTAI) has been performed
utilizing a left lateral thoracotomy and interposition graft.
The majority of cases of BTAI are now repaired using thoracic endovascular aor-
tic repair, especially for injuries of the aortic isthmus and descending aorta.
Use of the stent graft excludes the pseudoaneurysm from the systemic blood
pressure, reducing the risk of rupture in the first few days following injury.
Current evidence suggests that patients with BTAI who arrive in hospital hemo-
dynamically stable can be treated with beta blockade and delayed repair, a few
days after injury. However, endovascular repair is now frequently performed
early.
Overall, short-term mortality with endovascular repair is lower than with open
repair. However, long-term consequences are still unknown as BTAI typically
occurs in young patients, and their life expectancy exceeds current outcome
data on endovascular repair of BTAI, aneurysms, or aortic dissection.
Traditionally, the principal technical obstacle to the management of BTAI with
stents was the shortage of suitable stents. Most aortic stent grafts were designed
to treat aneurysms. The smallest stent was too wide for the aorta in young trauma
patients, who have an aortic diameter of about 20 mm. Consequently, there was a
risk of stent graft collapse. Newer, narrower, stents are becoming available.
The aorta in young patients typically has a steep curvature. Precurved and con-
formable stents are becoming available that allow for a better seal without the
risk of poor alignment and stent collapse.
Isthmic injuries to the thoracic aorta typically occur close to the left subclavian
artery (LSCA) origin (6.815 mm). Approximately 30% of patients will have to
undergo intentional coverage of the LSCA with the proximal end of the stent. If
a patient has a left dominant vertebral artery, absent right vertebral artery, an
incomplete circle of Willis, or left internal mammary artery bypass graft, these
findings must be noted in the CT report, as these patients may need bypass
surgery to ensure persistent LSCA arterial supply. Likewise, iliac and femoral
artery minimum diameters should be noted in the report. Diameters in the
6- to 9-mm range may prove challenging for the large catheters needed for stent
deployment.
Following repair, examine the aorta for endoleaks, branch vessel occlusion, kink-
ing, migration, and collapse. Patients with a sharply angulated aortic arch and
injuries close to the LSCA origin are most at risk of collapse.

Chapter 3 Torso 133
A.
B.
FIGURE 3.23. A. Angiogram of an endovascular repair of a pseudoaneurysm in the

region of the aortic isthmus. Two short overlapping stents have been deployed to cover
the pseudoaneurysm. The left subclavian artery (LSCA) (black arrow) is partially covered.
B. Sagittal thin-slab MIP of the same patient. The pseudoaneurysm is sealed from the systemic
circulation. The proximal stent projects into the lumen of the aorta (arrow), sometimes called
the birds-beak deformity. This is due to the use of a nonconformable stent and puts the
patient at a higher risk of type 1a endoleaks and stent collapse.

134 Chapter 3 Torso
A.
B.
FIGURE 3.24. A. Sagittal MIP of a 17-year-old man who injured his aorta during a fall from
height. The proximal aspect of the pseudoaneurysm (asterisk) is directly opposite the distal
aspect of the LSCA (arrow), with no landing zone for the proximal aspect of the stent
between the LSCA and the pseudoaneurysm. B. Following endovascular repair with a con-
formable stent (white arrows), there is a good seal. The LSCA origin is covered, without
antegrade flow from the aorta into the LSCA (white asterisk). Due to collateral pathways,
this patient tolerated the procedure well and did not need a bypass procedure.

Chapter 3 Torso 135
SUGGESTED READING
Atkins MD, Marrocco CJ, Todd Bohannon W, et al. Stent-graft repair for blunt traumatic aor-
tic injury as the new standard of care: is there evidence? J Endovasc Ther 2009;16(Suppl I):
I53I62.
Morgan TA, Steenburg SD, Siegel EL, et al. Acute traumatic aortic injuries: posttherapy mul-
tidetector CT findings, RadioGraphics 2010;30:851867.

136 Chapter 3 Torso
INJURY TO THE GREAT VESSELS
KEY FACTS
Injury to the origins of the great vessels (described here to include the superior
vena cava [SVC], inferior vena cava [IVC], pulmonary artery, brachiocephalic
artery, and common carotid and subclavian artery) is an uncommon problem
that can occur secondary to both blunt (see also scapulothoracic dissociation
and sternal/manubrial fractures) and penetrating injuries.
Injuries to the branch vessel origins of the thoracic aorta represent 4% to 10% of
aortic injuries.
In blunt trauma, the brachiocephalic artery is the most frequently injured branch
vessel. It is associated with manubrial fractures (10%), posterior left sternoclavic-
ular dislocations (10%), and scapulothoracic dissociation.
Subclavian artery injury is most commonly associated with gunshot and knife
wounds. Almost 50% of patients with subclavian artery injuries will have concur-
rent severe brachial plexus injury, especially when caused by blunt trauma. Early
angiography (CT or catheter) should be considered in all patients with signs of
brachial plexus injuries, scapulothoracic dissociation, or a mechanism sugges-
tive of subclavian artery injury. Although fractures of the clavicle are common,
associated subclavian artery injuries are very rare. Endovascular repair has been
successfully used for these injuries.
Most injuries of the vena cava involve the IVC. Blunt SVC injuries are extremely
rare, and injuries to the intrapericardial portion are almost universally fatal.
IVC injuries usually result from penetrating injuries to the retroperitoneum.
Blunt injuries to the IVC usually occur in the retrohepatic segment, and are
likely underdiagnosed by portal venous phase CT. Findings include peri-
caval hematoma, irregular filling defects, and an irregular contour. Contrast
extravasation is usually not seen. A late venous phase is ideal to avoid con-
trast-mixing artifacts in the IVC. This can be achieved by using a 120-second
fixed delay or using bolus triggering with a region of interest centered on
the infrarenal IVC.

Chapter 3 Torso 137
A.
B.
FIGURE 3.25. Value of multiplanar reformations for injury to great vessel origins. CTA of
a 29-year-old pedestrian hit by a car while crossing the road. Axial CTA (A) shows perivas-
cular hematoma (H) surrounding the great vessels. The left subclavian artery (white arrow)
appears larger than expected, but no discrete contour deformity is obvious. Note that a
right arm vein was used for the peripheral intravenous contrast injection to minimize streak
artifact (black double headed arrow) impairing visualization of the great vessels. Coronal
multiplanar reformat (B) displays the pseudoaneurysm more clearly (white arrowhead).
SUGGESTED READING
Hoff SJ, Reilly MK, Merrill WH, et al. Analysis of blunt and penetrating injury of the innomi-
nate and subclavian arteries. Am Surg 1994;60:151154.
Netto FA, Tien H, Hamilton P, et al. Diagnosis and outcome of blunt caval injuries in the
modern trauma center. J Trauma 2006;61(5):10531057.

138 Chapter 3 Torso
PERIPHERAL VASCULAR TRAUMA
KEY FACTS
Penetrating injuries account for approximately 90% of peripheral vascular
injuries. Popliteal artery injury should always be considered in cases of posterior
knee dislocation.
Injuries in the upper limb most commonly occur in the axillary artery, antecu-
bital fossa, and anterior upper arm. More distal injuries can usually be managed
with ligation, if necessary. In the lower limb, the highest risk regions include the
popliteal fossa, inguinal region, and medial thigh.
Signs of peripheral vascular injury have been divided into hard and soft
signs.
Hard signs include the following:
Pulsatile bleeding
Expanding hematoma
Absent pulse
Distal ischemia
Thrills and bruits
Reduced ankle-brachial index (ABI) (<0.91.0) following knee dislocation
Soft signs include stable hematoma, hypotension, neurological deficits, and

trauma in proximity to a major artery.
Catheter angiography has long been considered the gold standard for these inju-
ries. However, multidetector-row CT peripheral angiography has been shown
to be effective in diagnosing these injuries, and can be combined with CT of
other regions in the multitrauma patient. Timing of arterial enhancement can
be achieved with a high-rate intravenous contrast bolus (56 mL/s) with either
bolus triggering or a timing bolus taken from the aorta. For upper extremity CTA,
placing the injured arm above the head should be considered, if possible.
Findings include the following:
Active arterial bleeding: irregular extraluminal collections of contrast not con-
tained within the vessel wall or perivascular soft tissues that are hyperdense in
comparison to the adjacent soft tissues and enlarge on later contrast phases
Pseudoaneurysms: extraluminal extensions from the vessel that demonstrate
similar contrast density to the adjacent artery

Arterio-venous fistula: direct communication between an injured artery and
adjacent vein. The principal finding is early filling of the vein.

Occlusion: complete luminal termination. Always check that an apparent occlu-
sion is not due to a tourniquet applied to the limb to prevent exsanguination.

Intimal injury: a focal contour defect in the wall of the vessel projecting into
the lumen
A focally narrowed vessel may be the consequence of adjacent hematoma, tour-
niquet, vasospasm, dissection, or intimal injury. In indeterminate cases, close
clinical follow-up, Doppler ultrasound, and/or reimaging may be necessary.

Chapter 3 Torso 139
A.
FIGURE 3.26. CTA of an 18-year-

old man who was stabbed in his
right leg. Axial reconstruction (A)
demonstrates a bilobed pseudoa-
neurysm (white arrow) with sur-
rounding hematoma anterior and
lateral to the superficial femoral
artery. 3D volume-rendered image
(B) shows that the pseudoaneu-
rysm (arrow) is fed by a small per-
forator branch (arrowhead) arising
from the superficial femoral artery.
B.
Although CTA can be used in many cases of arterial injuries, catheter angiography
should always be considered first in the unstable patient and in patients with
adjacent metal (e.g., shrapnel), which can cause excessive beam-hardening arti-
facts on CTA.
SUGGESTED READING
Shah N, Anderson SW, Vu M, et al. Extremity CT angiography: application to trauma using
64-MDCT. Emerg Radiol 2009;16(6):425432. [Epub 2009 Mar 20.]

140 Chapter 3 Torso
MYOCARDIAL CONTUSION
KEY FACTS
Cardiac injury occurs in up to 15% of patients with a history of major blunt chest
trauma.
Myocardial contusions result from rapid deceleration or application of great
force to the anterior chest.
They represent an intramural hematoma in the myocardial wall.
They are commonly, but not exclusively, associated with sternal factures.
Myocardial contusions remain difficult to diagnose. However, diagnosis is vital
in unstable patients, as well as in hemodynamically stable patients, despite its
low morbidity.
Myocardial contusion is characterized at surgery or during autopsy as areas of
muscle necrosis and hemorrhagic infiltrate. These findings are not seen with
standard imaging, such as CT, so a radiographic diagnosis is rarely, if ever made.
Myocardial contusion is often a clinical diagnosis made in specific patients with
a history of blunt chest trauma.
Chest radiographs (CXR) and CT are of little value in the diagnosis of myocardial
contusion but are useful in finding associated injuries as markers of injury sever-
ity such as flail chest, sternal fracture, mediastinal hematoma, and pulmonary
contusion.
Baseline CXR, ECG, and cardiac-enzyme levels may be obtained in patients in
whom there is a high suspicion of cardiac injury. Close clinical monitoring of
patients admitted to the hospital should be performed. Echocardiography is
reserved for those patients who are unstable, have ischemic patterns on ECG or
complex arrhythmias.
Findings on echocardiogram may include the following:
Pericardial effusion (hemopericardium)
Regional wall motion abnormalities
Intramyocardial hematoma in the free wall of the right ventricle
Decreased ejection fraction

Chapter 3 Torso 141
SUGGESTED READING
Pretre R, Chilcott M. Blunt trauma to the heart and great vessels. N Eng J Med 1997;336:
626632.
McLean RF, Devitt JH, McLellan BA, et al. Significance of myocardial contusion following
blunt chest trauma. J Trauma 1992;33:240243.

142 Chapter 3 Torso
CARDIAC PERFORATION AND RUPTURE
KEY FACTS
Cardiac rupture can occur from either penetrating injuries to the chest, such
as stab or gunshot wounds, or from severe blunt trauma to the chest, usually
anteriorly.
Blunt traumatic cardiac rupture is associated with a high rate of mortality and
most frequently results from motor vehicle accidents, crush injuries, and falls.
The mean Injury Severity and Trauma Scores are usually very high.
Severe blunt trauma can lead to right atrial rupture (most common), followed by
right ventricular rupture, left atrial rupture, and, least commonly, left ventricular
rupture.
Mortality is due to acute tamponade and is >80% for single atrial chamber rup-
ture and 100% with multichamber rupture.
Survivors usually have a small rupture with a slow, contained leak under low
pressure.
The primary imaging modality for the diagnosis is pericardial ultrasound, usu-
ally as a component of focused abdominal sonography for trauma (FAST). This
should be considered in all unstable patients with penetrating trauma that could
have violated the pericardial space. A subxiphoid view and a left parasternal view
are favored. In addition to a hemopericardium, evaluate the patient for cardiac
tamponade. Signs of pericardial tamponade include a large pericardial effusion,
right atrial and/or right ventricular diastolic collapse, and a dilated IVC. Evidence
favoring FAST for blunt cardiac injury is incomplete, but it is recommended as a
component of FAST in all hemodynamically unstable blunt trauma patients.
Chest CT scanning occasionally makes the diagnosis, usually serendipitously.

Chapter 3 Torso 143
FIGURE 3.27. Right ventricular rupture in a 56-year-old man involved in a high-speed motor
vehicle collision. He had a history of an atrial septal defect, with failed surgical closure, sub-
sequently treated by an Amplatzer closure device several years prior to the injury. There is
rupture (black arrowhead) of the free wall of the right ventricle (RV) with a contained collec-
tion of contrast anterior to the right heart (white arrow). A 4-cm linear defect was surgically
repaired without complication.
SUGGESTED READING
Brathwaite CE, Rodriguez A, Turney SZ, et al. Blunt traumatic cardiac rupture. A 5-year
experience. Ann Surg 1990;212:701704.
Pretre R, Chilcott M. Blunt trauma to the heart and great vessels. N Eng J Med 1997;336:
626632.

144 Chapter 3 Torso
DIAPHRAGM INJURY
KEY FACTS
Hemidiaphragm rupture can occur following both blunt and penetrating mecha-
nisms of injury. In blunt injury, high intra-abdominal pressures are speculated as
the usual mechanism of hemidiaphragm rupture, although penetrating rib frac-
tures can also lacerate the hemidiaphragm.
It occurs in up to 8% of severe traumatically injured patients.
It is rarely an isolated injury and is associated with other significant intra-
abdominal injuries in most cases.
Sine qua non is abdominal viscera in the thorax.
Incidence of right-sided versus left-sided hemidiaphragm rupture, after blunt
abdominal trauma, is controversial. The classic teaching is that 90% of ruptures
are left-sided; however, the true incidence may be more equal, the liver just pre-
venting clinical manifestations.
Ninety percent of strangulated diaphragmatic hernias are of traumatic etiology.
Diagnosis can be delayed for several reasons:
Low clinical suspicion
Imaging findings obscured by other more compelling or associated injuries.
For example, hemothorax

Mechanical ventilation is a confounding variable. Positive pressure ventilation
removes the normal pressure gradient from the abdomen to the thorax that
leads to herniation.
True delayed rupture (not related to removal of positive pressure ventilation) is
uncommon.
Small lacerations of the hemidiaphragm are hard to detect; the chest radiograph
can be normal.
With a large hemidiaphragm rupture, chest radiographs are never normal.
Radiographic findings of left hemidiaphragm rupture include the following:
Loops of bowel, usually stomach and colon within the thorax
Nasogastric tube showing the position of the stomach within the thorax
Pleural effusion
Ill-defined soft tissue mass obscuring the hemidiaphragm
Apparently elevated but distorted hemidiaphragm
CT with multiplanar imaging is very helpful in diagnosis. Always perform a single

helical acquisition through the diaphragm. CT signs include
Direct visualization of the defect
Visceral or omental fat herniation
Collar sign
Dependent viscera sign

Chapter 3 Torso 145
A.
B.
FIGURE 3.28. A. Initial AP chest radiograph from a 37-year-old man involved in a motor
vehicle accident shows obscuration of the left hemidiaphragm, with the nasogastric tube
extending slightly above the expected position of the hemidiaphragm contour (arrow). B. AP
chest radiograph obtained 12 hours later shows marked distention of the stomach appar-
ently within the thorax. Hemidiaphragm rupture was confirmed surgically.

146 Chapter 3 Torso
A.
B.
FIGURE 3.29. CT of a 39-year-old man involved in a high-speed motor vehicle collision.

A. The dependent viscera sign is present with the stomach (S) and colon (black arrow)
lying against the posterior left chest wall. B. On the coronal reformat, the left hemiia-
phragm rupture is visible between the remaining portions of the diaphragm (white arrow-
heads). The stomach (S), jejunum (J), and colon (black arrows) have herniated into the
thoracic cavity.

Chapter 3 Torso 147
SUGGESTED READING
Bergin D, Ennis R, Keogh C, et al. The dependent viscera sign in CT diagnosis of blunt trau-
matic diaphragmatic rupture. Am J Roentgenol 2001;177(5):11371140.
Carter YM, Karmy-Jones RC, Stern EJ. Delayed recognition of diaphragmatic rupture in a
patient receiving mechanical ventilation. Am J Roentgenol 2001;176(2):428.
Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of
plain chest radiographs. Am J Roentgenol 1991;156:5157.
Rees O, Mirvis SE, Shanmuganathan K. Multidetector-row CT of right hemidiaphrag-
matic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol 2005;60(12):
1280128s9.

148 Chapter 3 Torso
PULMONARY CONTUSION
KEY FACTS
The most common traumatic lung injury is pulmonary contusion.
Unlike bruising ones shin, it takes a substantial amount of kinetic energy absorp-
tion to contuse the lung; therefore, pulmonary contusion is a marker of injury
severity.
Pulmonary contusion occurs in both blunt and penetrating injuries, with or with-
out rib fractures, and from blast injuries. They are also caused by shearing forces
(variable rates of deceleration that compress and stretch the lung).
Extensive, often bilateral pulmonary contusions can cause dyspnea, tachycardia,
and hypoxia. Hemoptysis is uncommon.
Pulmonary contusions caused by stab or gunshot wounds are usually small and
clinically inconsequential, the exception being shotgun wounds that can have a
pronounced blast effect.
Pulmonary contusions can be an independent injury that resolves to leave the
chest radiograph normal; however, they can initially mask more serious underly-
ing injuries that only become apparent as the contusions resolve (e.g., lacerations
with resulting pneumatoceles or hematomas).
Conversely, pulmonary contusions can be masked by other injuries (e.g., pneu-
mothorax, hemothorax, etc.).
Basilar pulmonary contusions, especially with associated rib fractures, should
alert the radiologist to associated intra-abdominal injuries.
Pulmonary contusions are typically evident radiographically immediately after
injury in most patients and in all patients within 12 hours.
Imaging features include the following:
Patchy, nonsegmental, ill-defined parenchymal opacity, usually with no ana-
tomic boundary
Opacities are typically peripheral and under the point of injury but can be
patchy and scattered.

Key feature is that the opacities do not conform to expected anatomical lung
units such as lobar or segmental distributions as the absorbed kinetic energy
does not respect these boundaries.
Pulmonary contusions start clearing in 2 to 3 daysit is a dynamic process that
usually resolves within 4 to 5 days (range 110 days). CT scanning is generally
not indicated.
When new lung parenchymal opacities appear >24 hours after injury, strongly
consider other etiologies such as aspiration or superimposed pneumonia.

Chapter 3 Torso 149
FIGURE 3.30. CT scan from

a young man involved in
motor vehicle crash shows
extensive right-sided pulmo-
nary contusion. The contu-
sion in this case is outlined
by the rim of extrapleural air
(arrows) that collected as a
result of an associated rib
fracture and pneumothorax.
Note the nonanatomic dis-
tribution of the lung opacity
around the periphery of the
lung resulting from the blunt
trauma to the right side of
the torso.
FIGURE 3.31. CT scan

from a young man involved
in motor vehicle crash again
shows a peripheral nonana-
tomically distributed lung
opacity at the periphery of
the right lung typical for pul-
monary contusion (arrows).
SUGGESTED READING

150 Chapter 3 Torso
PULMONARY LACERATION
KEY FACTS
The term pulmonary laceration implies frank disruption of lung tissue resulting
in a cavity that may fill with air (pneumatocele) and blood (hematoma) in vari-
able quantities.
Pulmonary lacerations occur in both blunt and penetrating chest injuries
and result from tearing and crushing of lung tissue from penetrating objects
(knife, bullet, rib), or shearing forces and tissue stresses that occur during chest
compression.
They can be deep within the lung or superficial and subpleural.
Associated hemoptysis is very common.
Radiographically, pulmonary lacerations are as follows:
Usually round in shape, secondary to inherent lung elasticity, but can take
days to form classic appearance; become more evident on serial exams as sur-
rounding pulmonary contusions and hemorrhage clear
Usually 2 to 5 cm in diameter, although can be up to 20 cm
Multiple or isolated; multiple usually secondary to compression injuries
Simple and spherical or complex and irregularly shaped
May contain air, blood, or a combination of the two. Therefore, they can have
air/fluid levels.
Present immediately after injury, but they are often masked by pulmonary
contusions, hemorrhage, hemothorax, or pneumothorax. Therefore, they are

better identified and characterized with CT scan
Can be confused with lung abscess. Temporal appearance important to distin-
guish: abscess develops much later in the patients hospital course.

Four types of lacerations are described on the basis of CT scan findings and
mechanism of injury:
Compression rupture. These are the most common, occurring after blunt
trauma, and are usually deeper, larger, and more complex in appearance.
Compression shear. These are often vertically oriented and paravertebral in
location.

Chapter 3 Torso 151
Rib penetration. These are usually smaller, often multiple, and typically
peripheral.
Adhesion tears (rare)
Detection of lacerations is important because they can become secondarily

infected and, most importantly, can lead to prolonged chest tube drainage sec-
ondary to development of a bronchopleural fistula.
FIGURE 3.32. Coronal reformat CT scan through the posterior chest from a patient involved
in a high-speed motor vehicle crash shows a large right-sided pulmonary air-filled laceration
(arrows). This type of oblong laceration adjacent to the spine is typical for a shearing type of
pulmonary laceration. There is extensive underlying nonspecific lung injury.

152 Chapter 3 Torso
FIGURE 3.33. Coronal thin slab-MIP CT scan through the mid chest from a patient involved
in a high-speed motor vehicle crash shows a small right-sided air-filled pulmonary laceration
(arrow). This type of round laceration deep within the lung is typical for a compression-
rupture type of pulmonary laceration. Note the surrounding pulmonary hemorrhage.
FIGURE 3.34. CT scan through the lower chest from a patient involved in a high-speed
motor vehicle crash shows a right-sided pulmonary laceration in the lower lobe (arrow-
heads). This type of peripheral laceration is often associated with a rib fracture, not shown.
In this case, the laceration is filled with blood, not air; note the active extravasation of con-
trast material (arrow).

Chapter 3 Torso 153
SUGGESTED READING
Wagner RB, Crawford WO Jr, Schimpf PP. Classification of parenchymal injuries of the lung.
Radiology 1988;167:7782.

154 Chapter 3 Torso
PULMONARY LACERATION: PENETRATING INJURIES
KEY FACTS
A pulmonary laceration is present immediately after injury, but hemothorax
or pneumothorax can obscure the underlying lung injury; the laceration may
become evident after satisfactory pleural fluid drainage.
As in blunt trauma, pulmonary lacerations due to stab wounds cause pulmonary
hematomas, traumatic pneumatoceles, and bronchopleural fistulae.
It can take days for the classic appearance of a traumatic pneumatocele to appear.
Look for a thin-walled, rounded lucency, usually 2 to 5 cm, depending upon the
size of the knife or bullet track.
If blood fills the laceration instead of air, the laceration will appear more mass-like
(a hematoma), whereas if air fills the laceration, it is known as a pneumatocele.
Simple pneumatoceles heal more quickly than hematomas.
Stab wounds do not usually have associated pulmonary contusion, whereas a
gunshot wound track is surrounded by a zone of contusion of variable size.
Multiplanar CT imaging is useful in better defining and characterizing the extent
and severity of these types of lacerations.

Chapter 3 Torso 155
FIGURE 3.35. Pulmonary laceration secondary to stab wound. Traumatic hematocele.

CT scan through the mid chest from this patient who suffered a stab wound to the left
chest shows a typical blade-shaped pulmonary laceration (arrow) and associated left pneu-
mothorax (arrowhead) and hemothorax. Note that there is very little pulmonary hemorrhage
around the laceration in this case.
SUGGESTED READING
de Vries CS, Africa M, Gebremariam FA, et al. The imaging of stab injuries. Acta Radiol
2010;51(1):92106.
Shanmuganathan K, Matsumoto J. Imaging of penetrating chest trauma. Radiol Clin North
Am 2006;44(2):225238.

156 Chapter 3 Torso
PULMONARY LACERATION: PULMONARY HEMATOMA
KEY FACTS
Pulmonary hematoma results from extensive hemorrhage into a pulmonary
laceration. The clot undergoes typical organization and can have a fibrous wall;
hence they become progressively opaque over time.
Several weeks after an injury, a pulmonary hematoma can begin to appear and
can be confused with a solitary pulmonary nodule. However, they usually resolve
spontaneously and are sometimes called vanishing lung tumors.
A.
B.
FIGURE 3.36. A. AP chest radiograph from a 24-year-old-woman with a gunshot wound to

the right chest shows a rounded lucency with surrounding opacity (zone of contusion) con-
sistent with a pulmonary laceration in the right upper lobe (arrow). B. PA chest radiograph
from the same patient, 6 weeks after initial injury, shows a spiculated mass at the site of
the previous gunshot wound (arrow). This represents a healing hematoma that can simulate
a lung neoplasm.

Chapter 3 Torso 157
FIGURE 3.37. CT scan of the chest from a patient who suffered a motor vehicle crash
shows a peripheral focal fluid-filled pulmonary laceration (arrowhead) surrounded by a halo
of ground-glass opacity, representing surrounding pulmonary contusion.
Pulmonary hematomas can take weeks or months to heal, sometimes with sub-
stantial lung scarring.
Occasionally, pulmonary hematomas form an air crescent sign and can be con-
fused with a mycetoma.
SUGGESTED READING
Am 2006;44(2):225238.

158 Chapter 3 Torso
LUNG INJURY: BLAST EFFECT
KEY FACTS
Blast effect from explosions and the resulting pressure wave can cause direct
injury to the lung, usually seen as focal or diffuse pulmonary contusion.
Other injuries to the chest related to primary blast effect include pneumothorax
and alveolar rupture with air embolism.
The lung injury is proportional to the associated auditory injury and the blast
force.
In patients with flail chest (see Fig. 3.5) and underlying pulmonary contusion, it is
the contusion that is frequently the primary cause of hypoxia and morbidity.
Pulmonary contusions from high-velocity (assault/military weapons) gunshot
wounds can lead to refractory hypoxemia. Contused lung loses autoregulation
and literally shunts blood to itself, away from more normal lung. This type of
severe lobar contusion can be treated with lobectomy.
Shotgun pellets are considered low-velocity projectiles. However, at close range,
there is a large blast effect and massive soft tissue injury that can compromise
the structural and mechanical integrity of the chest wall and underlying lung
parenchyma.

Chapter 3 Torso 159
FIGURE 3.38. AP chest radiograph from a 69-year-old man with a shotgun wound to the
right chest wall. Note the extensive soft tissue injury. Also, there is a large parenchymal
opacity representing pulmonary contusion (secondary to blast effect).
SUGGESTED READING
Am 2006;44(2):225238.

160 Chapter 3 Torso
TRAUMATIC PNEUMOTHORAX
KEY FACTS
Pneumothorax is defined as a collection of air in the pleural cavity, between visceral
and parietal layers. Possible causes include
Blunt trauma: Air can enter the pleural cavity from a leak in proximal or distal
airways, and lung parenchyma.
Penetrating trauma: accumulation of air in pleural cavity from the lung, airways,
esophagus, or from outside the patient
Resuscitative attempts related to central line placement and positive pressure
ventilation
Detection of a small pneumothorax is important due to its potential to progress
into a tension pneumothorax, which impairs venous return to the heart, potentially
leading to cardiac arrest and death. Untreated simple pneumothorax is thought to
progress to tension pneumothorax in up to one third of trauma patients.
Radiography
AP erect view: Air collects in the superolateral portion of the thoracic cavity and
outlines the thin visceral pleural line. No lung markings are visible beyond this
line.
Mimicks (pitfalls): skin folds, tape on skin, bedclothes, overlying tubes and lines,
subcutaneous air, and sub pleural lung cysts
Supine AP view:
Air collects in the anteroinferior aspects of the pleural space, creating hypoden-
sity over the lower chest and upper abdomen.

Deep sulcus sign: Air in the lateral costophrenic recess, giving an appearance
of a deep costophrenic sulcus.

Double diaphragm sign: pleural air outlining both the anteroinferior insertion
of the diaphragm as well as the dome, projecting as a double density on radio-

graphs.
Pleural Sonography
In supine trauma patients, sonography for the detection of anterior pneumotho-
rax may be beneficial, particularly if focused sonography for trauma (FAST)

Chapter 3 Torso 161
is performed at the same time. A linear high-frequency probe is advised in a

longitudinal scan plane (orthogonal to the ribs). In the absence of pneumothorax,
normal respiratory motion of the interface of parietal and visceral pleura can be
demonstrated, referred to as lung sliding or lung gliding. Comet-tail artifacts
caused by the pleural interface are an additional normal finding. Pneumothorax
is inferred if lung sliding and comet-tail artifact are absent. See case Focused
Assessment with Sonography for Trauma, p. 174.
CT Scan
Clinical exam and initial chest radiographs miss small pneumothoraces in 30%
to 55% of trauma patients. CT is considered the gold standard in the diagnosis
of pneumothorax owing to its high sensitivity and specificity. Trauma CT scans of
the abdomen should include the lung bases for lung window review. Small apical
pneumothoraces are often detected on the most caudate portion of a cervical
spine CT (coronal reformations).
Tension Pneumothorax
Air enters the pleural cavity but does not egress during expiration. Findings
include
Mediastinal shift to the contralateral side
Flattening of the ipsilateral diaphragm
Spreading of the ipsilateral ribs
Compression of the ipsilateral lung
Causes of persistent tension pneumothorax in the presence of chest tube

include
Occluded or malpositioned chest tube
Major airway injury, allowing air to leak into the pleural space as quickly as it
can be evacuated by the chest tube

162 Chapter 3 Torso
A.
B.
FIGURE 3.39. A 40 year-old bicyclist hit by a car. A: Supine initial chest radiograph obtained
in the trauma bay shows a left deep sulcus sign (white arrow) adjacent to left-sided lateral
rib fractures, indicative of left pneumothorax. B: Axial CT images after left chest tube place-
ment shows small residual left pneumothorax (white arrow). Small right pneumothorax
(black arrowheads) diagnosed on CT was not visualized radiographically.

Chapter 3 Torso 163
SUGGESTED READING
Alsalim W, Lewis D. Towards evidence based emergency medicine: best BETs from the Man-
chester Royal Infirmary. BET 1: Is ultrasound or chest x ray best for the diagnosis of
pneumothorax in the emergency department? Emerg Med J 2009;26:434435.

164 Chapter 3 Torso
INTRATHORACIC ECTOPIC AIR COLLECTIONS
KEY FACTS
Intrathoracic air located outside the aero-digestive tract has multiple potential
causes:
Blunt or penetrating chest trauma with injury to the lung or GI tract
Foreign body in upper or lower airways, with subsequent airway rupture
Iatrogenic injuries to the airways or GI tract
Fractures of paranasal sinuses
Infection by gas-producing organism
Mechanical ventilation
Diving accidents
Radiographically, disruption of the pulmonary parenchyma and airways can

cause the following:
Pulmonary interstitial emphysema
Pneumothorax
Pneumomediastinum
Pulmonary lacerations (pneumatoceles)
FIGURE 3.40. CT scan through the lower chest from a middle-aged man receiving high-pressure
mechanical ventilation shows extensive ectopic air collecting in many different fascial planes and
spaces. In this case, there is pneumomediastinum, subcutaneous emphysema, and bilateral
pneumothorax. Note that the subcutaneous emphysema has extended into the soft tissues in
the patients arms.

Chapter 3 Torso 165
* *
FIGURE 3.41. CT scan through the lower chest from a patient involved in a high-speed
motor vehicle crash shows extensive ectopic air collecting in many different fascial planes
and spaces. The primary injury is to the right chest wall. Note the disruption of the integrity
of the chest wall (white arrows), allowing pleural free air to escape into the soft tissues.
In this case, there is pneumomediastinum (short black arrow), subcutaneous emphysema
(long black arrow), and bilateral pneumothorax (asterisks).
Pneumopericardium (rare)
In severe cases, air can dissect from the mediastinum to the neck, face, chest,
abdominal wall, and retroperitoneum.
SUGGESTED READING
Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema: pathophys-
iology, diagnosis, and management. Arch Intern Med 1984;144:14471453.

166 Chapter 3 Torso
ASPIRATION OF FOREIGN BODY
KEY FACTS
Most common substances to be aspirated in trauma patients are food/vomitus,
teeth, and assorted road debris.
In nontrauma patients (especially children) frequently aspirated foreign bodies
include coins, nuts, and small toys, most of which are radiopaque.
Distribution is the same as aspiration in any supine patient: dependent lung seg-
ments, namely the posterior basal segmental bronchi of the lower lobes, superior
segmental bronchi, and the apical-posterior segments of the upper lobes.
Larger objects lodge in the central airways, while smaller objects can be seen at
the periphery of the lung.
Removal of foreign bodies should be done expeditiously to avoid bronchial steno-
sis and obstructive pneumonitis.
CT imaging is better for identifying the type and location of these foreign
objects within the airways, as well as characterizing the typical bilateral, gravity-
dependent distribution of vomitus.
FIGURE 3.42. AP chest radiograph from a 20-year-old man involved in a motor vehicle
accident shows a tooth in the right bronchus intermedius (arrow). This must be retrieved,
usually bronchoscopically, to avoid chronic obstruction and infection.

Chapter 3 Torso 167
FIGURE 3.43. CT scan through the mid chest from patients who suffered a witnessed
large aspiration of gastric contents shows extensive fluffy infiltrates in both lungs, with a
predominantly gravitationally dependent bilateral distribution, typical for aspiration.
SUGGESTED READING
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001;11(4):
861872.

168 Chapter 3 Torso
NEAR-DROWNING
KEY FACTS
Two prominent components of near-drowning are cerebral anoxia and pulmonary
aspiration of water. The volume aspirated is more important than the nature of
the fluid ( fresh versus salt water).
Radiographic appearance of near-drowning victims may vary greatly, ranging
from a completely normal appearance to varying degrees of pulmonary edema.
Important mechanisms of pulmonary edema appear to be loss of functional pul-
monary surfactant, osmotically driven influx of plasma after salt-water aspira-
tion, and activation of inflammatory mediators with resultant diffuse alveolar
damage and pulmonary capillary leakage.
There may be a delay of 24 to 48 hours before pulmonary edema develops, or the
edema may be present initially and resolve very rapidly, even within hours.
In most instances, there is marked clearing of the lungs within 3 to 5 days, with
complete resolution of pulmonary edema within 7 to 10 days.
In a near-drowning patient, scuba diving further increases the risks of developing
lung barotrauma and decompression sickness.
Mild decompression sickness (Type I): Symptoms relate to the formation of
periarticular soft tissue gas bubbles (the bends).

Severe decompression sickness (Type II): Direct transit of inert molecular gas
into the pulmonary or systemic arterial circulations (gas embolism) may

result in pulmonary insufficiency (the chokes) or central nervous signs and
symptoms. Severe decompression sickness, especially with cerebral gas embo-
lism, always requires urgent hyperbaric therapy.

Chapter 3 Torso 169
FIGURE 3.44. CT scan through the lower chest from a patient who suffered an episode of
near drowning. Note the extensive diffuse nonspecific lung opacities that resulted from pul-
monary edema and witnessed aspiration. In this particular case, the patient had an inciden-
tal intralobar pulmonary sequestration. Note the distorted left lower lobe anatomy (arrows)
and the associated aortic feeding vessel (arrowheads). Because of the sequestration, this
region of the lung remained well aerated.
SUGGESTED READING
Hunter TB, Whitehouse WM. Fresh-water near-drowning: radiological aspects. Radiology
1974;112:5156.

170 Chapter 3 Torso
INTRAPERITONEAL FLUID IN TRAUMA
KEY FACTS
Inraperitoneal fluid in an acutely traumatized patient represents one or more of
the following:
Blood (+/ IV contrast)
Intestinal fluid (+/ oral contrast)
Urine
Bile
Lymphatic fluid
Preexisting ascites
Physiologic fluid related to the menstrual cycle or from aggressive fluid
resuscitation
The attenuation of fluid, as measured on CT scan in Hounsfield units (HU), can
indicate its origin.
Bowel contents (without oral contrast), urine, bile, and preexisting ascites
measure near water density (<20 HU).

Clotted blood generally measures 45 to 70 HU and unclotted blood 30 to 45
HU. In the anemic or aggressively hydrated patient, the attenuation of hemo-

peritoneum may be <30 HU.
High-attenuation peritoneal fluid (>100 HU) indicates extraluminal oral con-
trast due to bowel perforation, active extravasation of contrast-enhanced

blood from a vascular injury, or extravasated contrast-enhanced urine.
The highest attenuation hematoma (sentinel clot) is near the site of bleeding
and can help localize the source of hemoperitoneum.

Sedimented red blood cells can produce a dependent layer of high attenua-
tion within a hematoma within hours (hematocrit effect); this finding confirms
hemoperitoneum.
Typical sites of fluid accumulation include Morisons pouch (liver laceration), the
splenorenal fossa, and the dependent pelvis.
Fluid between loops of bowel (interloop fluid) is characteristically triangular-
shaped and centrally located. When interloop fluid is detected in the absence
of (or out of proportion to) intraperitoneal fluid in the more typical and acces-
sible locations, it is suggestive of bowel or mesenteric injury. Water-attenuation
interloop fluid suggests perforation; extraluminal oral contrast is more specific.
Intermediate-attenuation interloop fluid (2550 HU) represents mesenteric
hematoma.

Chapter 3 Torso 171
Free fluid in the absence of identifiable injury may not require surgical exploration.
In women of reproductive age, volumes of free fluid up to 50 mL in the pouch of
Douglas can be physiologic.
Initial survey with FAST protocol ultrasound can detect free fluid volumes
>200 mL but is insensitive for the detection of most solid organ injuries.
When unexplained intraperitoneal fluid of >100 mL is encountered, consider
occult bowel, bladder, and solid organ injuries. Diagnostic peritoneal lavage, CT
cystogram, and/or laparotomy should be considered in order to avoid missed
bowel or intraperitoneal bladder injuries.
A.
FIGURE 3.45. A. Intraperitoneal clot following blunt trauma. Focused abdominal sonogram
in trauma of the left upper quadrant performed in a 52-year-old woman who was assaulted.
There is acute clot (asterisk) between the left kidney (K) and spleen (S). (continued )

172 Chapter 3 Torso
B.
C.
FIGURE 3.45. (continued ) B. Axial contrast-enhanced venous phase CT of the upper abdo-
men shows multiple splenic lacerations (black arrows) associated with sentinel clots (white
arrows), which measure 60 to 65 HU. Extensive hemoperitoneum is present in the upper
abdomen (asterisk). C. Axial contrast-enhanced CT of the pelvis demonstrates the hemat-
ocrit effect, typical of hemoperitoneum. Clotted and cellular components of the blood layer-
ing dependently (white arrow) are more dense than the more anterior serum components
(black arrow).

Chapter 3 Torso 173
SUGGESTED READING
Drasin TE, Anderson SW, Asandra A, et al. MDCT evaluation of blunt abdominal trauma:
clinical significance of free intraperitoneal fluid in males with absence of identifiable
injury. Am J Roentgenol 2008;191:18211826.
Korner M, Krotz M, Degenhart C, et al. Current role of emergency US in patients with major
trauma. Radiographics 2008;28:225244.
Lubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum.
Radiographics 2007;27:109125.

174 Chapter 3 Torso
FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA (FAST)
KEY FACTS
FAST is an adjunct to the American College of Surgeons Advanced Trauma Life
Support (ATLS) primary survey. It follows the performance of the ABCs.
Rapid bedside ultrasound aims to identify intraperitoneal hemorrhage and peri-
cardial fluid, reducing time to the operating room
Ideally suited to the hemodynamically unstable blunt trauma patient and patients
with penetrating chest trauma
Should be performed in <2 minutes
Identifies >200 mL of free intraperitoneal fluid
Evidence of efficacy is limited by varying study design and inclusion criteria.
The sensitivity for hemoperitoneum varies from 69% to 99%.
A negative FAST does not exclude significant intra-abdominal injury.
FAST is unsuitable as an endpoint in the assessment of penetrating abdominal trauma.
Serial (or repeat) FAST, performed 30 minutes to 24 hours following the initial
scan, may increase accuracy, although other tests (e.g., CT) may be more suitable
for the hemodynamically stable patient.
The following views constitute the minimum for performance of a FAST scan:
Right upper quadrant (Morisons pouch)
Left upper quadrant (Perisplenic, splenorenal pouch)
Sagittal and coronal views of the pelvis to examine the pouch of Douglas or
retrovesical pouch
Pericardial view (usually subxiphoid, but also consider left and right paraster-
nal view, and apical views.)

Additional examination of the paracolic gutters, subdiaphragmatic spaces,
and between loops of bowel may increase yield.

Acute clotted blood is often echogenic and heterogeneous, especially in the pelvis.
If the bladder is empty except for a Foley catheter, consider refilling with either
the urine in the catheter bag or normal saline.
Signs of pericardial tamponade include a large pericardial effusion, right atrial
and/or right ventricular diastolic collapse, and a dilated IVC.
An extended FAST can be performed to include the pleural spaces to evaluate
for hemothorax and pneumothorax. To evaluate for a pneumothorax, place the
probe perpendicular to the ribs in the mid-clavicular line, covering the 2nd to 3rd
intercostal spaces. An echogenic pleural line represents the visceral and parietal
pleura. Normally, part of this echogenic line slides back and forth during respira-
tion (sliding lung.) M-mode can depict this (sea-shore sign). In the presence of a
large pneumothorax, the sliding lung sign is absent and M-mode does not depict
pleural movement. (stratosphere sign.)

Chapter 3 Torso 175
FIGURE 3.46. Subcostal oblique right upper quadrant sonogram in a young woman who
was involved in a high-speed motor vehicle crash. Fluid (white arrow) is present in Morisons
pouch, between the right kidney (K) and right lobe of the liver (L). Fluid also tracks around
the lower edge of the liver (white arrowhead). This latter sign, as well as the absence of
peristalsis, can be valuable in differentiating small quantities of intraperitoneal fluid from fluid
within the bowel.

176 Chapter 3 Torso
FIGURE 3.47. Midline sagittal sonogram of the pelvis in a 38-year-old man who tripped,
falling on a chair and injuring his spleen. Blood containing low level echoes (asterisk) is
present in the rectovesical pouch, superior and posterior to the bladder (B).

Chapter 3 Torso 177
FIGURE 3.48. Subxiphoid view of the pericardium in a woman who was stabbed several
times in the anterior chest. Fluid (asterisk) is present in the pericardial space, between the
right ventricle (RV) and left lobe of the liver (L). During diastole, there was collapse of the
RV and right atrium (RA), indicating pericardial tamponade. At surgery, a laceration of the RV
free wall was found and repaired. LV denotes a normal-sized left ventricle.
SUGGESTED READING
Gillman LM, Ball CG, Panebianco N, et al. Clinician performed resuscitative ultrasonogra-
phy for the initial evaluation and resuscitation of trauma. Scand J Trauma Resusc Emerg
Med 2009;17:34.

178 Chapter 3 Torso
EXTRAPERITONEAL FLUID IN TRAUMA
KEY FACTS
The retroperitoneum extends from the diaphragm to the pelvic inlet. It is
traditionally divided by the anterior and posterior renal fasciae into the poste-
rior pararenal space, the perirenal spaces, which contain the kidneys and adrenal
glands, and the anterior pararenal space, which contains the pancreas, the retro-
peritoneal segments of the duodenum and colon, and the root of the small bowel
mesentery. Inferior to the kidneys, there is essentially a single retroperitoneal
compartment, which is contiguous with the extraperitoneal (EP) pelvic spaces.
Anteriorly, the EP space includes the preperitoneal space, which lies between the
peritoneum and transversalis fascia.
The fasciae are variably fused and can be disrupted by trauma; therefore, EP fluid
collections may traverse fascial planes.
Focal fluid collections adjacent to a retroperitoneal segment of bowel may indi-
cate focal bowel injury, including perforation.
FIGURE 3.49. CT scan of retroperitoneal fluid. Young adult male who sustained a knife
wound to left flank. Oral, rectal, and intravenous contrast have been administered. There
is extraluminal contrast in the left retroperitoneal space indicating an EP colon laceration
(arrow). Note the horseshoe kidney.

Chapter 3 Torso 179
A. B.
FIGURE 3.50. A. Unexplained retroperitoneal fluid. A 39-year-old woman who was in a

motorcycle collision. Axial contrast-enhanced CT on the day of the injury. Unexplained retro-
peritoneal fluid is present surrounding the aorta (white arrow). The pancreas appeared grossly
normal. Injuries to the pancreas, duodenum, blood vessels, and pelvis should always be
considered potential causes of unexplained retroperitoneal fluid. B. Axial contrast-enhanced
CT 1 day later showing increased retroperitoneal fluid (black arrows), now surrounding the
body and tail of the pancreas (P). The patients pancreatic amylase was elevated. A few days
after admission, the pancreatic amylase returned to normal, and a follow-up CT demon-
strated no signs of pancreatic laceration and complete resolution of retroperitoneal fluid.
Retroperitoneal fluid without solid organ injury may be due to a major vascu-
lar injury involving the aorta, IVC, occult pancreatic injury, EP bladder injury, or
mesenteric root injury.
Retroperitoneal hemorrhage can be the source of significant but clinically occult
blood loss in the trauma patient. Blood can dissect upward into the abdominal
retroperitoneum from pelvic fractures and associated vascular injuries.
Zones of retroperitoneal hemorrhage have been described:
Zone I: midline area between diaphragmatic hiatus and sacral promontory
Zone II: flank or lateral retroperitoneum
Zone III: EP pelvis; most common location of hemorrhage
Low-attenuation (<20 HU) retroperitoneal fluid accumulation can be seen

in the absence of retroperitoneal injury and can be due to aggressive volume
resuscitation.
SUGGESTED READING
Daly KP, Ho CP, Persson DL, et al. Traumatic retroperitoneal injuries: review of multidetector
CT findings. Radiographics 2008;28:15711590.

180 Chapter 3 Torso
INTRAPERITONEAL AND RETROPERITONEAL GAS
KEY FACTS
Traumatic pneumoperitoneum and pneumoretroperitoneum can originate from
a perforated viscus, a penetrating wound, or peritoneal lavage.
Retroperitoneal and extraperitoneal (EP) gas can also originate from injuries to
the chest and neck, resulting in pneumothorax or pneumomediastinum. Gas
can travel from here to the subcutaneous, prevertebral, visceral, and previsceral
spaces in the abdomen (pseudopneumoperitoneum).
Extraluminal air is only present in about 50% of transmural bowel injuries
from blunt trauma. Free air in the setting of penetrating trauma is not specific
for bowel injury as it can occur at the time of peritoneal violation by the knife
or bullet, or can be due to a peritoneal defect that communicates with the
exterior.
A.
B.
FIGURE 3.51. Pseudopneumoperitoneum from chest trauma. A 39-year-old man, involved

in a high-speed motor vehicle collision with bruising on the chest and subcutaneous emphy-
sema. A. Axial contrast-enhanced CT of the upper abdomen, shown in lung windows.
Apparent free air in the upper abdomen (black arrow) lies anterior to the small bowel, but
does not go between bowel loops or mesenteric folds. There is gas tracking superficial and
deep to the anterior abdominal musculature (black arrowhead). B. Axial CT of the chest
demonstrates a right pneumothorax, communicating through the intercostal space with the
subcutaneous tissues (black arrowhead). In addition, there is florid pneumomediastinum
(black arrow). Gas can track between the mediastinum and extraperitoneal soft tissues into
the extraperitoneal spaces in the anterior abdominal wall, simulating pneumoperitoneum.

Chapter 3 Torso 181
A. B.
FIGURE 3.52. Pneumoperitoneum from colon injury in a 22-year-old man involved in a

high-speed motor vehicle collision. A. Axial contrast-enhanced CT of the abdomen shows
a bubble of intraperitoneal air beneath the right hemidiaphram (white arrow). In addition,
there is a large quantity of free fluid. B. Coronal reformation demonstrates thickening of
the wall of the ascending colon (white arrows) and a small quantity of localized EP air (black
arrowhead). A CT seat-belt sign in the subcutaneous fat (asterisk) is also present, a risk
factor for bowel and mesenteric injury.
CT is the most sensitive modality for detecting small quantities of free intraperi-
toneal gas. Look for it in the most nondependent portion of the peritoneal cavity
using wide (lung) windows, as well as around the site of suspected injury.
Nondependent intraperitoneal gas is nonspecific if the patient has had a peri-
toneal lavage or recent abdominal surgery. Gas trapped within the leaves of the
mesentery suggests bowel perforation in the acute setting and abscess formation
later.
A focal retroperitoneal gas collection near a retroperitoneal segment of bowel
(duodenum, ascending colon, descending colon, rectum) suggests a retroperito-
neal hollow viscus injury. Note that a gas-containing duodenal diverticulum can
simulate a solitary retroperitoneal gas bubble.
SUGGESTED READING
Daly KP, Ho CP, Persson DL, et al. Traumatic retroperitoneal injuries: review of multidetector
CT findings. Radiographics 2008;28:15711590.

182 Chapter 3 Torso
ACTIVE BLEEDING: FINDINGS ON CT SCAN
KEY FACTS
Contrast-enhanced CT scan is essential to depict active extravasation, which
indicates ongoing, potentially life-threatening, hemorrhage. This finding is asso-
ciated with failure of nonoperative management and predicts the need for emer-
gent embolization or surgical treatment, although small areas of active bleeding
are now commonly identified with MDCT.
In children, active bleeding is most often seen associated with solid organ injury,
particularly involving the spleen and liver. In adults, the branches of the iliac ves-
sels (associated with pelvic fractures) are the most frequent sites of active bleed-
ing; however, the spleen, liver, and kidney are also common sites.
The primary finding on CT scan is a jet or focal area of contrast-enhanced blood
within a hematoma. The attenuation of actively extravasating contrast-enhanced
blood usually ranges from 85 to 370 (mean 132) HU and is visually similar to
the attenuation within the aorta or adjacent arteries. On delayed CT images,
the focus of hyperattenuation may increase in size or fade into the enlarged,
enhanced hematoma.
Active bleeding must be differentiated from a pseudoaneurysm, which appears
as a round or oval focus of hyperattenuation with well-defined edges, sometimes
with a neck connecting to the affected vessel. Pseudoaneurysms do not enlarge
on delayed images.
The role of CT scan is to locate the bleeding vessel. This information guides the
initial surgical approach or selective angiographic embolization.
Indicators of shock and hypovolemia include the following:
IVC short-axis diameter <9 mm (intrahepatic IVC, and at the level of the renal
veins)
Small caliber, hyperdense aorta and mesenteric vessels
Persistent nephrogram without excretion
Dilated, fluid-filled loops of small bowel with hyperenhancing mucosa +/
circumferential wall thickening (target or double halo appearance)

Increased enhancement of the adrenal glands
Decreased enhancement of the spleen (relative to the liver)

Chapter 3 Torso 183
A. B.
FIGURE 3.53. A. Active bleeding from a right adrenal injury in a 52-year-old motorcyclist
who crashed into a bus. Axial venous phase contrast-enhanced CT scan shows extravascu-
lar contrast arising from the right adrenal gland (white arrow), which is of similar density to
the aorta. Surrounding hematoma is present. B. A 10-minute delayed phase axial CT scan
shows an increase in volume of extravascular contrast (white asterisk) in the right adrenal
bed, indicating rapid active bleeding.
A. B.
FIGURE 3.54. A. Axial CT scan with intravenous contrast in a 46-year-old man involved in
a motorcycle collision demonstrates a comminuted and displaced left sacral fracture with
active vascular extravasation arising from left internal iliac artery branches (black arrow).
B. Catheter angiogram of the pelvis shows active bleeding from the posterior division of the left
internal iliac artery (black arrow). This was successfully embolized using coils and Gelfoam.
SUGGESTED READING
Hamilton JD, Kumaravel M, Censullo ML, et al. Multidetector CT evaluation of active extrava-
sation in blunt abdominal and pelvis trauma patients. Radiographics 2008;28:16031616.
Lubner M, Demertzis J, Lee JY, et al. CT evaluation of shock viscera: a pictorial review. Emerg
Radiol 2008;15:111.

184 Chapter 3 Torso
LIVER INJURY: ACUTE
KEY FACTS
The liver is the second most frequently injured organ in blunt abdominal trauma
and the most commonly injured organ when blunt and penetrating trauma are
combined. Isolated injuries carry a low mortality (4%12%), but this increases
significantly when the liver injury is associated with multiple other injuries.
Right hepatic lobe injuries are associated with rib fractures, adrenal hematomas,
and lung and renal contusions, while left hepatic lobe injuries are associated with
pancreatic, duodenal, and colonic injuries.
Contrast-enhanced CT scan is the diagnostic modality of choice for the evalua-
tion of liver injuries in the hemodynamically stable patient.
The CT appearance of blunt liver trauma includes
Lacerations: irregular linear or branching low-attenuation areas. Lacerations
that extend to the bare area of the liver (posterosuperior region of segment
VII) may be associated with retroperitoneal hematomas around the IVC. Lac-
erations that extend to the porta hepatis are commonly associated with bile
duct injury.
Fractures: through-and-through parenchymal lacerations that may result in
avulsion of a portion of the liver

Hematomas: subcapsular (lentiform collections of low-attenuation blood
between the liver capsule and enhancing liver parenchyma, which cause
indentation or flattening of the underlying liver margin) or parenchymal
hematomas or contusions ( focal low- or high-attenuation areas with poorly
defined irregular margins)
Major hepatic venous injury: Suspect if liver lacerations or hematomas extend
into one or more major hepatic veins or the IVC. Surgical treatment may be
indicated.
Periportal low attenuation: Regions of low attenuation that parallel the portal
vein and its branches may represent dissection of hemorrhage into the peripor-
tal connective tissue. More commonly, they represent distention of periportal
lymphatic vessels due to elevated central venous pressure from vigorous
volume resuscitation, tension pneumothorax, or pericardial tamponade.

Chapter 3 Torso 185
CT findings usually underestimate injury severity.

Injury to the intrahepatic bile ducts should be considered in liver lacerations that
extend to the expected location of the intrahepatic bile ducts (which travel adja-
cent to the portal veins) and in grade IV and V liver injury. Bile duct injuries can
be evaluated with hepatobiliary iminodiacetic acid (HIDA) scans or endoscopic
retrograde cholangiopancreatography (ERCP). See the biliary injury section.
Artifacts on CT scans that can simulate a liver laceration include the following:
Streak artifact from air-fluid level or enteric tube in stomach
Beam hardening from ribs or patients arms
Focal fatty infiltration
Liver Injury Scale (1994 Revision)

Grade* Type of injury Description of injury
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapsular, 10%50% surface area; intraparenchy-
mal, <10 cm in diameter
Laceration Capsular tear 13 parenchymal depth, <10 cm in
length
III Hematoma Subcapsular, >50% surface area of ruptured subcap-
sular or parenchymal hematoma; intraparenchymal
hematoma >10 cm or expanding
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25%75% hepatic
lobe or 13 Couinauds segments
V Laceration Parenchymal disruption involving >75% of hepatic
lobe or >3 Couinauds segments within a single lobe
Vascular Juxtahepatic venous injuries; i.e., retrohepatic vena
cava/central major hepatic veins
VI Vascular Hepatic avulsion
*Advance one grade for multiple injuries up to grade III.

186 Chapter 3 Torso
FIGURE 3.55. Low attenuation within posterior subcapsular liver (white arrow ) consistent
with Grade II liver laceration.
FIGURE 3.56. Low attenuation laceration ( 13 cm in length) extending through the poste-
rolateral capsular margin (arrow) consistent with Grade II liver laceration.

Chapter 3 Torso 187
FIGURE 3.57. Laceration more than 3 cm in parenchymal depth involving the right posterior
lobe of the liver.

188 Chapter 3 Torso
A.
B.
FIGURE 3.58. A. Grade IV liver laceration with active extravasation from right hepatic artery
branch (arrows) and devascularization of large section of the right lobe of the liver. B. Image
obtained more inferiorly demonstrates bilobar extension of laceration into the left and right
lobes of the liver and extensive perihepatic hematoma. (continued )

Chapter 3 Torso 189
C.
FIGURE 3.58. (continued ) C. Angiogram showing massive extravasation from right hepatic
artery. This was successfully treated with coil embolization.
SUGGESTED READING
Trauma Source: The American Association for the Surgery of Trauma. http://aast.org/
library/traumatools/injuryscoringscales.aspx. Accessed February 5, 2011.

190 Chapter 3 Torso
LIVER INJURY: FOLLOW-UP AND NATURAL HISTORY
KEY FACTS
Nonsurgical management has become the standard of care in hemodynamically
stable patients with blunt liver trauma, regardless of grade of injury. Stab injuries
to the liver may also be managed nonoperatively, but nonoperative management
of gunshot wounds is controversial.
Grade IV and V injuries, significant contrast extravasation, or multiple solid
organ injuries predict failure of nonoperative management
Delayed complications occur in 5% to 23% of patients with nonsurgical manage-
ment of traumatic liver injury. These include
Delayed hemorrhage: most common complication often due to rupture of
pseudoaneurysm or expanding hematoma

Abscess: focal area of fluid attenuation with gas bubbles or air-fluid level
within the injured liver usually seen with grade IV or higher

Biloma and other biliary injuries: See case Biliary Injury, p. 192.
Hepatic artery pseudoaneurysm: round focal lesion with attenuation similar
to major arterial structures on early phase contrast-enhanced CT; generally

asymptomatic and found at follow-up CT; high risk of rupture; can form direct
fistula to duodenum or biliary system; treated with angiographic embolization.
Some have advocated routine use of arterial phase CT to evaluate for the pres-
ence of pseudoaneurysm when a liver injury is suspected.
Arteriovenous fistula: treated with angiographic embolization
Follow-up CT scan is generally unnecessary in asymptomatic patients with low-

grade injuries. Optimal time for follow-up CT in patients with high-grade injuries
is between 7 and 10 days postinjury.
Follow-up CT frequently demonstrates marked decrease in the size of paren-
chymal hematomas and lacerations. Subcapsular hematomas resolve in 6 to 8
weeks and lacerations in 3 weeks. Parenchymal homogeneity is restored in 4 to
8 weeks.
Most intraperitoneal fluid resorbs within 3 to 7 days. If the volume of fluid is
unchanged or has increased on a follow-up examination, continued bleeding or
bile leakage should be considered.
Discrete fluid collections such as bilomas and liquified hematomas can be fol-
lowed with ultrasound.

Chapter 3 Torso 191
A.
B.
FIGURE 3.59. An 18-year-old woman involved in a high speed motor vehicle collision. A.
Scan at arrival in the emergency department demonstrates a large laceration in the right
lobe of the liver (arrow). B. Follow-up CT due to persistent fevers performed one month later
demonstrates near complete resolution of the injury without biloma, pseudoaneurysm, or
collection (arrow). The follow-up CT was performed using a low radiation dose technique,
which accounts for the image noise.
SUGGESTED READING
Yoon W, Jeong YY, Kim JK, et al. CT in blunt liver trauma. Radiographics 2005;25:87104.
Franklin GA, Cass SR. Current advances in the surgical approach to abdominal trauma.
Injury 2006;37:11431156.

192 Chapter 3 Torso
BILIARY INJURY
KEY FACTS
Injury to biliary system that requires definitive treatment is relatively rare and is
usually associated with injuries to other organs.
Intrahepatic biliary injuries are caused by severe liver lacerations that disrupt
the biliary tree.

Extrahepatic biliary injuries typically occur at sites of anatomic fixation, such
as the intrapancreatic portion of the common bile duct.

Radionuclide biliary (HIDA) scan and endoscopic retrograde cholangiopancre-
atography (ERCP) are useful to show actively extravasating bile at the site of duct
disruption.
Complications due to biliary injuries are often found on follow-up CT and include
the following:
Bilomas: well-circumscribed, low-attenuation intraparenchymal or peri-
hepatic collections of bile outside of the biliary system. Most resolve spon-
taneously but may require treatment with percutaneous catheter drainage
+/ ERCP with stent placement if infected or causing pain or obstruction.
Bile peritonitis: persistent or increasing amount of low-attenuation free
fluid in the peritoneal cavity with associated peritoneal thickening and

enhancement
Hemobilia: communication between a vascular structure (usually hepatic
arterial branch) and the biliary tree

Bilhemia: leakage of bile into the systemic venous system
Jaundice: Enlarging subcapsular hematoma can exert a compressive effect on
central biliary ducts adequate to cause obstructive jaundice.

Gallbladder injuries:
Contusion: thickened gallbladder wall, intraluminal hemorrhage, perichole-
cystic fluid
Perforation: collapsed or nonvisualized gallbladder with adjacent perichole-
cystic fluid; requires cholecystectomy

Complete avulsion: hematoma in the gallbladder bed and hemoperitoneum
due to hemorrhage from the transected cystic artery, bile ascites

Chapter 3 Torso 193
A.
B.
FIGURE 3.60. A 44-year-old woman who was stabbed multiple times in the chest and sub-
sequently developed a biloma. A. Axial contrast-enhanced CT following emergent laparo-
tomy shows multiple hepatic lacerations in the right hepatic lobe (black arrows), some of
which pass close to the expected location of intrahepatic bile ducts. Laparotomy sponges (S)
were deliberately left to control hepatic bleeding. B. ERCP demonstrates a biliary injury with
contrast leakage from an anterior branch of the right hepatic duct (white arrow). A stent was
placed.(continued )

194 Chapter 3 Torso
C.
D.
FIGURE 3.60. (continued ) C. On a follow-up CT 3 weeks later, the laceration has organized,
and there is a clear fluid tract representing a biloma (black arrow). D. More cranial slices
through the liver demonstrate a large subcapsular biloma (asterisk) that tracked around the
liver (arrow). Gas in the biloma likely arises from the gastrointestinal tract via the biliary stent
and bile duct injury.

Chapter 3 Torso 195
SUGGESTED READING
Gupta A, Stuhlfaut JW, Fleming KW, et al. Blunt trauma of the pancreas and biliary tract:
a multimodality imaging approach to diagnosis. Radiographics 2004;24:13811395.
Yoon W, Jeong YY, Kim JK, et al. CT in blunt liver trauma. Radiographics 2005;25:87104.

196 Chapter 3 Torso
SPLENIC TRAUMA
KEY FACTS
The spleen is the most frequently injured abdominal organ in blunt abdominal
trauma.
Homogenous appearance of splenic parenchyma during portal venous phase
contrast-enhanced CT is optimal for detecting splenic injuries.
Lacerations and hematomas are lower attenuation than the unaffected
parenchyma.
The sentinel clot sign, in which the attenuation of hemoperitoneum is highest
adjacent to the injured organ, is a reliable predictor of splenic trauma.

Arterial phase and/or delayed imaging (510 minutes after the beginning of
the contrast bolus) is useful to differentiate parenchymal active extravasation

from contained vascular injury (pseudoaneurysm/arteriovenous (AV) fistula).
When pseudoaneurysms or AV fistulas are identified, consider splenectomy
or angioembolization.
Active extravasation: Hyperattenuating foci increase in size or are 10 HU
greater than that of aorta on the delayed images.

Contained vascular injury: Hyperattenuating foci decrease or remain stable in
size and are within 10 HU of the aorta on the delayed images.

Potential pitfalls in splenic injury evaluation:
Streak artifact from adjacent ribs, or arms if they are left at the patients side.
Heterogeneous enhancement on early contrast phase CT images may produce
a striped or tigroid appearance, which may simulate lacerations or contusions

for the novice, or make it more difficult to identify small traumatic lesions.
Diffusely hypodense spleen associated with hypovolemic shock
Congenital clefts; usually seen on the medial aspect; use multiplaner reforma-
tions to help differentiate from lacerations

Islands of perfused parenchyma in a shattered part of the spleen can simu-
late active vascular extravasation or pseudoaneurysms.

Delayed complications occur >48 hours after injury and include pseudocysts,
abscesses, pseudoaneurysms, and delayed splenic rupture.
Decision to operate or perform angioembolization is based on the patients
hemodynamic status rather than injury grade. There is a trend toward interven-
tion with increasing grade of injury and evidence of active bleeding.

Chapter 3 Torso 197
Spleen Injury Scale (1994 Revision)

I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapsular, 10%50% surface area;
intraparenchymal, <5 cm in diameter
Laceration Capsular tear 13 cm parenchymal depth that does
not involve a trabecular vessel
III Hematoma Subcapsular, >50% surface area or expanding;
ruptured subcapsular or parenchymal hematoma;
intraparenchymal hematoma 5 cm or expanding
Laceration >3 cm parenchymal depth or involving trabecular
vessels
IV Laceration Laceration involving segmental or hilar vessels pro-
ducing major devascularization (>25% of spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury with devascularizes spleen
*Advance one grade for multiple injuries up to grade III.

198 Chapter 3 Torso
A.
B.
FIGURE 3.61. A 24-year-old man involved in a dirt bike accident. A. Axial venous phase CT
demonstrates a fracture through the body of the spleen (white arrow). A large volume of
peritoneal blood is present, and there is clotted blood in the left upper quadrant. On the
coronal reformation (B), the fracture is shown to extend into the splenic hilum, and there is
arterial extravasation of contrast, indicating active bleeding. (continued )

Chapter 3 Torso 199
C.
FIGURE 3.61. (continued ) Five-minute delayed axial CT (C) demonstrates a large volume of
accumulated extravascular contrast (asterisk). The patient went for immediate splenectomy.
SUGGESTED READING
Anderson SW, Varghese JC, Lucey BC, et al. Blunt splenic trauma: delayed-phase CT for dif-
ferentiation of active hemorrhage from contained vascular injury in patients. Radiology
2007;243(1):8895.
Franklin GA, Cass SR. Current advances in the surgical approach to abdominal trauma.
Injury 2006;37:11431156.
Lynn KN, Werder GM, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive
review. Pediatr Radiol 2009;39:904916.
Trauma Source: The American Association for the Surgery of Trauma, http://aast.org/

200 Chapter 3 Torso
SOLID ORGAN INJURY: INDICATIONS FOR ANGIOGRAPHY
KEY FACTS
The standard of care for patients with abdominal injury and hemodynamic
instability remains exploratory laparotomy in many hospitals across the country.
However, hemodynamically stable patients are frequently managed nonopera-
tively or endovascularly.
Further, endovascular management in selected unstable patients is becoming
more common in centers where these techniques are readily available.
Splenic Injuries
The spleen is the most commonly injured organ in blunt abdominal trauma.
Surgical intervention may be indicated in the setting of parenchymal destruction
and injury to hilar vessels, or an injury involving multiple vessels.
Nonoperative management has become the standard of care in hemodynam-
cially stable patients with splenic injuries in order to preserve immunological
and hematological function.
Although there are no strict guidelines to select patients for angiography and/or
embolization, common indications demonstrated on CT include active bleeding
or contrast blush (seen in 13%17% of patients), pseudoaneurysm, high-grade
injury, or hemoperitoneum. These findings serve as an adjunct to the patients
clinical status.
Liver Injuries
The liver is the second most commonly injured abdominal organ following blunt
trauma, and frequently occurs in association with splenic injury.
The management of liver injuries is most frequently nonoperative, as most liver
injuries heal effectively without the need for intervention, particularly those in
hemodynamically stable patients.
Angiography is indicated with signs of active extravasation/contrast blush on CT
(seen in only 9% of patients with liver injuries) or as an adjunct to surgery for
hemostasis following urgent laparotomy (damage control/liver packing).
Embolization of the liver is typically well-tolerated secondary to the livers dual
blood supply and is generally performed with Gelfoam embolization of the
hepatic artery. Large or transected hepatic artery branches can also be treated
with coils in addition to Gelfoam if subselective catheterization is possible.
Renal Injuries
Most renal injuries occur in combination with other solid organ injuries.
Most are minor and, in the absence of hemodynamic instability, will heal spon-
taneously.

Chapter 3 Torso 201
Surgical indications may include hemodynamic instability, avulsion of the renal

pelvis, or injury to the vascular hilum.
Embolization can be performed in select patients, which often helps preserve as
much renal function as possible.
Angiographic indications include CT findings of renal artery dissection, pseudo-
aneurysm, high-grade injury with disruption of Gerotas fascia, and active hemor-
rhage typically not involving the vascular hilum.
A.
FIGURE 3.62. A. Axial CT image through the upper abdomen demonstrating active arte-
rial extravasation of contrast within the liver (white arrow), indicating arterial injury. Exten-
sive packing material is present around the liver from prior exploratory laparotomy to control
bleeding. (continued )

202 Chapter 3 Torso
B.
FIGURE 3.62. (continued ) B. Digital subtraction image demonstrating selective catheter-

ization of the right hepatic artery. Extravasation of contrast consistent with active bleeding
from a superior branch of the right hepatic artery is demonstrated. The patient underwent
embolization for hemostasis.

Chapter 3 Torso 203
SUGGESTED READING
Fu CY, Wu SC, Chen RJ, et al. Evaluation of need for angioembolization in blunt renal injury:
discontinuity of Gerotas fascia has an increased probability of requiring angioemboliza-
tion. Am J Surg 2010;199(2):154159.
Wallis A, Kelly MD, Jones L. Angiography and embolisation for solid organ abdominal injury
in adultsa current perspective. World J Emerg Surg 2010;5:18.
Zealley IA, Chakraverty S. The role of interventional radiology in trauma. Br Med J
2010;340:c497.

204 Chapter 3 Torso
PANCREATIC INJURY
KEY FACTS
Less than 2% of abdominal injuries involve the pancreas.
A blow to the epigastrium is the usual etiology: steering wheels in adults, handle-
bars in children, and child abuse in infants.
Coexisting injuries are seen in 50% to 98%, often the liver.
The most common site of pancreatic laceration is the pancreatic body (>65%).
Injury to the pancreatic duct and delay in diagnosis result in increased morbid-
ity and mortality. Complications after pancreatic injury range from 30% to 60%
often due to delayed or missed diagnosis.
Serum amylase may initially be normal in up to 40% of patients with pancreatic
injury.
Evidence suggests that the sensitivity of MDCT for pancreatic injury is subop-
timal, possibly as low as 47%. CT may be normal in the first 12 hours following
injury. If the clinical suspicion for pancreatic injury remains high, a repeat CT
scan may be warranted. MRI and MRCP are other imaging alternatives that may
be more practical for follow-up imaging than they would be for initial imaging.
CT scan findings include the following:
Linear low attenuation area (laceration or transection)
Pancreatic enlargement or inhomogeneity indicating edema or hematoma
Peripancreatic fat stranding or fluid
Lesser sac fluid
Fluid or hematoma between pancreas and splenic vein
Extensive parenchymal hypoperfusion in complete disruption
CT curved planar reformations and minimal intensity projections are useful
to evaluate the pancreatic duct.

Laceration of greater than one half the parenchymal diameter suggests ductal
injury.
Magnetic resonance cholangiopancreatography, endoscopic retrograde cho-
langiopancreatography, or intraoperative pancreatography may be used to

establish pancreatic duct integrity.
Complications of pancreatic trauma include pancreatitis, pseudocysts, and
fistulae.

Chapter 3 Torso 205
A.
B.
FIGURE 3.63. 7-year-old girl involved in a bike accident. Axial (A) and coronal (B) contrast-
enhanced CT images demonstrate linear low-density transection of the pancreatic neck
(arrows) with adjacent peripancreatic hemorrhage.
SUGGESTED READING
Linsenmaier U, Wirth S, Reiser M, et al. Diagnosis and classification of pancreatic and duo-
denal injuries in emergency radiology. Radiographics 2008;28(6):15911602.
Rekhi S, Anderson SW, Rhea JT, et al. Pictorial essay: imaging of blunt pancreatic trauma.
Emerg Radiol 2010;17(1):1319.

206 Chapter 3 Torso
GASTROINTESTINAL AND MESENTERIC INJURY
KEY FACTS
Gastrointestinal perforation is a surgical emergency. Bowel wall contusions can
cause paralytic ileus, while hematomas can cause obstruction.
Mesenteric vascular injuries can cause segmental bowel ischemia or infarction.
Large mesenteric tears can result in internal hernias.
Patterns of bowel injury include the following:
Injuries to the small bowel, colon, and stomach are relatively common in pen-
etrating trauma.
Hollow viscus injuries are less common in blunt trauma and usually involve
the small bowel, less frequently colon and stomach.

In blunt trauma, small bowel injuries tend to occur near points of attachment:
the ligament of Treitz and the ileocecal valve.

CT scan signs of intestinal or mesenteric injury:
Extraluminal oral contrast (most specific sign)
Intraperitoneal or extraperitoneal gas without other source to explain its
presence
Focal bowel wall thickening and/or enhancement
Bowel wall discontinuity
Triangular-shaped interloop fluid in the mesentery
Focal dense mesenteric hematoma
Substantial free intraperitoneal fluid without visible solid organ injury
Mesenteric vascular pseudoaneurysms or active bleeding
Abrupt termination of mesenteric vessels

Chapter 3 Torso 207
A.
B.
FIGURE 3.64. A 26-year-old man involved in a motor vehicle collision. Axial contrast-en-
hanced CT (A) demonstrates focal hematoma (horizontal white arrow) in the small bowel
mesentery with small area of active extravasation (arrow head). There is abnormal wall
thickening of the ascending colon (black arrow) with pericolonic hemorrhage from a trans-
mural colonic transection. A traumatic lumbar hernia is seen (long arrows on left side of
image) containing loops of abnormally thickened small bowel injury. B. Coronal contrast-
enhanced CT also demonstrates the lumbar hernia.

208 Chapter 3 Torso
FIGURE 3.65. A 48-year-old man involved in a motorcycle crash. Axial contrast-enhanced

CT demonstrates free intraperitoneal gas (arrow) with mesenteric hemorrhage surrounding
a focally thickened loop of jejunum with focal wall discontinuity consistent with a traumatic
jejunal perforation.

Chapter 3 Torso 209
SUGGESTED READING
Atri M, Hanson JM, Grinblat L, et al. Surgically important bowel and/or mesenteric injury
in blunt trauma: accuracy of multidetector CT for evaluation. Radiology 2008;249:
524533.
Brofman N, Atri M, Hanson JM, et al. Evaluation of bowel and mesenteric blunt trauma with
multidetector CT. RadioGraphics 2006;26:1119 1131.
Lubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum.
Radiographics 2007;27(1):109125.

210 Chapter 3 Torso
DUODENAL INJURY
KEY FACTS
Duodenal perforation is a surgical emergency. Diagnostic delay results in
increased morbidity and mortality. Duodenal hematoma, without perforation,
can be treated conservatively.
A blow to the epigastrium is the usual etiology: steering wheels in adults, handle-
bars in children, and child abuse in infants. Penetrating trauma may also cause
duodenal injury.
Associated pancreatic injuries are common.
CT scan is the imaging modality of choice in blunt duodenal injury; CT can
sometimes distinguish duodenal perforation from an isolated duodenal
hematoma.
CT scan findings of retroperitoneal duodenal injury:
Focal paraduodenal fluid in the absence of diffuse retroperitoneal fluid
Retroperitoneal gas near the duodenum (indicates perforation)
Lack of duodenal wall continuity
Intramural gas (may be seen with duodenal contusion and hematoma)
Focal duodenal wall thickening (>4 mm) (suggests intramural hematoma)
Heterogeneous attenuation of duodenal wall
Causes for a false-positive CT scan include the following:

Unopacified bowel loops adjacent to duodenum
Retroperitoneal hematoma from nonduodenal source
Duodenal diverticulum simulating retroperitoneal air
FIGURE 3.66. A 26-year-old woman involved in a motor vehicle collision. Contrast-enhanced

CT demonstrates focal discontinuity of the duodenal wall (arrow ) with periduodenal hem-
orrhage extending medially between the splenic vein and pancreas. Low density of the
pancreatic head indicates pancreatic contusion. Hemoperitoneum identified in Morisons
pouch secondary to liver laceration (not shown).

Chapter 3 Torso 211
FIGURE 3.67. Duodenal perforation axial triple contrast (oral, rectal and intravenous) CT
scan in a 23-year-old male who was stabbed in the right flank shows extraluminal gas
in the extraperitoneal space beside the second portion of the duodenum (white arrow).
Extraluminal oral contrast is present in the right anterior pararenal space (black asterisk). An
ascending colon laceration was also identified at surgery.
SUGGESTED READING
Linsenmaier U, Wirth S, Reiser M, et al. Diagnosis and classification of pancreatic and duo-
denal injuries in emergency radiology. Radiographics 2008;28(6):15911602.
Velmahos GC, Tabbara M, Gross R, et al. Blunt pancreatoduodenal injury: a multicenter
study of the Research Consortium of New England Centers for Trauma (ReCONECT).
Arch Surg 2009;144(5):413419; discussion 419420.

212 Chapter 3 Torso
COLORECTAL INJURY
KEY FACTS
Colorectal injury occurs in 1% to 5% of patients with blunt abdominal trauma
and is the second most commonly injured organ in gunshot wounds.
Rectal injuries occur in penetrating trauma and with blunt pelvic trauma asso-
ciated with fractures. Intraperitoneal and extraperitoneal sites of injury require
different surgical approaches.
The anterior and lateral walls of the upper two thirds of the rectum are con-
sidered intraperitoneal.
The posterior upper two thirds and the cirumferential lower one third of the
rectum are considered extraperitoneal.

With penetrating injury, always consider performing the CT scan with IV, oral,
and rectal contrast (triple contrast).
Direct CT findings of colorectal injury:
Focal wall discontinuity
Extravasation of oral contrast
Free intraperitoneal gas
Free extraperitoneal gas: Ascending and descending colon and rectum are
covered by peritoneum only along their anterior surfaces.

Indirect CT findings of colorectal injury:
Focal or abnormal bowel wall thickening or enhancement
Stranding of adjacent mesentery or mesocolon
Extraperitoneal and free intraperitoneal fluid
FIGURE 3.68. A 72-year-old man involved in a motor vehicle collision. Axial contrast-
enhanced CT demonstrated a focal hematoma in cecal wall involving the ileocecal valve
region (arrow).

Chapter 3 Torso 213
FIGURE 3.69. A 48-year-old woman sustaining a 40-foot fall. Axial contrast-enhanced CT

demonstrates focal wall thickening (arrow) of the ascending colon with small focus of extra-
peritoneal gas (arrowhead) and pericolonic extraperitoneal hematoma.
SUGGESTED READING
Bondia JM, Anderson SW, Rhea JT, Soto JA. Imaging colorectal trauma using 64-MDCT tech-
nology. Emerg Radiol 2009 Nov;16(6):43340.

214 Chapter 3 Torso
ADRENAL HEMORRHAGE
KEY FACTS
Adrenal hemorrhage from blunt trauma is usually unilateral occurring on the
right side twice as often as the left. Right-sided hemorrhage may be more com-
mon because of elevated venous pressures in a shorter adrenal vein propagated
from the adjacent IVC or from liver compression.
Adrenal hemorrhage is a marker of high energy injury. Additional injuries occur
in 96% of patients.
Proposed mechanisms of injury include direct crush, vascular shear injury, acute
increased venous pressure transmitted from a compressed IVC, and IVC/adrenal
vein thrombosis.
Adrenal hemorrhage is usually unilateral and of little clinical significance. Bilat-
eral hemorrhage can result in acute adrenal insufficiency.
CT findings of adrenal injury:
Focal hematoma causing expansion or distortion
Indistinct margins or enlargement with maintenance of adreniform shape
Hyperattenuating mass: typically 2 to 4 cm with average attenuation of
55 HU
Periadrenal fat stranding
Frank adrenal hemorrhage
Retroperitoneal hemorrhage
Differential diagnosis for adrenal mass also includes adenoma, carcinoma,
metastasis, pheochromocytoma, granulomatous disease.

Adrenal hematomas: nonenhancing; resolution within weeks to months and
may calcify
Adenomas: less than 4 cm, hypoattenuating (<10 HU on non-contrast CT) with
>50% washout on 10 minute delays. No associated stranding

Chapter 3 Torso 215
FIGURE 3.70. A 34-year-old man involved in a motor vehicle collision. Focal enlargement
of the left adrenal gland with a small amount of periadrenal fat stranding indicates adrenal
hemorrhage. Follow-up CT scan revealed resolution of the hematoma.
SUGGESTED READING
Choyke PL; ACR Committee on Appropriateness Criteria. ACR Appropriateness Criteria on
incidentally discovered adrenal mass. J Am Coll Radiol 2006 Jul;3(7):498504.
Sinelnikov AO, Abujudeh HH, Chan D, Novelline RA. CT manifestations of adrenal trauma:
experience with 73 cases. Emerg Radiol 2007 Mar;13(6):3138. Epub 2007 Jan 25.

216 Chapter 3 Torso
RENAL INJURIES
KEY FACTS
A surgical grading system for renal injuries was developed by the Organ Injury
Scaling (OIS) Committee of the American Association for the Surgery of Trauma
(AAST). This was developed by and for surgeons, prior to the widespread use of
CT, and reflects findings the surgeons may identify during exploration.
The injury grade is defined by the highest grade injury encountered.
Several different injuries can result in the same grade of injury; thus, a Grade I
injury may be due to a contusion or a subcapsular hematoma, or both.
Kidney Injury Scale

I Contusion Microscopic or gross hematuria, urologic studies
normal
Hematoma Subcapsular, nonexpanding without parenchymal
laceration
II Hematoma Nonexpanding perirenal hematoma confined to
renal retroperitoneum
Laceration <1 cm parenchymal depth of renal cortex without
urinary extravasation
III Laceration >1 cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through renal
cortex, medulla, and collecting system
Vascular Main renal artery or vein injury with contained
hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that devascularizes kidney
*Advance one grade for bilateral injuries up to grade III.
These recommendations are not consistently followed by many surgeons and radi-
ologists, resulting in some confusion regarding the final injury grade reported.
CT grading systems have also been proposed for renal injuries, and these describe
injuries not included in the AAST system. However, these systems are not cur-
rently used by many surgeons.
Thus the AAST scale for renal trauma identifies the following injuries:
Contusion
Subcapsular and perinephric hematoma

Chapter 3 Torso 217
Lacerations, with or without urinary extravasation

Main renal artery or vein injury with contained hemorrhage
Shattered kidney
Avulsed renal hilum with devascularized kidney
But it does not fully identify or unambiguously grade the following injuries:
Active extravasation (not resulting from renal hilum avulsion)
Pseudoaneurysm and arteriovenous fistula
Main renal artery or segmental artery occlusion, resulting in complete or seg-
mental infarction
Ureteropelvic junction (UPJ) avulsion
Expanding hematoma
More than 90% of renal injuries secondary to blunt trauma are minor injuries
(grade I or II).
Kidneys with preexisting abnormalities are at increased risk for injury, some-
times from minor trauma, and present more commonly in children.
Examples include UPJ obstruction, hydronephrosis, cyst, tumor, ectopic kidney,
horseshoe kidney, and fragile infected kidney.
FIGURE 3.71. Superficial renal laceration (Grade II injury). CT shows posterior, wedge-
shaped defect (arrow) associated with small, localized perinephric hematoma.

218 Chapter 3 Torso
A.
B.
FIGURE 3.72. Renal laceration with large subcapsular hematoma and perinephric hema-
toma. A. Long arrow demonstrates anterior renal laceration. Short arrow demonstrates
streaky perinephric hematoma, which is differentiated from confined subcapsular hema-
toma (*) with smooth borders and parenchymal compression. B. Subcapsular hematoma
demonstrates smooth borders (arrows) without the streaky appearance of perinephric
hematoma. More medially, it is closely apposed to the renal parenchyma.

Chapter 3 Torso 219
SUGGESTED READING
Alonso RC, Nacenta SB, Martinez PD, et al. Kidney in danger: CT findings of blunt and pen-
etrating renal trauma. Radiographics 2009;29:20332053.
Federle MP. Evaluation of renal trauma. In: Pollack HM, ed. Clinical Urography: An Atlas and
Textbook of Urological Imaging. Philadelphia, PA: WB Saunders, 1990:14721494.
Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review.
Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. Surg Clin North Am
1995;75:293303.
Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney.
J Trauma 1989;29:16641666.

220 Chapter 3 Torso
RENAL INJURIES: IMAGING
KEY FACTS
Radiographs and ultrasound are unreliable in identifying renal injuries.
MRI cannot typically be obtained rapidly and safely in acutely injured patients
and is usually reserved for follow-up imaging or problem solving.
The one-shot IVU is rarely used today in our institution and is reserved for
hemodynamically unstable patients who are being rushed to surgery.
Intravenous contrast-enhanced MDCT is the most reliable and accurate method
for rapidly imaging patients following trauma.
Although criteria exist for determining when to image patients for renal trauma
(gross hematuria; microhematuria and an episode of hypotension; etc), our
patients are (almost) always imaged as part of their abdominal and pelvic evalu-
ation, and these criteria are rarely, if ever, applied.
Our standard trauma CT of the abdomen and pelvis includes optional delayed
images to evaluate for urinary extravasation, and thus no dedicated renal trauma
CT protocol is necessary, simplifying patient management.
While some institutions propose arterial phase imaging as part of their routine
workup, we believe that the extra radiation dose incurred with this additional
phase of imaging is not appropriate for most patients. We perform a single scan
through the abdomen and pelvis during the portal venous (parenchymal) phase
of contrast enhancement, which allows evaluation of the parenchyma and vas-
culature. In very rare circumstances, absence of the arterial phase may require
further imaging to clarify abnormal but indeterminate findings, but this conser-
vative approach to imaging reduces the radiation burden for the vast majority of
patients imaged.
CT findings of renal injuries:
Contusion: focal region(s) of decreased enhancement on parenchymal phase,
which may demonstrate increased enhancement or staining on delayed

images. Borders are usually indistinct, in contrast to the sharper borders of
segmental infarctions.
Acute subcapsular hematoma: blood between the renal parenchyma and
capsule. Small hematomas are usually crescentic, but larger hematomas may
be biconvex. On noncontrast CT, the acute hematoma may have higher attenu-
ation than renal parenchyma, but on enhanced imaging, they are hypoattenu-
ating compared with normal enhancing renal parenchyma. Small subcapsular
hematomas may be difficult to differentiate from perinephric hematomas, but
flattening of the underlying renal parenchyma helps make the diagnosis of
subcapsular hematoma.
Perinephric hematoma: blood within the perinephric space. Unless large, this
does not compress or flatten the renal parenchyma. Typically, it is less well-
defined and more diffuse and streaky than subcapsular hematoma.

Chapter 3 Torso 221
Superficial laceration: small linear or wedge-shaped cortical defect, most

reliably seen on the parenchymal phase. It may be missed on noncon-
trast images. It often has associated perinephric or subcapsular hematoma
(Fig. 3.72). Note that the American Association for the Surgery of Trauma
(AAST) classification grades the injury by the depth from the parenchymal
surface, not by the length of the laceration. Superficial lacerations are <1cm
deep.
Deep laceration: usually associated with moderate or large perinephric hema-
toma. Collecting system intact. >1 cm deep.
Deep laceration with tear of collecting system: Collecting system injuries with
extravasation of urine are the most common form of Grade IV injuries. Refer
to following sections for more details.
Shattered kidney: multiple deep lacerations. Fragments of kidney may be
mildly or significantly displaced by interposed hemorrhage and/or urine.
Some or all fragments may remain perfused and enhance (near) normally,
while other fragments may be infarcted. On parenchymal phase images, it
may be difficult to differentiate perfused parenchyma from vascular extrava-
sation, and delayed images may be necessary for clarification.
Segmental ( focal) infarction: Segmental infarctions are imaged as focal, geo-
graphic, sharply marginated wedge-shaped defects on the parenchymal phase,
without increased enhancement (staining) on delayed images.
Total renal infarction: usually caused by dissection/thrombosis of main renal
artery. Complete renal infarctions demonstrate absence of renal enhancement
initially. A cortical rim sign may be present, typically days to weeks after the
injury, due to collateral supply from capsular arteries.
Ureteropelvic junction (UPJ) avulsion: usually in children. Identified by absence
of contrast-enhanced urine in the ureter distal to the UPJ, and large amount of
extravasated contrast around the region of the UPJ on delayed scans.
Avulsed renal hilum with devascularized kidney: Much less common cause
of total renal infarction than dissection. Kidney demonstrates appearance of
total renal infarction, and large hematoma is often present in the region of the
main renal artery, possibly with evidence of active vascular extravasation.
Pseudoaneurysm: typically oval or round structure demonstrating similar
enhancement to adjacent arteries.
Areteriovenous fistula: abnormal enhancement due to abnormal connec-
tion between a renal artery and vein. It may be difficult to differentiate from
pseudoaneurysm on CT, and may require catheter angiography to demon-
strate early filling of venous structures.
Active vascular extravasation: high-density material external to the vascu-
lature, of higher density than nonenhancing hematoma. Small amounts of
extravasation may require delayed imaging to demonstrate accumulation and
spread of high-density material beyond the normal vessels.

222 Chapter 3 Torso
A.
B.
FIGURE 3.73. Segmental infarction. Large segmental infarction of the right kidney is dem-
onstrated between the arrows on the axial (A) and coronal (B) images.

Chapter 3 Torso 223
A.
B.
FIGURE 3.74. Left renal pseudoaneurysm. A. Portal venous phase images demonstrate an
oval structure (arrow) with similar density to nearby vessels and the aorta (asterisk). This
could represent active extravasation or pseudoaneurysm. B. Delayed phase images demon-
strate that the high density contrast previously noted in this lesion (arrow) is no longer pres-
ent, as would be expected with extravasation. Instead it has washed out, demonstrating
that the lesion is a pseudoaneurysm, which continues to demonstrate similar density to
the aorta (asterisk).

224 Chapter 3 Torso
A.
B.
FIGURE 3.75. Shattered right kidney (Grade V injury) with active bleeding. A. Vascular phase
CT shows enhancing fractured parenchyma; large perinephric, paranephric, and central ret-
roperitoneal hemorrhage; and several sites of extravasation of contrast material (arrows)
from lacerated blood vessels. The vena cava is compressed by the hematoma. B. Delayed
CT scan at 8 minutes, same level as in (A). Extravasated contrast has now mixed with
hematoma in the perinephric, paranephric, and central retroperitoneal spaces. Excreted
contrast opacifies portions of the right collecting system and proximal ureter.

Chapter 3 Torso 225
SUGGESTED READING
Alonso RC, Nacenta SB, Martinez PD, et al. Kidney in danger: CT findings of blunt and pen-
etrating renal trauma. Radiographics 2009;29:20332053.
Trauma Source: The American Association for the Surgery of Trauma, http://aast.org/

226 Chapter 3 Torso
RENAL INJURIES: CLINICAL MANAGEMENT ISSUES
KEY FACTS
In the past, renal exploration often led to nephrectomy. Yet, most blunt renal inju-
ries do not require surgery and can be treated conservatively. Identification and
characterization of renal injuries with MDCT assist in the appropriate selection
of patients for conservative treatment, resulting in improved outcomes. Even
severe injuries such as shattered kidneys may be managed nonoperatively in the
appropriate clinical context.
Absolute indications for surgical exploration include life-threatening hemorrhage
and hemodynamic instability, expanding uncontained retroperitoneal hematoma
(usually due to avulsion of the renal pedicle), and uretropelvic junction avulsion.
Relative indications for surgical exploration include large areas of infarcted renal
parenchyma with concurrent bowel or pancreatic injuries, urinary extrava-
sation not successfully treated with conservative management, and arterial
thrombosis.
Traumatic thrombosis of the main renal artery results in progressive irreversible
loss of function starting only 2 to 3 hours following injury. If surgical repair is
attempted, it should be performed within 4 hours of injury, but even within this
short window of opportunity, less than one third of kidneys return to normal
function. However, if the injured kidney is the patients only kidney (or primary
functioning kidney), more aggressive measures may be taken to preserve renal
function, including surgery beyond the usual 4-hour window.
Better results are obtained with surgical repair of isolated renal vein injury.
An unusual complication is a Page kidney in which chronic subcapsular hema-
toma causes decreased renal perfusion and increased renin production, leading
to refractory hypertension.

Chapter 3 Torso 227
A.
B.
FIGURE 3.76. Traumatic occlusion of right renal artery causing total infarction. A. Contrast-
enhanced CT scan within hours of injury shows absent parenchymal enhancement except
for backflow of contrast-laden blood from vena cava into central renal veins. There is no cor-
tical rim sign. Well-defined wedge-shaped region of diminished nephrogram in left kidney
represents parenchymal ischemia, but not infarction, as there is enhancement of this region
when compared with the right kidney. Findings are suggestive of decreased perfusion to
this region, likely due to partial occlusion or compression of a segmental artery. B. Repeat
scan at 1 week shows well-developed cortical rim sign in right kidney reflecting collateral
capsular arterial supply. Central parenchymal enhancement reflects peripelvic collateral
blood supply. No change in left kidney region of ischemia.
SUGGESTED READING
Alonso RC, Nacenta SB, Martinez PD, et al. Kidney in danger: CT findings of blunt and
penetrating renal trauma. Radiographics 2009;29:20332053.
Malmed AS, Love L, Jeffrey RB. Medullary CT enhancement in acute renal artery occlusion.
J Comput Assist Tomogr 1992;16:107109.

228 Chapter 3 Torso
RENAL LACERATION WITH URINARY EXTRAVASATION
KEY FACTS
Evidence of injury to the collecting system should be sought whenever unex-
plained perinephric fluid is identified, especially when associated with a renal
laceration. Minimal amounts of bilaterally symmetric perinephric stranding, as
is often seen in older patients, does not usually require additional evaluation for
urinary extravasation.
On the parenchymal phase scan, perinephric or periureteral fluid may repre-
sent hematoma and/or urinoma. To exclude a urinoma, delayed phase imaging
is necessary, to allow concentration of contrast by the kidneys and excretion
into the collecting system. If the collecting system injury is still patent at the
time of exam, and if contrast-enhanced urine passes by the injury, high-density
contrast-containing urine will leak through the defect and be evident on CT
images. Most clinically significant collecting system disruptions are identified
with these delayed images. Although many institutions obtain delayed images
at 5 minutes (or even 3 minutes) after contrast injection, we usually delay for
10 minutes, to increase the amount of contrast excreted and passed beyond the
site of injury (especially for distal ureteral injuries).
If the injured kidney does not excrete contrast (e.g., because of total infarction),
collecting system or ureteral injury cannot be diagnosed on CT.
Extravasation of urine from a lacerated kidney is not a surgical emergency. The
majority of renal lacerations that extend into the collecting system and cause
extravasation can be managed without surgery. Collecting system tears usually
heal provided that the path of least resistance for urine is down the ureter.
Obstruction of the ureter by blood clot may cause absence of ureteral visual-
ization on CT and promote urine extravasation through a deep parenchymal
laceration. When this is discovered, retrograde ureteropyelography can be per-
formed to assess the integrity of the ureter and ureteropelvic junction.
Potential complications of nonsurgical management of renal laceration with
extravasation:
Urinoma: A persistent urine leak with an enlarging urinoma requires either
ureteral stenting or surgical repair.

Infection: An injured kidney or urinoma is more likely to develop an infection
in immunocompromised patients, and those with bowel injury or sepsis.

Chapter 3 Torso 229
FIGURE 3.77. Grade IV renal lacera-

tion. (A) CT performed at outside
hospital demonstrates deep lac-
eration through the mid left kidney
(bordered by arrows) as well as
splenic lacerations. Adjacent peri-
nephric hematoma (asterisk) is also
present. No delayed images were
obtained, so urinary extravasation
could not be ruled out on this study.
Axial (B) and coronal (C) images
from the follow-up study performed
2 days later (following patient trans-
fer) demonstrate urinary extrava-
sation through the deep renal
lacerations, demonstrating the
importance of delayed images in
A. evaluating perinephric fluid.
B.
C.
SUGGESTED READING
Alonso RC, Nacenta SB, Martinez PD, Guerrero AS, Fuentes CG. Kidney in danger: CT find-
ings of blunt and penetrating renal trauma. Radiographics 2009;29:20332053.

230 Chapter 3 Torso
URETERAL INJURIES
KEY FACTS
Ureteral injuries are rare, accounting for <1% of traumatic genitourinary
injuries.
Twenty percent of ureteral injuries are caused by (external violent) trauma, while
eighty percent occur intraoperatively.
Most noniatrogenic ureteral injuries are from penetrating trauma and are often
associated with injuries to solid organs, major blood vessels, and bowel.
Common causes of traumatic injury: gunshot wounds (81%), stab wounds (9%),
blunt trauma (10%)
The ureter is fixed at two points along its retroperitoneal course, the ureteropelvic
junction (UPJ) and ureterovesical junction (UVJ), making it susceptible for injury
at these sites following blunt trauma.
UPJ avulsion is more common in children than adults.
Imaging protocol
Urine leaking through a ureteral laceration will result in fluid around the ureter,
and delayed images should be obtained through the region of concern.
Thicker images with decreased radiation exposure are obtained to minimize
patients radiation dose.
Although these images may be noisier than images obtained during the paren-
chymal phase, they are adequate to identify extravasation of high-density
contrast.
Despite a common misconception, the trauma abdomen and pelvis along with
these additional images do not constitute a CT-IVP, which is a higher radiation
dose study performed with thinner section images to evaluate for genitourinary
tumors. The study to evaluate for ureteral trauma should not be ordered, proto-
colled, or performed as a CT-IVP.
High-density material adjacent to ureter on delayed images usually represents

extravasated contrast-enhanced urine.
Extremely rare exception vascular extravasation with accumulation of
contrast on delayed images. But this is usually evident on parenchymal phase

images, and/or is not as dense as excreted urinary contrast.
Contrast in ureter distal to site of injury demonstrates that injury is a partial lac-
eration, with some continuity of the proximal and distal ureter.

Chapter 3 Torso 231
Absence of contrast in ureter distal to site of injury raises concern for

transection, without continuity between proximal and distal ureter. However,
this is a nonspecific finding, as contrast may be absent secondary to passage
into bladder.
Contrast often is absent in portions of the ureter, so primary issue to evaluate
is presence of contrast at some point beyond the injury, not necessarily along
entire course of the ureter.
Dilated collecting systems, or kidneys that excrete contrast slowly, may require
additional maneuvers to adequately evaluate ureters, such as longer delays before
imaging (to allow more contrast to be excreted) or prone imaging (to move dense
contrast against anterior walls of the ureters).
A.
FIGURE 3.78. Proximal ureteral transection from blunt trauma. Value of delayed CT images.
A. Contrast-enhanced CT shows large mixed attenuation fluid collection medial and pos-
terior to right kidney. Extravasated contrast material is visible near the UPJ, and a small
amount pools posteriorly (arrow). (continued )

232 Chapter 3 Torso
B.
C.
FIGURE 3.78. (continued ) B. CT scan in lower lumbar region shows contrast in normal left
ureter but no contrast is seen in the right ureter. The large right retroperitoneal fluid collec-
tion contains no contrast at this time. Absent opacification of the ureter, when the kidney
is excreting contrast, is presumptive evidence of ureteral transection. C. Delayed CT at
7 hours, same level as in (B). Contrast material now opacifies the entire urinoma.

Chapter 3 Torso 233
SUGGESTED READING
Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am
2006;33:5566, vi.

234 Chapter 3 Torso
BLADDER INJURIES: EXTRAPERITONEAL RUPTURE
KEY FACTS
Bladder ruptures are rare, occurring in <2% of patients with abdominal injuries
requiring surgical repair or exploration.
83% of patients with bladder rupture have pelvic fractures. In contrast, <10% of
patients with pelvic fractures have bladder ruptures.
Almost all blunt force extraperitoneal (EP) bladder ruptures have pelvic frac-
tures.
Usually due to motor vehicle crash, motorcycle crash, or car versus pedestrian
Types of bladder injuries (percentage of bladder ruptures):
Contusionintramural injury. It may be difficult to identify on imaging stud-
ies and is the most common injury.

Interstitial rupturetear through inner wall of bladder that does not extend
through outer wall. It may be difficult to identify on imaging studies and is

extremely uncommon.
EP bladder rupture (70%90%)
Intraperitoneal (IP) bladder rupture (15%25%)
Combined bladder ruptureboth IP and EP rupture (5%12%)
Causes of EP bladder rupture:

Blunt trauma: pelvic fracture fragment lacerates bladder or shear injury related
to disruption of urogenital diaphragm (UGD) and/or pubovesical fascia, tears

bladder wall
Penetrating injury
Isolated EP bladder rupture can be managed nonoperatively with Foley catheter

drainage in most cases.
However, if orthopedic surgery is performed to repair pelvic fractures, bladder
laceration is usually repaired intraoperatively to keep urine away from the surgi-
cal site.
CT cystography (CTC) has replaced conventional radiographic cystography for
the evaluation of bladder rupture and can be performed rapidly while the trauma
patient is on the CT scanner for evaluation of other injuries, without the need to
move them to another area of radiology.
Following blunt trauma, CTC should be obtained if either of the following condi-
tions are present:
Gross hematuria and free IP fluid
High levels of hematuria and pelvic ring injury

Chapter 3 Torso 235
Greater than 30 RBC/HPF or gross hematuria

One or more of the following injuries:
Obturator ring fracture
Sacral fracture
Pubic symphysis or sacroiliac joint diastasis
Displaced osseous fragments within or abutting the bladder
CTC technique
Drain urine via Foley catheter.
Hang bag containing dilute water-soluble contrast (23 g of iodine per
100 mL of volume) 40 cm above bladder.

Instill contrast until flow stops, at least 350 mL of contrast has been instilled,
or bladder distension becomes intolerable to patient.

Obtain 2.5-mm to 5-mm low-dose axial images through the pelvis. Coronal
and sagittal reformations may help with evaluation.

If delayed images of the pelvis are being obtained, CTC images can be obtained
as part of that imaging series, without radiating the patient again specifically
for bladder evaluation. Otherwise, CTC is obtained following the parenchymal
(+/ vascular) phase imaging.
EP bladder rupture urinary extravasation may extend into:
The perivesical space around the bladder
The anterior prevesical (Retzius) space, sometimes extending cephalad to the
umbilicus and laterally and posteriorly to the retrorectal presacral spaces. Th e

prevesical space is a very large potential space.
The anterior abdominal fascial layers, including the sheaths of the rectus
abdominus muscles
The femoral or inguinal canal
The scrotum
Presence of contrast in these locations on CTC provides the diagnosis of EP blad-

der rupture, even if the actual bladder tear is not visualized on CT, as long as no
other potential source for this contrast is identified (vascular contrast extravasa-
tion, retrograde urethrogram contrast extravasation, etc). Prior studies should be
evaluated to exclude other sources of contrast extravasation, which may confuse
the diagnosis.
We do not use the American Association for the Surgery of Trauma (AAST)
classification system for bladder ruptures, as size of laceration is difficult to accu-
rately define on CTC.

236 Chapter 3 Torso
A.
B.
FIGURE 3.79. EP bladder rupture. Importance of adequate bladder distension to avoid

falsely negative exam. A. Cystogram with 100 mL of contrast material shows no extrava-
sation. Note pubic and sacroiliac joint diastasis and right inferior pubic ramus fracture. B.
With instillation of additional contrast material (400 mL), there is extensive extravasation
of contrast material into the perivesical tissues and anterior abdominal wall to the right and
below the bladder. None of the extravasated contrast is IP.

Chapter 3 Torso 237
A.
B.
FIGURE 3.80. EP rupture of bladder base. A. CT cystogram, near bladder base. Contrast
material extravasates extraperitoneally into prevesical spaces, lateral and anterior to blad-
der. Contrast also enters anterior abdominal wall fascial planes. B. CT cystogram, cephalad
to that in (A). No hematoma or contrast in the perivesical space. Contrast opacifies anterior
prevesical space (of Retzius) and extends around left rectus abdominus muscle.

238 Chapter 3 Torso
A.
B.
FIGURE 3.81. EP rupture near bladder dome causing potential confusion with IP rupture.
A. CT cystogram shows contrast extravasation from right side of bladder into prevesical
space. There is extensive anterior EP hematoma (H). No contrast enters the vesicouterine
recess. (U, uterus.) B. CT cystogram, cephalad to (A). Extravasated contrast mixes with EP
hematoma anteriorly. No contrast in paracolic gutters or around bowel loops. Exploration
confirmed that laceration was entirely EP.

Chapter 3 Torso 239
SUGGESTED READING
Avey G, Blackmore CC, Wessells H, et al. Radiographic and clinical predictors of bladder rup-
ture in blunt trauma patients with pelvic fracture. Acad Radiol 2006;13:573579.
Chan DP, Abujudeh HH, Cushing GL Jr, et al. CT cystography with multiplanar reforma-
tion for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187:
12961302.
Corriere JN Jr, Sandler CM. Mechanisms of injury, patterns of extravasation and manage-
ment of EP bladder rupture due to blunt trauma. J Urol 1988;139:4344.
Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radio-
graphics 2000;20:13731381.

240 Chapter 3 Torso
BLADDER INJURIES: INTRAPERITONEAL RUPTURE
KEY FACTS
Please refer to previous section for details on epidemiology and imaging technique
and indications.
Intraperitoneal (IP) rupture accounts for 15% to 25% of bladder ruptures.
Causes:
Blunt lower abdominal or pelvic trauma in a patient with a distended bladder,
raising intravesical pressure and resulting in a tear of the dome of the bladder,
the weakest and most mobile part of the bladder
Penetrating trauma that lacerates the portion of bladder covered by parietal
peritoneum
IP bladder rupture requires prompt surgical repair.
Findings on CTC:
Cystographic contrast in the IP spaces, similar to the fluid seen in patients
with ascites. Other etiologies of contrast (such as mesenteric vascular extrava-

sation) should be excluded to ensure that the IP contrast represents spillage
of bladder contrast.
Contrast commonly collects in the dependent vesicorectal or vesicouterine
peritoneal recesses. Larger extravasations cause contrast to flow into the lateral
paracolic gutters, around loops of bowel, and under the surface of the liver
Potentially confusing picture: Contrast accumulates cephalad and anterior to
bladder; in the absence of contrast material around bowel loops or in the paracolic
gutter or other clearly defined IP spaces, this usually represents EP rupture.
A combined bladder rupture consists of both an EP and IP rupture and accounts
for 5% to 12% of bladder ruptures. Diagnosed when features of both types of
bladder rupture are demonstrated
However, if one component dominates the picture, the other component can be
missed. For example, a large EP bladder rupture through which all the contrast
rapidly leaks out from the bladder may prevent adequate distension of the blad-
der, limiting evaluation for an IP rupture.
If adequate bladder distension is not achieved, the study is limited, and other
methods of evaluation may be necessary.

Chapter 3 Torso 241
FIGURE 3.82. IP bladder rupture on standard cystogram. Contrast opacifies vesicorectal

pouch, right paracolic gutter, and Morisons pouch and outlines tip of liver.

242 Chapter 3 Torso
A.
B.
FIGURE 3.83. Intraperitoneal bladder rupture on CTC. Axial (A) and coronal (B) images
from CTC demonstrate a large IP bladder rupture in the dome of the bladder (arrow), with
extravasated contrast diffusely throughout the peritoneum.

Chapter 3 Torso 243
SUGGESTED READING
Chan DP, Abujudeh HH, Cushing GL, Jr, et al. CT cystography with multiplanar reforma-
tion for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187:
12961302.
Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radio-
graphics 2000;20:13731381.

244 Chapter 3 Torso
URETHRAL INJURIES
KEY FACTS
Most urethral injuries occur in men.
Anatomy: The urethra is divided by the urogenital diaphragm (UGD) into ante-
rior (penile and bulbous) and posterior (membranous and prostatic) portions.
The membranous urethra is contained within the UGD and is very short.
Location and mechanism:
Posterior urethra injuries: Over 95% are associated with pelvic fractures; 5%
to 10% of patients with pelvic fractures have urethral laceration; two thirds of
men with pubic diastatic fracture sustain urethral injury.
Anterior urethra injuries: Injuries caused by blunt force to the perineum cause
crush (straddle) injuries to bulbous urethra. Other causes include iatrogenic

(e.g., instrumentation) and insertion of foreign bodies
Clinical signs: inability to void, hematuria, blood at the external meatus, and
high riding prostate on digital rectal exam. Blood at meatus present in only
50% of patients with urethral trauma.
Although CT is commonly used for the initial imaging evaluation of patients
with polytrauma, urethral injury is better assessed and classified by using
urethrography.
Retrograde urethrography (RUG): the examination of choice to evaluate patients
with suspected urethral trauma. See the urethrogram technique on page 15. Blind
catheterization can convert a partial urethral tear to a complete disruption.
Concomitant bladder injury is found in 10% to 20% of men with pelvic fracture
and urethral laceration.
Classification of posterior urethral injuries

Type I (Stretch Posterior urethra is stretched but not lacerated; hema-
type injury) toma collects in prostatic fossa, displacing bladder base
superiorly
Type II The urethra is disrupted at membranoprostatic junction
above UGD. During RUG, contrast dissects mainly into EP
pelvic spaces above the UGD
Type III Disruption of the urethra above the UGD, but extending
into the proximal bulbous urethra. UGD disrupted. Contrast
extravasation typically extends above and below UGD. This
is the most common type of injury.
Long-term complications of urethral injury in males are stricture, incontinence,

and impotence.

Chapter 3 Torso 245
FIGURE 3.84. Type 1 urethral (stretch) injury. RUG immediately after pelvic arteriography.
Marked diastasis of pubic symphysis, elevation of bladder, and elongation of posterior
urethra without contrast extravasation. Large intravesical blood clot forms a cast of the
widened bladder neck and proximal prostatic urethra.

246 Chapter 3 Torso
FIGURE 3.85. Type 2 urethral rupture, complete. RUG shows contrast extravasation above
the UGD (arrow). Contrast that extends below the left ischial tuberosity is in the low anterior
abdominal wall and thigh. The penile and bulbar urethra are normal.

Chapter 3 Torso 247
FIGURE 3.86. Type 3 urethral rupture, partial. Pericatheter RUG shows small extravasation
(E) at UGD. Proximal bulbar urethra is narrowed by extrinsic hematoma. Verumontanum (V),
Foley catheter balloon (F).

248 Chapter 3 Torso
ANTERIOR URETHRAL LACERATION
KEY FACTS
The most common traumatic injury to the anterior urethra is a partial tear of the
bulbous urethra caused by a straddle mechanism.
RUG shows extravasation of contrast into the corpus spongiosum at the site of
injury, but the entire anterior urethra is usually opacified; complete rupture is
much less common and results in nonvisualization of the urethra proximal to
the disruption.
If Bucks fascia is torn, urine and contrast can dissect into the scrotum and super-
ficial tissues of the abdominal wall.
Female urethral laceration: Due to the short length of the female urethra, injury
is less common than in men; diagnosis is usually by direct inspection or VCUG.
Retrograde urethrography (RUG) is technically difficult.

Chapter 3 Torso 249
FIGURE 3.87. Straddle injury to bulbar urethra. Pericatheter RUG shows extravasation of
contrast into corpus spongiosum with visualization of dorsal vein. Small laceration in deep
bulb (arrow).
SUGGESTED READING
Ingram MD, Watson SG, Skippage PL, et al. Urethral injuries after pelvic trauma:
evaluation with urethrography. Radiographics 2008;28:16311643.

250 Chapter 3 Torso
IMAGING THE GRAVID UTERUS
KEY POINTS
Trauma is the leading cause of nonobstetric maternal mortality and complicates
up to 7% of pregnancies.
Maternal death usually results in fetal death. When the mother survives, the
most common cause of fetal death is placental abruption. Both major and minor
traumas are associated with an increased risk of fetal loss.
The risks of radiation to the fetus are small and almost never warrant termina-
tion of the pregnancy. Pregnant trauma patients are imaged like all other trauma
patients with radiographs, CT, and angiography as necessary. IV contrast is
administered with no adverse effects to the fetus.
Emergent ultrasound is performed to evaluate for fetal cardiac activity, to evalu-
ate the placenta, and to date the pregnancy. The fetus is viable and may be deliv-
ered after 24 weeks.
Pregnant patients are predisposed to the same spectrum of injuries as non-
pregnant trauma patients as well as to retroperitoneal bleeding from rupture of
dilated ovarian veins and uterine injuries.
The most common uterine injury is placental abruption. The most sensitive
diagnostic test to diagnose placental abruption is external fetal monitoring with
devices that monitor fetal heart rate and uterine contractility. Ultrasound may
be used to diagnose placental abruption. Unfortunately, it is an insensitive diag-
nostic test with a false-negative rate of 50% to 80%. On ultrasound, placental
abruption is characterized by clot between the placenta and uterine wall that
may be hypoechoic or hyperechoic. Placental abruption may be diagnosed on
CT performed to evaluate for other maternal injuries. On CT, placental abrup-
tion is characterized by an area of diminished enhancement that extends from
the placental base to the placental surface. The placental may appear focally
thickened.
Uterine laceration and uterine rupture are less common consequences of trauma
in pregnancy. Uterine rupture complicates up to 0.6% of pregnancies, and the
fetal loss rate is approximately 100%. It is characterized by fetal parts outside the
uterine cavity and an empty uterus. There may be amniotic fluid in the peritoneal
cavity.
Injury to the fetus itself is unusual but may occur late in pregnancy when the
fetal head is fixed in the pelvis and the amniotic fluid volumefetal volume ratio
is low. Fetal injuries include skull fractures and intracranial hemorrhage that is
usually fatal.

Chapter 3 Torso 251
A.
B.
FIGURE 3.88. Uterine rupture on transabdominal US. This woman sustained blunt abdomi-
nal trauma in an MVA during the second trimester of her pregnancy. A. Sagittal section
through the uterus shows discontinuity of the normal myometrium (arrow) indicating the
site of uterine rupture. B. Sagittal section at the maternal mid-abdomen confirms that the
19-week fetus has been ejected from the uterus. The fetal head (FETUS) can be seen in
the maternal peritoneal cavity with maternal small bowel (BOWEL) and extruded placenta
(arrow) interposed between the fetus and the uterine fundus (UT). (Reprinted from Scott D,
Hanh V, Kirk Shy. Uterine rupture with fetal death following blunt trauma. Am J Roentgenol
1995;165:1452, with permission.)

252 Chapter 3 Torso
FIGURE 3.89. Marginal placental abruption. 23 weeks pregnant pedestrian hit by a car.
There is marginal placental abruption with hypoechoic clot extending from the placental
base to the placental surface and elevating the placenta at the left lateral aspect (arrow ).
Less than 30% of the placental surface is involved and the mother and fetus did well.

Chapter 3 Torso 253
SUGGESTED READING
Bernstein M. Imaging of traumatic injuries in pregnancy. State of the Art Emergency and
Trauma Radiology Categorical Course and Syllabus. ARRS 2008:203210.
Fildes J, et al. Trauma: the leading cause of maternal death. J Trauma 1992;32:643645.
Ikossi K, et al. Profile of mothers at risk: an analysis of injury and pregnancy loss in 1,195
trauma patients. J Am Coll Surg 2005;200(1):4956.
Lowdermilk C, et al. Screening helical CT for evaluation of blunt traumatic injury in the
pregnant patient. Radiographics 1999;19:S243S255.
McCullough C, et al. Radiation exposure and pregnancy: when should we be concerned?
Rothenberger D, et al. Blunt maternal trauma: a review of 103 cases. J Trauma 1978;18(3):
173178.
STAT dx. Amirsys Publishing. Online Diagnostic Clinical Decision Support.

254 Chapter 3 Torso
TESTICULAR TRAUMA
KEY FACTS
The spectrum of scrotal injury from penetrating and blunt trauma includes
scrotal wall hematoma, hematocele (blood in the tunica vaginalis) and testicular
contusion, hematoma, and rupture. Approximately 20% of patients presenting
with scrotal trauma will have testicular rupture.
Urgent surgical treatment of testicular rupture maximizes the probability of sal-
vaging the testis. The presence of scrotal bleeding and swelling hinders the clini-
cal distinction between testicular rupture and less severe scrotal injury.
Specific ultrasound findings for testicular rupture include the following:
Disruption of testicular contours
Extrusion of testicular substance
Hypoechoic testicular fracture plane (present in <20%).
Not all cases of testicular rupture will present with specific ultrasound (US) find-
ings, although virtually all will have sonographic abnormalities. Patients with a
completely normal testicular US can be treated conservatively; those patients at
risk for rupture with an abnormal, but nonspecific US, may still warrant surgical
exploration.
The US appearance of hematoceles and testicular hematomas varies depending
on their age. In general, they will be hypoechoic acutely, relatively hyperechoic
as clot formation progresses, and become progressively hypoechoic as clot lysis
occurs.
Color and spectral Doppler assessment of the injured testis confirm adequate
blood flow in areas compressed by adjacent hematomas. They can also help in
surgical planning for the ruptured testis by identifying potentially devitalized
areas.
Testicular tumors can present with hemorrhage following relatively minor
trauma. Color and spectral Doppler may distinguish a vascular tumor from an
avascular hematoma. An apparent testicular hematoma, without a history of
significant trauma, warrants follow-up US to exclude a neoplasm.

Chapter 3 Torso 255
FIGURE 3.90. Scrotal US from a 34-year-old man with blunt trauma to the right scrotum.
Transverse section through the mid-testicle shows extrusion of testicular contents (curved
black arrow), indicating testicular rupture. There is a hematoma adjacent to the testicle
(white arrow).
SUGGESTED READING
Deurdulian C, Mittelstaedt CA, Chong WK, et al. US of acute scrotal trauma: optimal tech-
nique, imaging findings, and management. Radiographics 2007;27:357369.

CHAPTER
4 Upper Extremity
CLAVICLE FRACTURES
KEY FACTS
Clavicle fractures are very common in children and adults but fortunately heal
rapidly and respond well to conservative management. Clavicle fractures are
usually a result of a fall onto the shoulder or motor vehicle collision.
Clavicle fractures are classified primarily by location and secondarily by the
amount of deformity. The clavicle is a somewhat S-shaped bone with a flat cross
section laterally and a round cross section medially. This changing cross section
influences the location of fractures. Middle third (group I) fractures account for
about 80% of the total, lateral third (group II) account for about 15%, and medial
third (group III) only 5%.
Comminution is not uncommon in all three types. Displacement of the frag-
ments is largely a function of muscle and ligament attachments. Gravity tends
to pull the shoulder joint and distal clavicle fragments down, while the muscles
tend to hold medial fragments up.
In distal third fractures (group II), the integrity of the coracoclavicular ligaments
influences the type and severity of displacement. Intact ligaments provide frac-
ture stability.
Clavicle fractures are usually diagnosed clinically, and the main function of radio-
graphs is to assess the nature and severity of the fracture. Two projections are
usually used. One is a straight AP view and the other is AP with the beam directed
20 to 40 degrees cephalad.
Associated subluxations or dislocations of the acromioclavicular and sterno-
clavicular joints are often present.
Clavicle fractures are most commonly isolated injuries. Associated injuries to the
lung apex, subclavian vessels, brachial plexus, and first rib are infrequent.
256

Chapter 4 Upper Extremity 257
A.
B.
FIGURE 4.1. (A) AP and (B) up-angled AP views of a comminuted clavicular shaft fracture.
Note the upward displacement of the proximal fragment. The distal fragment moves with
the scapula, confirming the integrity of the coracoclavicular ligaments.
SUGGESTED READING
Mayo KA, Swiontkowski MF. In: Hansen ST, Swiontkowski MF, eds. Orthopaedic Trauma
Protocols. New York, NY: Raven Press, 1993:7779.
Pope TL, Bloem HL, Beltran J, et al. Imaging of the Musculoskeletal System. Philadelphia,
PA: Saunders, 2008:101220.
Rogers LF, ed. Radiology of Skeletal Trauma. New York, NY: Churchill Livingstone, 2002:594604.

258 Chapter 4 Upper Extremity
ACROMIOCLAVICULAR JOINT DISLOCATION
KEY FACTS
The acromioclavicular joint is supported by a thin fibrous capsule and by discrete
acromioclavicular ligaments situated anteriorly, posteriorly, superiorly, and inferi-
orly. Further support for this joint is provided by the coracoclavicular ligaments.
The exact relationship between the acromion and clavicle varies, with orienta-
tion of the joint being anywhere from parallel to the glenoid to 50 degrees of
obliquity. The clavicle can lie somewhat superior to the acromion, a normal vari-
ant that should not be mistaken for traumatic dissociation.
Acromioclavicular joint injuries are classified into six types, according to the
associated ligament injuries:
Type I is a simple sprain of the acromioclavicular ligaments (without frank
rupture) and radiographically shows no joint displacement.

Type II has disrupted acromioclavicular ligaments, allowing some displace-
ment of the joint, but the coracoclavicular ligaments are intact, preventing
complete dissociation. There may be widening of the acromioclavicular joint,
but minimal if any elevation of the distal clavicle.
Type III has disruption of both the acromioclavicular and coracoclavicular
ligaments with complete dissociation of the scapula and clavicle. Identified by

elevation of the distal clavicle with respect to the acromion.
Types IV (posterior clavicle dislocation), V (marked superior clavicle separa-
tion with muscular puncture), and VI (inferior clavicle dislocation) are all rare.
Type I and II injuries are usually managed conservatively. Type III injuries are usu-
ally repaired surgically.
The acromioclavicular joint is best seen on modified AP views of the shoulder
with the beam angled 10 to 15 degrees cephalad. The opposite joint should be
imaged for comparison, to allow for the large variations in normal anatomy. The
radiographs should be obtained with the patient sitting or standing and the arms
hanging loosely at the sides. A second similar examination should then be per-
formed, with 10 to 15 pound weights in each hand, to evaluate instability.
In some Type II injuries, the acromioclavicular displacement can actually
decrease with weights as the patient contracts the shoulder muscles in reaction
to the load. This still represents joint laxityany motion with weight bearing
should be considered abnormal.

FIGURE 4.2. Type III acromioclavicular injury with disruption of both acromioclavicular
(arrow ) and coracoclavicular (double arrow ) ligaments.
SUGGESTED READING
Mayo KA, Swiontkowski MF. In: Hansen ST, Swiontkowski MF, eds. Orthopaedic Trauma
Pope TL, Bloem HL, Beltran J, et al. Imaging of the Musculoskeletal System. Philadelphia, PA:
Saunders, 2008:101220.
Rogers LF, ed. Radiology of Skeletal Trauma. New York, NY: Churchill Livingstone, 2002:
604619.

SHOULDER JOINT DISLOCATION
KEY FACTS
Dislocation of the shoulder joint accounts for more than half of all major joint
dislocations.
Shoulder dislocations are classified according to the position of the humeral
head, relative to the glenoid labrum. The positions in which the head can reside
are anterior, posterior, inferior, and superior.
Anterior dislocations account for more than 90% of the total and posterior
dislocations account for most of the remainder. Inferior dislocations are very
uncommon and superior dislocations are rare. The rarest variant is intrathoracic
dislocation, with the humeral head protruding through the chest wall.
In anterior dislocations, the humeral head is displaced not only anteriorly but
most commonly also medially and inferiorly to a subcoracoid position (Fig. 4.3).
The resultant deformity is readily visible both clinically and radiographically.
Associated fractures of the glenoid margin (Bankart fractures) and humeral head
(Hill-Sachs fractures) are common.
In posterior dislocations, the humeral head usually lies directly behind the gle-
noid, usually with minimal medial or inferior displacement (Fig. 4.5).
In inferior dislocations (also known as luxatio erecta), the humeral head lies
directly below the glenoid and the shaft of the humerus is fixed in marked abduc-
tion (Fig. 4.4). This deformity is obvious both clinically and radiographically.
Adequate evaluation requires good quality conventional radiographs (usually AP,
Grashey [tangential to the glenohumeral joint], and axillary views).

A.
B.
FIGURE 4.3. Anterior shoulder dislocation. A. AP view following injury shows the humeral
head lying anterior and inferior to the glenoid fossa. B. A postreduction AP view shows not
only that the dislocation has been reduced but also that there is a Hill-Sachs impaction frac-
ture (black arrow) on the posterosuperior margin of the humeral head. (continued )

C.
FIGURE 4.3. (continued ) C. CT scan shows the Hill-Sachs fracture (curved white arrow) even
more clearly.
FIGURE 4.4. Shoulder dislocationluxatio erecta. A single AP view shows the humeral
head lying anteromedial and inferior to the glenoid fossa with the arm fixed in abduction.
Incidentally noted is a superior glenoid margin fracture.

SUGGESTED READING
Mayo KA, Swiontkowski MF. In: Hansen ST, Swiontkowski, MF, eds. Orthopaedic Trauma
Saunders, 2008:101220.
650675.

SHOULDER DISLOCATION: POSTERIOR
KEY FACTS
The subtle deformity of the posterior shoulder dislocation can easily be over-
looked by the unwary physician, both clinically and radiographically.
Associated injuries such as humeral neck fractures can occur. Such injuries can draw
the attention of the unwary physician away from the less conspicuous dislocation.
Most reports in the literature list failed diagnosis rates close to 50%. Failure rates
this high cannot be justified, since all of these injuries can be diagnosed with
adequate radiographs.
A Grashey (posterior oblique), a standard AP radiograph, and an axillary view
should be obtained for shoulder trauma.
The important signs on the Grashey and AP views are overlap of the humeral
head and glenoid articular surfaces, imperfect alignment of the humeral head
with the glenoid fossa (too high or too low), persistent internal rotation of the
humerus on all views, and the presence of the trough line.
The trough line represents an impaction fracture of the anterior articular sur-
face of the humeral head. It is most commonly seen on AP projections as a curved
dense line that parallels the articular margin of the humeral head (Fig. 4.5). This
fracture is relatively common in posterior dislocations.
The posterior internally rotated position of the head is readily confirmed by the
axillary view. If an axillary view cannot be obtained, a scapular Y view can be
obtained.
A. B.

C. D.
FIGURE 4.5. A. The AP view of a posteriorly dislocated shoulder demonstrates abnormal

alignment between humeral head and glenoid. B. The Grashey view demonstrates overlap
between humeral head and glenoid and a trough line (arrows ). C. Axillary view demon-
strates the humeral head (H ) is posterior to glenoid (G ) with a trough fracture (arrow ). In
this view, the coracoid process (arrowhead ) indicates the anterior aspect of the scapula.
D. Humeral head has been reduced on CT scan. Trough fracture present with impaction
fracture of anterior humeral head (arrow ).
SUGGESTED READING
Saunders, 2008:101220.
650675.

PROXIMAL HUMERAL FRACTURES
KEY FACTS
Injuries to the proximal humerus include fractures of the head, neck, and tuber-
osities. Humeral neck fractures are the most common and typically involve the
surgical (rather than the anatomic) neck. Articular and periarticular fractures of
the humeral head are usually associated with joint dislocations or subluxations.
Isolated tuberosity fractures are the least disabling of these injuries.
The most widely used classification for surgical neck fractures was developed by
Neer. This classification counts the number of major displaced fragments and
defines the specific parts involved. It does not include nondisplaced fractures.
The major parts included in the Neer classification are the greater and lesser
tuberosities, humeral head, and humeral shaft. A displaced fracture can have
two, three, or four of these parts.
The humeral head tends to remain in the glenoid fossa, while the other three
fragments are displaced away from it. The direction of displacement of each of
these fragments is a function of their muscle attachments.
The greater tuberosity is pulled superiorly and posteriorly by supraspinatus and
infraspinatus, the lesser tuberosity is pulled medially by subscapularis, and the
shaft is pulled medially by pectoralis major.
A. B.
FIGURE 4.6. A. Markedly displaced two-part humeral neck fracture with abduction and
external rotation of the proximal fragment by the rotator cuff muscles. The shaft is displaced
medially by the pectoralis major. B. Minimally displaced impacted humeral neck fracture in
another patient, 2 days postinjury. Note how the humeral head has subluxed inferiorly out
of the glenoid fossa, secondary to hemarthrosis and muscle weakness. This should not be
confused with a shoulder dislocation.

A. B.
FIGURE 4.7. A. AP radiograph of the left shoulder, showing comminuted, avulsed, greater
tuberosity fracture (arrow). B. STIR MRI image of the right shoulder in a different patient
demonstrates bone marrow edema and nondisplaced greater tuberosity fracture.
The presence or absence of articular surface involvement is important. Fractures

splitting the humeral head can also occur, either as part of more complex head
and neck fractures or as isolated injuries. Humeral head fractures that simply
indent the surface of the bone are most commonly the result of dislocations.
Complications are relatively infrequent in humeral neck fractures but include
avascular necrosis, nonunion, malunion, infection, neurovascular injury, hard-
ware failure, and frozen shoulder.
SUGGESTED READING
Flatow EL. Fractures of the proximal humerus. In: Bucholz RW, Heckman JD, eds. Rockwood
and Greens Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2001.
Saunders, 2008:101220.
593683.

HUMERAL SHAFT FRACTURES
KEY FACTS
Classified by location: above pectoralis major insertion; below pectoralis major,
but above deltoid insertion; below deltoid insertion
Also classified by direction and character of fracture: longitudinal, transverse,
oblique, spiral, segmental, comminuted; open or closed
Fracture location impacts fragment displacement based on muscular insertions.
Complications are
Injuries to the brachial vessels
Injuries to the radial (most commonabout 10% of cases), ulnar, and median
nerves. Permanent wrist drop can result if the radial nerve is transected.

FIGURE 4.8. This patient sustained a transverse midshaft humeral fracture in a motor vehi-
cle accident. There is greater than 100% displacement with shortening and marked angula-
tion. The shortening has resulted from the forearm extensors and flexors pulling the distal
fragment proximally and the angulation has resulted from the abductors of the shoulder
pulling the proximal fragment laterally.
SUGGESTED READING
Ekholm R, Adami J, Tidermark J, et al. Fractures of the shaft of the humerus. An epidemio-
logical study of 401 fractures. J Bone Joint Surg Br 2006;88(11):14691473.
Ekholm R, Ponzer S, Trnkvist H, et al. Primary radial nerve palsy in patients with acute
humeral shaft fractures. J Orthop Trauma 2008;22(6):408414.
Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated with fractures of the
shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005;87(12):16471652.

DISTAL HUMERAL FRACTURES
KEY FACTS
Distal humeral fractures are classified by their relationship to the humeral
condyles. Four types are described: supracondylar, intercondylar, condylar, and
epicondylar.
Supracondylar fractures are most the common and are usually seen in children
aged 9 to 12 years.
Supracondylar fractures are due to hyperextension, with posterior angulation
and displacement of the condyles.
Supracondylar fractures are subclassified into three types:
Type I. Nondisplaced
Type II. Displaced with posterior cortical continuity
Type III. Totally displaced
Intercondylar (T and Y) fractures are subclassified into four types:

Type I. Nondisplaced
Type II. Displaced
Type III. Displaced and rotated
Type IV. Displaced, rotated, and comminuted
Condylar fractures involve the capitellum and trochlea either separately or

together.
Epicondylar fractures occur both medially and laterally.
Anteroposterior and lateral radiographs of the elbow are usually adequate to
evaluate distal humeral fractures.

FIGURE 4.9. Type II supracondylar

fracture. This 12-year-old boy fell
onto his outstretched hand. (A) AP
and (B) lateral views of the elbow
show a typical supracondylar frac-
ture. The distal fracture fragment
can be seen on the lateral view
to be tilted posteriorly, but it is
still articulating normally with the
radius and ulna.
A.
B.
SUGGESTED READING
Hotchkiss RN, Green DP. In: Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Greens
Fractures. Philadelphia, PA: Lippincott, 1991:739774.
Saunders, 2008:101272.

HUMERUS: EPICONDYLE INJURY
KEY FACTS
While direct injury to the epicondyles is possible, most epicondylar fractures are
the result of avulsion.
Medial epicondyle fractures are much more common than lateral and are usually
seen in children, prior to physeal closure.
The medial epicondyle provides the common origin for the forearm flexor mus-
cles and is avulsed when sudden stress is applied to these muscles.
Medial epicondyle avulsion is also associated with elbow dislocations and the epi-
condyle can become trapped within the elbow joint, prior to or during reduction.
The medial epicondyle is usually displaced distally but the displacement is not
always obvious radiographically and a comparison view of the opposite elbow is
often helpful.
The lateral epicondyle provides the common origin for the forearm extensors and
can be avulsed in a similar fashion to the medial epicondyle. This injury, however,
is infrequent.

A. B.
FIGURE 4.10. This child has avulsed his right medial humeral epicondyle. A. AP view of the
injured elbow with the medial epicondyle (arrow) displaced medially. The normal position of
the epicondyle (arrow) is shown on (B) an AP view of the opposite (normal) elbow that was
obtained for comparison. The radiograph of the normal elbow has been reversed so that the
anatomy of the two sides will match.
SUGGESTED READING
Hotchkiss RN, Green DP. In: Rockwood CA, Green DP, Bucholz RW. eds. Rockwood and Greens
Saunders, 2008:101272.
593779.

ELBOW DISLOCATION
KEY FACTS
The elbow joint is very stable and therefore dislocates less frequently than the
shoulder joint.
Elbow dislocations are classified by the position of the ulna relative to the
humerus. Most are posterior, but anterior, lateral, medial, and divergent types
are possible.
Associated fractures can occur, affecting the medial humeral epicondyle, the
coronoid and olecranon processes of the ulna, the radial head, and the articular
surfaces of the elbow joint.
Medial epicondyle and coronoid fractures are the most common associated
injuries and have been reported in up to 60% of dislocations.
Injuries to the brachial vessels and radial, ulnar, or median nerves are
uncommon.
A. B.

C.
FIGURE 4.11. (A) AP and (B) lateral views of the elbow show complete dislocation, with
medial and posterior displacement of the forearm bones. A small bony fragment (arrows)
has been avulsed from the coronoid process. The avulsion is more apparent on (C) the
postreduction lateral view.
Typically the radial head and proximal ulna dislocate together.

Isolated radial head or ulnar dislocations are rare in adults, but are more common
in young children.
As with dislocations in other large joints, the diagnosis is obvious clinically, and
the main roles of radiography are to categorize the injury and detect associated
fractures. Standard AP and lateral views are usually adequate for these injuries,
but addition of a radial head view increases sensitivity for fracture detection.
SUGGESTED READING
Hotchkiss RN, Green DP. In: Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Greens
Saunders, 2008:101272.
683779.

RADIAL HEAD FRACTURES
KEY FACTS
Common mechanisms include a fall on outstretched arm and less commonly a
lateral blow to the elbow.
They are more commonly seen in adults.
Most radial head fractures will be seen on the AP and lateral views. However,
oblique views or radial-capitellar views aid in visualizing minimally displaced
fractures.
Radial head fractures are intra-articular and usually produce hemarthroses.
Hemarthroses can be identified by displacement of the elbow fat pads on the
lateral radiographs. This produces the sail sign.
Radial head fractures should be suspected in all elbow injuries when there is pain
and tenderness laterally with displaced anterior or posterior fat pads visible on
lateral radiographs.
CT can be used to determine the degree of displacement and to direct further
management, particularly postreduction.
Nondisplaced or minimally displaced radial head fractures are usually treated
conservatively. More severe displacement may require surgical intervention.
Radial head fractures can also be associated with injuries to the interosseous
membrane.
Essex-Lopresti injury is defined by a complex radial head fracture, complete tear
of the interosseous membrane, and dislocation of the distal radioulnar joint.
The classification for radial head fractures is the Mason classification (I-IV).

A.
B.
FIGURE 4.12. A. The lateral view shows displaced fat pads (arrows) indicating a joint
effusion. The fracture is not apparent on this view, nor was it seen on the AP projection.
B. A radial head view shows the minimally displaced radial head fracture (arrows) well.
SUGGESTED READING
Greenspan A. Orthopedic imaging, a practical approach. New York, NY: Lippincott
Williams & Wilkins, 2004:146152.
Pope TL. Imaging of the musculoskeletal system. Philadelphia, PA: Saunders, 2008:241253.

RADIUS AND ULNA SHAFT FRACTURES
KEY FACTS
The radius and ulna articulate proximally and distally forming a fibro-osseous
ring. This ring is stable if only fractured in one place and unstable if fractured in
two places.
Common mechanism for producing a stable single bone fracture includes a direct
blow to the ulna, known as a night stick fracture.
Common mechanism for an unstable two-bone fracture includes a fall on out-
stretched arm. Unstable fractures are commonly caused by indirect trauma.
Both bone fractures are the most common unstable injuries and occur most
commonly in the mid-forearm.
Monteggia fracture dislocation is defined by a proximal ulnar shaft fracture and
proximal radioulnar (and radiocapitellar) joint dislocation.
Galleazzi fracture dislocation is defined by a distal radial shaft fracture and distal
radioulnar joint dislocation.
With seemingly isolated fractures of either the radial or ulnar shafts, look for
dislocation of the radioulnar joints to diagnose Galleazzi or Monteggia fracture
dislocations.
FIGURE 4.13. Monteggia fracture. A lateral view of the elbow shows a proximal ulnar shaft
fracture with marked displacement, angulation, and shortening. Note that the radial head
(white arrow) is dislocated from its normal articulation with the capitellum (black arrow).

A. B.
FIGURE 4.14. Galleazzi fracture. (A) AP and (B) lateral views of the distal forearm show
a displaced, angulated, and shortened fracture (arrows) of the distal radial shaft. The ulnar
head (H) is displaced distally and palmarly, out of its normal articulation (N) with the distal
radius.
SUGGESTED READING
Greenspan A. Orthopedic Imaging, a Practical Approach. New York, NY: Lippincott
Williams & Wilkins, 2004:159163.
Pope TL. Imaging of the Musculoskeletal System. Philadelphia, PA: Saunders, 2008:241253.

DISTAL RADIUS AND ULNA FRACTURES
KEY FACTS
Distal radius and ulna fracture patterns vary with patient age. These fractures
result most commonly from a fall onto the outstretched hand.
Prepubescent children are most likely to have buckle (torus) fractures of the
distal radial metaphysis or greenstick fractures of the distal shafts of both
bones (Fig. 4.15).
Adolescents are most likely to have fractures involving the distal radial physis
(Salter-Harris injuries).
Adults will tend to have complete fractures of the distal radial metadiaphyseal
region, often associated with fractures of the ulnar styloid process. These frac-
tures are most common in older, osteoporotic individuals.
A. B.

C. D.
FIGURE 4.15. Torus fracture. (A) AP and (B) lateral views of a 9-year-old girls wrist show a frac-
ture (curved arrows) through the distal radius. The buckling nature of the injury is best appreci-
ated on the lateral view. There is also a fracture through the ulnar styloid in this patient (straight
arrows). Torus fractures can be very subtle, as demonstrated by (C) the lateral view of a 7-year-
old boys wrist where the fracture (arrow) is seen simply as a sudden change in angulation of
the distal radius. In this second patient, the fracture is not visible on (D) the AP view. Follow-up
films showed clear evidence of healing with a line of sclerosis across the distal radius.
Distal radial fractures in adults with dorsal angulation and/or displacement of

the distal fragment are known as Colles fractures (Fig. 4.16).
When the distal radial fracture fragment is angulated and/or displaced palmarly,
it is called a Smith fracture.
An oblique coronal fracture separating off the dorsal rim of the radius, with dor-
sal displacement of this fragment and the wrist, is known as a (dorsal) Barton
fracture. This results in a fracture-dislocation of the radiocarpal joint. A similar
fracture involving the volar rim of the radius may be referred to as a reverse or
volar Barton fracture (Fig. 4.17).

A. B.
FIGURE 4.16. Colles fracture. This elderly woman fell onto her outstretched hand, sustain-
ing a transverse fracture through the metadiaphyseal region of her distal radius. (A) AP and
(B) lateral views of the wrist show that the fracture is slightly comminuted and extends
into the distal radial articular surface. The lateral view also shows dorsal tilting of the distal
fracture fragment.

A. B.
FIGURE 4.17. Anterior (volar) Barton fracture. (A) AP and (B) lateral views of an adult wrist
show fracture dislocation of the radiocarpal joint. On the lateral view, we can see that the
volar fracture fragment (closed broad arrow) still articulates with the proximal carpal row
(open broad arrow), while the remainder of the distal radius (curved arrow) lies dorsal to
the carpus.
SUGGESTED READING
Saunders, 2008:221353.
683874.

CARPAL FRACTURES
KEY FACTS
The scaphoid is the most common carpal bone fractured, constituting 60% to
70% of carpal fractures. These fractures are seen most frequently in young adults
and athletes, and result from a fall on an outstretched hand.
Most scaphoid fractures (80%) occur through the midportion or waist of the
bone (Fig. 4.18).
Blood supply to the proximal two thirds of the scaphoid arises from the radial
artery dorsally and supplies the proximal pole of the scaphoid in a retrograde
fashion. Thus, blood supply to the proximal pole can be compromised by scaphoid
waist fractures.
Displaced scaphoid waist fractures can lead to delayed union, nonunion, or
ischemic necrosis.
Distal pole and tubercle fractures (Fig. 4.19) are not subject to vascular compro-
mise, and usually heal without complication.
Most scaphoid fractures are minimally displaced. When there is marked
displacement, associated ligamentous injuries and carpal dislocations should be
considered.
The second most common carpal bone to fracture is the triquetrum (Fig. 4.20).
These usually occur with hyperextension while in ulnar deviation. Diagnosis is
made on the lateral radiograph when a bone fragment is observed dorsal to the
carpus.
A complete four-view series is necessary to evaluate the carpus, including PA,
oblique, lateral, and scaphoid views. The scaphoid view is taken in full ulnar devi-
ation.
If plain radiographs are equivocal and clinical suspicion is high, MRI or CT of the
wrist can be obtained, with sensitivity and specificity both exceeding 90%.

A.
B.
FIGURE 4.18. Scaphoid waist fracture. The fracture (arrow) is difficult to see on (A) the
standard PA view, but it is clearly visible on (B) the scaphoid view. This fracture was not
visible on either the oblique or lateral views.

FIGURE 4.19. Scaphoid tubercle fracture. While this oblique view clearly shows the fracture
(arrow), it could not be found on the PA view.
A. B.

FIGURE 4.20. Triquetral fracture. This frac-

ture (arrows) was visible on (A) the lateral
and (B) the oblique views, but was not
shown by the other two views of the wrist.
C. Triquetral fracture on MRI demonstrated
by bone marrow edema and a small frac-
ture line (arrow ).
C.
SUGGESTED READING
Kaewlai R, Avery LL, Asrani AV, et al. Multidetector CT of carpal injuries: anatomy, fractures,
and fracture-dislocations. Radiographics. 2008;28(6):17711784.

CARPAL DISLOCATIONS
KEY FACTS
The majority of carpal dislocations occur around the lunate, through the
midcarpal joint.
There is a zone of vulnerability that extends in an arc-like fashion across the
carpus. It begins laterally at the radial styloid and expands across the scaphoid
bone, through the proximal capitate and midcarpal joint, across the lunotrique-
tral joint, and onto the ulnar styloid process.
These dislocations are classified as perilunate if the lunate continues to articu-
late with the radius. They are called lunate dislocations when the lunate is dis-
located out of its radial articulation. An intermediate state has been labeled as a
midcarpal dislocation by some experts.
The most common variant of the lunate/perilunate series is the trans-scaphoid
perilunate dislocation (Fig. 4.21). As its name implies, this midcarpal joint dis-
ruption includes a scaphoid waist fracture and a perilunate dislocation. It also
frequently includes an ulnar styloid fracture.
Transradial variants include a radial styloid fracture.
Transcapitate variants include a capitate neck fracture. The detached capitate
head usually rotates, often a full 180 degrees.
Whenever scaphoid waist fractures are widely displaced, an associated midcarpal
joint disruption or other ligament injury should be suspected.

A. B.
FIGURE 4.21. Trans-scaphoid perilunate dislocation. This is the most common of all inter-
carpal dislocations. A. The PA view shows the displaced scaphoid fracture (curved white
arrow), an ulnar styloid fracture (curved black arrow), an abnormally shaped lunate (open
arrow), and overlap of the proximal and distal carpal rows. B. The lateral view shows that
the lunate (open arrow) is no longer articulating with the head of the capitate (closed arrow).
SUGGESTED READING
Rogers LF, et al. Radiology of Skeletal Trauma. New York, NY: Churchill Livingstone, 2002:
874930.
Yin Y, Mann FA, Gilula LA. In: Gilula LA, Yin Y. eds. Imaging of the Wrist and Hand.
Philadelphia, PA: WB Saunders, 1996:93157.

METACARPAL FRACTURES
KEY FACTS
Metacarpal fractures are classified by their location: base, shaft, neck, or head.
Metacarpal base fractures often involve the carpometacarpal (CMC) joints. They
are most common at the thumb metacarpal base.
First metacarpal base fractures are classified according to the pattern of articu-
lar involvement. They are known as Bennett (Fig. 4.22), Rolando (Fig. 4.23), and
extra-articular (Fig. 4.24) fractures.
Bennett fracture (Fig. 4.22) has a small palmar detached fragment, usually with
proximal displacement of the remainder of the metacarpal.
Rolando fracture (Fig. 4.23) has both palmar and dorsal detached fragments.
FIGURE 4.22. Bennett fracture. This articular fracture of the first metatarsal base has a
large palmar retained fragment (black arrow) with minimal proximal displacement of the
remainder of the bone (white arrow).

FIGURE 4.23. Rolando fracture. This

articular fracture of the first metatar-
sal base has both palmar (black arrow)
and dorsal (white arrow) fragments
with minimal proximal displacement
of the remainder of the bone (curved
white arrow).
FIGURE 4.24. Extra-articular first meta-

carpal base fracture. This angulated
fracture (arrows) is located distal to the
articular surface. The distal portion of the
bone is displaced proximally.

Fracture dislocations at the fourth and fifth carpometacarpal joints can be chal-
lenging to identify when not significantly displaced, and careful review of the
joint space may help detect subtle fractures (Fig. 4.25).
Metacarpal shaft fractures are usually the result of more indirect trauma and are
either transverse or oblique (Fig. 4.26). The direction of the fracture depends on
the direction of the forceeither bending or twisting.
Metacarpal neck fractures are the result of direct blows to the metacarpal head,
usually with the fist clenched. These fractures are usually unstable, with palmar
angulation and/or displacement of the metacarpal head.
The fifth metacarpal neck is fractured most commonly (Fig. 4.27), followed by the
second metacarpal neck. These fractures both result from punching.
Rotational deformity can occur with both shaft and neck fractures. This results in
significant morbidity as it interferes with the ability of the hand to grip or make
a fist.
Metacarpal head fractures are intra-articular and can lead to long-term joint
sequelae, such as osteoarthritis.
A. B.
FIGURE 4.25. A. AP view of hand demonstrates malalignment at fourth and fifth CMC
joints (arrows ). Note the normal joint space between the distal pole of the hamate and
the bases of the fourth and fifth metacarpals is not visible. Instead there is bony overlap.
Always examine this area carefully, for dislocations can be subtle. Additionally, there is
loss of the normal parallel articular margins of these joints. Small fractures of the base of
the fourth metacarpal and ulnar styloid are also present. B. Lateral view of hand demon-
strates dislocation at fourth (4) and fifth (5) CMC joints, small fracture fragment in dorsal
soft tissues (arrowhead), and soft tissue swelling.

B.
A.
C.
FIGURE 4.26. Fourth metacarpal shaft fracture. This fracture is usually caused by a blow to
the closed fist. In this patient the fracture (arrows) was only visible on (A) the lateral view. It
was not seen on (B) the PA view or (C) the oblique view. Another illustration of the need for
multiple views in extremity fractures. The most serious deformity in these spiral fractures is
rotation, which is more reliably assessed clinically than radiologically.

A.
FIGURE 4.27. Boxer fracture.

This patient punched a wall and
sustained a slightly comminuted
fracture of the fifth metacarpal
neck. (A) PA and (B) lateral views
show that the distal fracture
fragment (arrows) is angulated
palmarly and is slightly rotated.
As with spiral shaft fractures,
the rotation is the most signifi-
cant deformity.
B.

SUGGESTED READING
Saunders, 2008:272366.
Rogers LF. Radiology of Skeletal Trauma. New York, NY: Churchill Livingstone, 2002:874930.
Yin Y, Mann FA, Gilula LA. In: Gilula LA, Yin Y. eds. Imaging of the Wrist and Hand.
Philadelphia, PA: WB Saunders, 1996:93157.

PHALANGEAL FRACTURES
KEY FACTS
The commonest finger bone to be fractured is the distal phalanx. These bones are
typically crushed, resulting in a comminuted but minimally displaced fracture of
the terminal tuft.
Open injuries to the distal phalanx are not infrequent. In these injuries, portions
of the phalanx are often lost.
Avulsion of the extensor tendon from the base of the distal phalanx occurs as
a result of a blow to the end of an extended finger. The characteristic defor-
mity is persistent flexion of the distal interphalangeal jointknown as a mallet
deformity.
Mallet deformities are often associated with avulsion fractures of the dorsal lip of
the base of the distal phalanx.
Hyperextension injuries can avulse the cartilaginous volar plate (into which the
short flexor tendon inserts) from the palmar aspect of the base of the middle
phalanx. This usually results in a small fragment of bone being avulsed from the
phalanx (Fig. 4.28).
True lateral views of the injured fingers (without overlapping fingers) are essen-
tial to show the small avulsion fractures associated with mallet and volar plate
injuries.
Abduction injuries to the thumb result in avulsion of the ulnar collateral liga-
ment from the base of the proximal phalanx. This injury, known as gamekeepers
thumb, usually includes a small fragment of bone and may involve the articular
surface (Fig. 4.29).

A. B.
FIGURE 4.28. Volar plate fracture. (A)

Oblique and (B) lateral views of the little
finger show a small avulsed fragment
(arrows) at the base of the middle pha-
lanx. As with most of these injuries, the
fracture cannot be seen on (C) the PA
view. The lateral view is essential to show
displacement, and often is the only view
on which the fracture can be identified.
C.

FIGURE 4.29. Gamekeepers thumb. AP view of the thumb showing a small piece of bone
(arrow) that has been avulsed from the ulnar aspect of the base of the proximal phalanx.
This fragment is markedly displaced. It represents an avulsion of the ulnar collateral liga-
ment and the metacarpophalangeal joint is almost certainly unstable when the fragment is
displaced this much.

SUGGESTED READING
Saunders, 2008:272366.
874930.
Trumble TE, Sack JT. In: Hansen ST, Swiontkowski MF. eds. Orthopaedic Trauma Protocols.
New York, NY: Raven Press, 1993:153185.
Yin Y, Mann FA, Gilula LA. In: Gilula LA, Yin Y. eds. Imaging of the Wrist and Hand. Philadelphia,
PA: WB Saunders, 1996:93157.

CHAPTER
5 Pelvis/Lower Extremity
OVERVIEW OF PELVIC FRACTURES
KEY FACTS
The most common mechanisms for pelvic ring disruptions are motor vehicle
collisions (48%), car versus pedestrian (18%), falls (14%), motorcycle collisions
(11%), crush injuries (4%), and miscellaneous (5%). Mortality varies from 5% to
50% and correlates with the Injury Severity Score and the age of the patient.
Commonly associated injuries include hemorrhage, nerve injury, bowel injury,
intraperitoneal and extraperitoneal bladder rupture, and urethral injury in
men.
The most commonly used classification scheme to describe pelvic fractures is
the modified Young and Burgess classification. This classification is based on the
major vector force of injury: anteroposterior (AP) compression, lateral compres-
sion, vertical shear, and combined mechanism.
Determination of fracture mechanism and stability affect the surgical approach
to treatment.
When there is disruption of the anterior or posterior sacroiliac (SI) ligaments,
there is usually diastasis of the anterior or posterior portions of the SI joint. The
iliac wing becomes unstable with respect to rotation.
Vertical instability occurs when there is complete disruption of the SI ligaments.
The iliac wing is then unstable to vertical and rotational stress. Vertical displace-
ment of the inferior margin of the SI joint is a direct sign of instability, but vertical
instability should also be suspected when there is diastasis of both the anterior
and posterior SI joints.
Obturator ring fractures rarely occur in isolation, and close inspection for disrup-
tion of the posterior pelvic ring is indicated in their presence.
300

Chapter 5 Pelvis/Lower Extremity 301
SUGGESTED READING
Kellam JF, Mayo K. Pelvic ring disruptions. In: Browner BD, Jupiter JB, Levine AM, et al., eds.
Skeletal Trauma, 3rd ed. Philadelphia, PA: WB Saunders, 2003:10521062.
Stambaugh LE III, Blackmore CC. Pelvic ring disruptions in emergency radiology. Eur J Radiol
2003;48(1):7187.

302 Chapter 5 Pelvis/Lower Extremity
PELVIC APOPHYSEAL AVULSIONS
KEY FACTS
Pelvic apophyseal injuries are the result of a forceful muscular pull, usually
secondary to athletic activities.
These injuries typically occur in adolescents before closure of the physis, when
the muscle and tendon are stronger than their apophyseal attachment.
These avulsions are often initially diagnosed as a muscle pull.
When acute, the origin of the fracture fragment is usually obvious on radiographs.
However, if initial imaging is delayed into the healing phase, more ominous diag-
noses, such as tumor, may be considered. This can lead to unnecessary and at
times disastrous biopsies.
The pelvic apophyses and their associated muscles are as follows:
Iliac crest: abdominal muscles (avulsion known as hip pointer)
Anterior superior iliac spine: sartorius and tensor fascia lata
Anterior inferior iliac spine: rectus femoris
Ischial tuberosity: biceps femoris (hamstrings)
When an apophyseal avulsion is detected in an adult without an antecedent his-

tory of significant trauma, pathologic fracture should be considered until proven
otherwise.

A. B.
FIGURE 5.1. AP pelvis radiograph (A)

shows anterior superior iliac spine avulsion
fracture. AP hip (B) shows anterior inferior
iliac spine avulsion fracture and parent site
(arrow). AP hip (C) shows ischial tuberosity
avulsion fracture (arrow).
C.
SUGGESTED READING
Rogers LF. Radiology of Skeletal Trauma, 3nd ed. Philadelphia, PA: Churchill Livingstone,
2002:10091013.
Sanders TG, Zlatkin MB. Avulsion Injuries of the Pelvis. Semin Musculoskelet Radiol
2008;12(1):4253.

LATERAL COMPRESSION PELVIC INJURY
KEY FACTS
Lateral compression results from a blow to the side of the pelvis or hip, such as
when an automobile is broadsided.
The lateral compression fracture is the most common pattern encountered in
most series, accounting for 60% to 70% of pelvic ring fractures.
Horizontal or coronal plane obturator ring fractures are noted in nearly every
case. The fracture fragments may overlap.
A buckle type fracture of the sacral ala, often extending inferiorly into the
sacrum, is seen in nearly 90% of cases.
The sacral fracture may be quite subtle on conventional radiographs, with only
minimal asymmetry of the involved ala or disruption of arcuate lines of the
sacrum. The sacral fracture, however, is obvious on computed tomography (CT)
scan.
Internal rotation of the pelvis may cause diastasis of the SI joint from disruption
of the posterior SI ligament or a fracture of a crescent-shaped fragment from
the posterior ilium at the posterior SI ligament attachment. These injuries are
unstable to rotation.
Pubic symphysis diastasis does not occur with this mechanism of injury.
Complex or combined mechanisms are common. One pattern of interest is the
so-called windswept pelvis, an internal rotation (lateral compression) injury
on one side and external rotation (AP compression) injury on the contralateral
side.

FIGURE 5.2. Lateral compression fractures:

two patients. A. Patient 1. AP pelvis shows
horizontally oriented overlapping fractures
of the left superior and inferior pubic rami
(black arrowheads, superior; white arrow,
inferior). Fractures of the right root of the
superior pubic ramus (curved black arrow)
and inferior pubic ramus (white arrow) were
also seen. The arcuate line of the right S1
foramen (diagonal black arrow) is not con-
tinuous (compared to left) indicating sacral
fracture. B. Patient 2. The buckling fracture
of the upper sacrum may be subtle on plain
radiographs, but CT will show the lesion as
on this axial image (arrow).
A.
B.
SUGGESTED READING
Resnik CS. Pelvic and acetabular trauma. In: Mirvis SS, Shanmuganathan K, ed. Imaging in
Trauma and Critical Care. Philadelphia, PA: Saunders, 2003:559573.
2003;48(1):7187.

ANTEROPOSTERIOR COMPRESSION PELVIC INJURY
KEY FACTS
AP compression pelvic fracture follows a force applied either directly to the ante-
rior or to the posterior pelvis and results in varying degrees of open book or iliac
external rotation deformity.
AP compression pelvic fracture accounts for 15% of pelvic ring fractures and
is intermediate in frequency between lateral compression and vertical shear
injuries.
SI joint diastasis with either symphysis pubis diastasis or vertical fractures of the
obturator ring are the hallmarks of this fracture pattern.
The greater the separation of the symphysis pubis, the greater the implied liga-
mentous damage and, hence, the unstable nature of the fracture. Diastasis of
the symphysis pubis greater than 2.5 cm is associated with anterior SI ligament
disruption and rotational instability.
Obturator ring fractures are variable and usually indicative of a direct blow to the
symphysis.
CT scanning of the SI joints can show disruption anteriorly with intact posterior
articulation in the more stable types.
Widening of the posterior SI joints implies disruption of the important posterior
SI ligaments and a vertically, as well as rotationally, unstable injury.
Determination of pelvic stability, in our institution, is primarily a clinical decision,
with the imaging used as an adjunct.

A.
B.
FIGURE 5.3. Anteroposterior compression injury: A. Widening of the symphysis pubis

(black arrow) and left SI joint (white arrow) is the hallmark of this fracture pattern. There
is contrast in the bladder, which is compressed by a pelvic hematoma. B. Axial CT shows
anterior SI joint diastasis (open book) indicating rotational instability.
SUGGESTED READING
Resnik CS. Pelvic and acetabular trauma. In: Mirvis SS, Shanmuganathan K, eds. Imaging in
2003;48(1):7187.

VERTICAL SHEAR PELVIC INJURY
KEY FACTS
The mechanism of injury is an asymmetric axial load on the pelvis, often transmit-
ted through the ipsilateral lower extremity.
Vertical shear pelvic fractures account for 6% to 13% of pelvic ring fractures.
The characteristic finding in all cases of vertical shear pelvic fracture is supe-
rior displacement of the involved hemipelvis with respect to the opposite side on
conventional radiographs.
The pelvic outlet view radiograph is useful to confirm superior displacement of
the involved hemipelvis.

Anteriorly, vertical fractures of the obturator rings or symphysis diastasis are
noted.
Posterior disruption of the pelvis involves anterior and posterior SI diastasis or
sacral fracture or iliac wing fracture.

Occasionally, disruption of the symphysis pubis and SI joint are noted without
fracture, and displacement of the pelvis occurs through these structures.

These injuries are vertically and rotationally unstable.

A.
B.
FIGURE 5.4. Vertical shear fracture: A. AP pelvis radiograph shows upward displacement
of the right hemipelvis in relation to the sacrum. There are fractures of the right and left
obturator rings (black arrows), the left sacrum (white arrow), and a transverse fracture of the
right acetabulum (arrowhead ). B. Axial CT shows widening of the entire right SI joint (white
arrow) secondary to disruption of the anterior and posterior SI ligaments. This allows for
rotational and vertical instability. There is extravasated contrast (black arrow) from angiogra-
phy of a transected pelvic artery.
SUGGESTED READING
Resnik CS. Pelvic and acetabular trauma. In: Mirvis SS, Shanmuganathan K, ed. Imaging in
2003;48(1):7187.

PELVIC RING DISRUPTION AND ARTERIAL INJURY
KEY FACTS
The majority of associated deaths are due to hemorrhage. Sources of pelvic hem-
orrhage include arteries, veins, and muscular and osseous structures.
Modalities for treating pelvic hemorrhage include pneumatic antishock garment,
external fixation, surgical exploration and ligation, and angiographic emboliza-
tion. External fixation controls hemorrhage from osseous, venous, and minor
arterial origins.
Arterial bleeding is usually from internal iliac artery branches; frequency, in
descending order, are superior gluteal, internal pudendal, lateral sacral, and
obturator arteries.
Predictors of major hemorrhage related to pelvic fractures include pubic sym-
physeal diastasis of at least 1 cm, obturator ring fractures displaced by at least
1 cm, hematocrit at or below 30, or heart rate of 130 or higher.
There is a high frequency of arterial hemorrhage in AP compression, vertical
shear, combined mechanism, crush fracture of the sacrum, and any fracture
extending to the greater sciatic notch. Neither conservative management by
blood volume replacement nor aggressive management by surgical exploration
and ligation of the internal iliac arteries has proven successful in controlling arte-
rial hemorrhage. Bilateral internal iliac artery ligation usually fails because the
extensive pelvic collaterals prevent the isolation of the bleeding site. Further-
more, decompression of the hematoma may release its tamponade effect, leading
to intraoperative death from exsanguination.
Transcatheter embolization is utilized to control arterial hemorrhage. Seven to
eleven percent of the patients undergoing angiography may require emboliza-
tion; 1.7% in simple lateral compression and 20% in AP compression, vertical
shear, and combined mechanism. Transcatheter embolization, with Gelfoam
and/or coils, should be performed in all cases of arterial injury manifesting as
contrast extravasation, abrupt or tapered occlusion, and pseudoaneurysm. A
temporary occlusion balloon can be placed for active bleeding from transected
common iliac, external iliac, or common femoral artery. The patient can then be
transported for emergency surgical repair.

A.
B.
FIGURE 5.5. An 81-year-old woman involved in a high-speed motor vehicle accident sus-
tained a lateral compression pelvic fracture. She became hypotensive and developed an
expanding hematoma in the right pelvis. Selective angiography (A) demonstrated active
extravasation from an anteromedial branch of the right obturator artery (arrow ). The injured
vessel was successfully embolized (B) by placing microcoils across its origin.
SUGGESTED READING
Ben-Menachem Y, Coldwell DM, Young JWR, et al. Hemorrhage associated with pelvic
ring disruptions: causes, diagnosis, and emergent management. Am J Roentgenol
1991;157:10051014.
Blackmore CC, Cummings P, Jurkovich GJ, et al. Predicting major hemorrhage in patients
with pelvic fracture. J Trauma 2006;61(2):346352.
Metz CM, Hak DJ, Goulet JA, et al. Pelvic fracture patterns and their corresponding angio-
graphic sources of hemorrhage. Orthop Clin North Am 2004;35:431437.

SACRAL FRACTURE
KEY FACTS
Fewer than 5% of sacral fractures occur as isolated injuries. Most are associated
with pelvic or lumbar spine fractures.
Sacral fractures are usually vertical in orientation, with only 5% to 10% occurring
in the transverse plane.
High transverse fractures at the S1 or S2 level are usually secondary to a high
energy injury, such as a fall. Typically, there is kyphosis and overriding on the
lateral radiograph.
Low transverse fractures (S3 or S4) are usually due to a direct blow with a fracture
at the level of the lower end of the SI joints. Both types of transverse sacral frac-
ture are frequently associated with neurologic deficit.
Using plain radiographs and CT, approximately 90% of pelvic fractures have asso-
ciated sacral injury.
One useful classification is the Denis Classification, which divides the sacrum
into the following three zones:
Zone I. Lateral to foramina: 50% of cases, 6% neurologic deficits
Zone II. Transforaminal: 34% of cases, 28% neurologic deficits
Zone III. Central canal involvement: 16% of cases, 57% neurologic deficits
Plain radiographs initially detect only 30% of sacral fractures; another 35% can
be seen in retrospect. Transverse sacral fractures are difficult to see on frontal
radiographs, and careful analysis of the lateral radiograph is essential. Disruption
of the arcuate lines, the dense cortical arcs outlining the roof of each sacral fora-
men, is a useful sign of sacral fracture on the AP radiograph.
We perform CT for any recognized or suspected sacral fracture or SI disruption.
Transverse injuries may not be visible on axial images, but are easily identified
on sagittal images.
A.

B.
C.
FIGURE 5.6. A. AP view of the pelvis shows fractures of the right and left sacrum with
disruption of arcuate lines (black arrows). B. Axial CT shows left Zone I (black arrow) and
right Zone 2 (white arrow) sacral fractures. C. Sagittal CT reformation shows the transverse
component of this U-shaped fracture (arrow). The transverse component was not visible on
axial or coronal CT images.
SUGGESTED READING
Levine AM. Lumbar and sacral spine trauma. In: Browner BD, Jupiter JB, Levine AM, et al.,
eds. Skeletal Trauma, 3rd ed. Philadelphia, PA: WB Saunders, 2003:10311040.
Porrino JA Jr, Kohl CA, Holden D, et al. The importance of sagittal 2D reconstruction in pelvic
and sacral trauma: avoiding oversight of U-shaped fractures of the sacrum. Am J Roent-
genol 2010;194(4):10651071.
White JH, Hague C, Nicolaou S, et al. Imaging of sacral fractures. Clin Radiol 2003;58:
914921.

BASIC ACETABULAR ANATOMY
KEY FACTS
The supporting columns of the acetabulum when viewed from the side have been
likened to an inverted Y. The upper vertical limb is the iliac crest, the anterior
limb is the anterior acetabulum and anterior obturator ring, and the posterior
limb is the posterior acetabulum and posterior obturator ring.
The anterior column consists of the vertical and anterior limbs (anterior aspect
of the iliac wing, anterior acetabulum, and superior pubic ramus).

The posterior column consists of the posterior limb (the posterior acetabulum,
ischiopubic ramus, and ischium).

Acetabular imaging begins with the AP view of the pelvis. The AP is sometimes
supplemented with Judet views: 45-degree anterior and posterior oblique views
of the involved hemipelvis. CT is indicated in all acetabular fractures to complete
the workup.
Basic observations on the radiographs include detection and localization of frac-
tures to the appropriate column or wall.
On the AP radiograph, column markers are the following:
Anterior columniliopectineal line
Posterior columnilioischial line
On the Judet views:

The posterior (iliac) oblique shows the posterior column to best advantage.
The anterior (obturator) oblique shows the anterior column and posterior wall
to best advantage.
Observations on CT scans include localization of the fracture to the appropriate
wall or column, evaluation of the articular weight-bearing surface, detection of
intra-articular fragments, and femoral head injury.

FIGURE 5.7. AP view of the pelvis shows the iliopectineal line (black arrowheads) delineat-
ing the anterior column and the ilioischial line (white arrowheads) delineating the posterior
column. The arcuate lines are well demonstrated (white arrows).
SUGGESTED READING
Brandser E, Marsh JL. Acetabular fractures: easier classification with a systematic approach.
Am J Roentgenol 1998;171(5):12171228.
Durkee NJ, Jacobson J, Jamadar D, et al. Classification of common acetabular fractures:
radiographic and CT appearances. Am J Roentgenol 2006;187(4):915925.

ANTERIOR HIP DISLOCATION
KEY FACTS
These injuries account for approximately 10% of hip dislocations.
The mechanism of injury involves forced abduction and external rotation.
Anterior dislocations are usually displaced inferomedial, often projecting over
the obturator ring on the AP pelvic radiograph.
Femoral head injuries are common, with an acetabular rim fracture occurring
less commonly than with posterior hip dislocations. CT scans often show injuries
to the femoral head and rim better than conventional radiographs.
CT scanning is indicated for all hip dislocations. CT is the optimal procedure to
evaluate the joint space including joint congruity, retained osseous fragments,
and associated acetabular or femoral head fractures.
Failure to obtain an anatomic reduction of the joint should suggest entrapped
fragments or interposed cartilaginous labrum. If the CT scan does not show ossi-
fied loose fragments, CT or MR arthrography may be useful for detecting carti-
laginous bodies or a displaced labrum.

FIGURE 5.8. AP pelvis view demonstrates an anterior dislocation of the right hip. The fem-
oral head overlies the right obturator ring.
SUGGESTED READING
Erb RE, Steele JR, Nance EP Jr, et al. Traumatic anterior dislocation of the hip: spectrum of
plain film and CT findings. Am J Roentgenol 1995;165(5):12151219.
Goulet JA, Levine PE. Hip dislocations. In: Browner BD, Jupiter JB, Levine AM, et al., eds.

POSTERIOR HIP DISLOCATION
KEY FACTS
Posterior dislocations account for approximately 90% of hip dislocations. A cen-
tral dislocation refers to displacement of the femoral head into the pelvis via a
break in the medial wall of the acetabulum. This term is not favored by orthope-
dic surgeons because the injury really represents an acetabular fracture.
The mechanism of injury in most cases involves the knee striking the dashboard
during a motor vehicle collision, frequently involving unrestrained occupants,
thus forcing the femoral head posteriorly.
Femoral head injuries occur as the femoral head exits the acetabulum. Avulsions
from the ligamentum teres also occur.
Complications of a posterior hip dislocation include the following:
Osteoarthritis secondary to articular cartilage injury or retained loose frag-
ments
Osteonecrosis:
Reported incidence varies from 1% to 15% with an average of 10%.
Delay in reduction is considered an important etiologic factor.
Associated injuries include those typical of high energy trauma: central nervous
system, cardiovascular, lung and chest wall, visceral, and other musculoskel-
etal injuries. Ipsilateral lower extremity, hip, and acetabular fractures must be
excluded.
Radiographic hallmarks include the following:
Superior and lateral displacement of the femoral head
Involved femoral head smaller (closer to film) than the contralateral hip on AP
pelvis radiograph
Internal rotation of femur

A.
B.
FIGURE 5.9. A. Patient 1 with left posterior hip dislocation. Compare the sizes of the femo-
ral heads (H)the left appears smaller since it is closer to the film. A triangular piece of
posterior acetabular wall (arrows) is seen above the head (H). B. Patient 2. AP radiograph of
the pelvis shows superior displacement of the right femoral head (H), superiorly displaced
posterior wall fragments and comminuted fracture of the remainder of the posterior wall
(arrows).
SUGGESTED READING
Goulet JA, Levine PE. Hip dislocations. In: Browner BD, Jupiter JB, Levine AM, et al., eds.

POSTERIOR WALL ACETABULAR FRACTURE
KEY FACTS
About one third of acetabular fractures involve the posterior wall, and are usually
associated with posterior dislocation of the hip.
Associated femoral head injury, usually either an impaction fracture or a shear-
ing injury, is noted in 12% of posterior dislocations. It may be subtle and best seen
on CT.
Focal compression of the acetabular articular surface, or marginal impaction,
(die-punch fracture) is seen in about one quarter of posterior dislocations and
is seen best on axial CT scans. Preoperative diagnosis of marginal impaction is
essential for surgical planning; treatment includes elevation of the depression
and placement of bone graft in any residual defect.
Forty-five percent of patients with posterior wall fractures have associated frac-
tures elsewhere in the skeleton, often in the femoral neck or shaft and adjacent
pelvis.
Associated injuries include the following:
Sciatic nerve injury in 12% of patients
Laceration of the superior gluteal artery
Avascular necrosis of the femoral head in 8% to 10% of patients, usually
occurring 3 to 18 months following dislocation

A.
B.
FIGURE 5.10. A. AP pelvis shows a superiorly displaced right posterior wall fragment
(black arrows). Compare with the normal left posterior wall (white arrows). B. Axial CT
shows the displaced posterior wall fracture (arrow) and a small intra-articular fragment
(black arrowhead).
SUGGESTED READING
Am J Roentgenol 1998;171(5):12171228.

TRANSVERSE ACETABULAR FRACTURE
KEY FACTS
The term transverse can be confusing, but is based on the original anatomic
description of Judet and Letournel, viewing the acetabulum from a lateral per-
spective.
On the AP view of the pelvis, the transverse fracture disrupts the ileopectineal
and ilioischial lines.

On CT scanning, the fracture is oriented in the sagittal plane through the
acetabulum. It does not extend to the iliac wing or the obturator ring.
While this fracture involves the anterior and posterior columns, it is not classi-
fied as a both column fracture.
Both column fractures involve the iliac wing and the obturator ring.
Both column fractures are coronally oriented on CT.
Transverse fractures are elementary or simple lesions in the Letournel-Judet clas-

sification. Complex variations, T-shaped and transverse with posterior wall pat-
terns, also occur. Transverse fractures and its variants account for approximately
one third of acetabular fractures.
T-shaped fractures are transverse fractures with extension inferiorly into the
obturator ring.
Transverse with posterior wall fractures are transverse fractures with separate
posterior wall factures.

A.
B.
FIGURE 5.11. AP pelvis (A) and obturator (anterior) oblique Judet (B) radiographs show a
fracture of the left acetabulum disrupting the ilioischial line in (A) (left white arrow), and the
iliopectineal line in (A) and (B) (black arrow in B). On the normal right side, white arrows
show the ilioischial line, black arrows show the iliopectineal line. A comminuted fracture
of the posterior wall of the acetabulum is present with fragments above and below the
acetabulum (curved arrows, A and B). (continued )

C.
D.
FIGURE 5.11. (continued ) C. Axial CT scan through the tectum (roof) of the left acetabulum
shows the typical anterior-posterior orientation of the transverse fracture pattern (white
arrows). D. Axial CT scan through the hip joints show the obliquely oriented posterior wall
fracture (white arrows) and multiple displaced fragments of the posterior wall (curved
arrows).

SUGGESTED READING
Am J Roentgenol 1998;171(5):12171228.

BOTH COLUMN ACETABULAR FRACTURE
KEY FACTS
The both column acetabular fracture is the most common of the complex acetab-
ular fracture patterns and accounts for 20% to 25% of all acetabular fractures.
In this fracture, the acetabulum is dissociated from the intact portion of the ilium
and its SI attachments. The acetabulum essentially floats free, usually displaced
medially into the pelvis. It is highly unstable and requires surgical reduction.
This pattern must be distinguished from the transverse fracture pattern, since
the surgical approach is different. Both fractures involve the anterior and poste-
rior columns of the acetabulum, but the fracture patterns are distinct (see Trans-
verse Acetabular Fracture discussion).
Although not always present, the pathognomonic sign of the both column frac-
ture is the spur sign seen on the obturator oblique Judet view (injured side rotated
up 45-degree) and CT.
The spur represents the part of the ilium that remains attached to the sacrum
at the SI joint. Following the ilium caudally on CT scanning, the spur does not
attach to the roof of the acetabulum, confirming the diagnosis.
Anterior and posterior column fractures as well as both column fractures are
oriented in the coronal plane on CT scans through the roof of the acetabulum.
Anterior column fractures extend anteriorly at the mid acetabular level, poste-
rior column fractures extend posteriorly at the mid acetabular level, and both
column fractures usually extend centrally. Anterior and both column fractures
always extend into the iliac wing. Anterior, posterior, and both column fractures
always extend into the obturator ring.

A.
FIGURE 5.12. A. AP pelvis shows a left acetabular fracture with disruption of the ilio-
pectineal and ilioischial lines. The acetabulum is displaced medially into the pelvis. There
are associated fractures of the left iliac wing (black arrows) and the left obturator ring (white
arrows). (continued )

B.
C.

D.
E.
FIGURE 5.12. (continued ) BD. Axial CT scans of the pelvis show that a portion of the
ilium, the spur (S), remains attached to the SI joint but is not continuous with the roof of
the acetabulum. This is the hallmark of the both column fracture. The fracture line through
the acetabulum is coronal in orientation at the level of the acetabular roof, typical of a col-
umn fracture (arrow in D). E. Coronal CT shows medial displacement of the left acetabulum
into the pelvis. The left femoral head (H) is subluxed laterally in relationship to the acetabu-
lum, likely secondary to hemarthrosis.
SUGGESTED READING
Am J Roentgenol 1998;171(5):12171228.

INTRACAPSULAR FEMORAL NECK FRACTURE
KEY FACTS
Intracapsular femoral neck fractures occur predominantly in osteoporotic indi-
viduals. Ninety-seven percent occur in patients over the age of 50. Women are
affected more frequently than men by a ratio of 3:1 to 6:1.
Intracapsular femoral neck fractures occur in elderly osteoporotic individuals fol-
lowing minor trauma such as a ground level fall. Occasionally, they may occur in
the absence of trauma due to normal weight bearing, which is the insufficiency
fracture. The insufficiency fracture may occur first, leading to a fall (fracture and
fall).
Femoral neck fractures may involve the junction of the head and neck (subcapi-
tal), the mid portion (transcervical), or the base of the neck (basicervical). The
subcapital fracture is more common in acute trauma, whereas stress fractures
and insufficiency fractures are usually basicervical in location. Transcervical
fractures are uncommon.
Intracapsular femoral neck fractures are classified as follows:
Impacted
Displaced
Complete or incomplete
Gardens classification of subcapital fractures is as follows:

I: nondisplaced, impacted incomplete fracture
II: nondisplaced, complete fracture
III: complete fracture, partial displacement
IV: complete fracture, total displacement
Complications of intracapsular femoral neck fractures include the following:

Osteonecrosis:
15% to 35%
Major blood supply to the head is through the capsular branches of the cir-
cumflex femoral artery along the surface of the femoral head. The artery of
the ligamentum teres only supplies a small area of bone at the fovea capitis.
Increase in intracapsular pressure leading to decreased venous return and
diminished arterial perfusion has also been implicated in compromising
the blood supply to the femoral head.
Nonunion:
25% to 33% in displaced fractures undergoing surgical reduction
Rare with nondisplaced fractures
Treatment of intracapsular fractures of the femoral neck includes orthopedic

pins and screws for undisplaced fractures and total hip replacement for dis-
placed fractures.

A. B.
C. D.
FIGURE 5.13. Frontal (A) and lateral (B) radiographs of the left hip demonstrate a nondis-
placed complete intracapsular subcapital fracture of the left femoral neck. Coronal T1 (C)
and short tau inversion recovery (STIR) (D) images from an magnetic resonance imaging
(MRI) of the pelvis and both hips show a complete fracture of the left femoral neck. The
fracture line demonstrates low signal intensity on T1 (white arrow). There is surrounding
bone marrow edema with low signal intensity on T1 and high signal intensity on STIR. There
is a hip joint effusion.
SUGGESTED READING
Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency
department. Am J Roentgenol 2010;194:10541060.
Rogers L. Radiology of Skeletal Trauma, 3rd ed., vol. 2. 2002:10301109, Chapter 20.

OCCULT HIP FRACTURE
KEY FACTS
The usual clinical setting for an occult hip fracture is an elderly patient with new
onset of hip or groin pain and new inability to bear weight following a fall or
other minor traumatic event. The proximal femur is at particular risk for occult
fracture due to a high percentage of trabecular bone.
Failure to recognize occult hip fractures can lead to displacement and the com-
plications of nonunion or avascular necrosis (AVN). Delayed diagnosis of just
2 days doubles mortality.
Radiographs are 90% sensitive for the detection of hip fractures; however, 3% to
4% of patients undergoing radiographic evaluation for suspected hip fracture will
have radiographically occult fractures. If an elderly osteoporotic patient experi-
ences new onset of hip or groin pain and/or an inability to bear weight following
minor trauma and no fracture is detected on initial radiographs, additional imag-
ing with MRI is recommended.
MRI can show the radiographically occult fracture within hours of the injury and
is quite cost-effective. The fracture is readily seen as a linear band of decreased
signal intensity on T1 and T2/STIR images on a background of bone marrow
edema characterized by increased T2 signal intensity.
MRI is superior to nuclear medicine bone scan and CT in diagnosing occult frac-
tures of the femoral neck. MRI can characterize the fracture as incomplete or
complete. It may identify another occult fracture elsewhere in the pelvic ring. It
may diagnose another cause for hip pain such as osteonecrosis or neoplasm.
CT is less sensitive for fracture detection because of the decreased contrast reso-
lution of fractures in osteoporotic bone.
Radionuclide bone scanning is often negative in the first few hours following frac-
ture. Sensitivity improves with time: about 80% after 24 hours, 95% after 3 days,
and nearly all by 7 days. Sensitivity is generally reduced in the elderly.

A. B.
FIGURE 5.14. A. Frontal radiograph of the left hip shows no abnormality. B. Coronal STIR
image from an MRI of the pelvis and both hips demonstrates bone marrow edema in the
greater trochanter of the left hip (arrow) representing a bone contusion.
SUGGESTED READING
Haramati N, Staron RB, Barax C, et al. Magnetic resonance imaging of occult fractures of the
proximal femur. Skeletal Radiol 1994;23:1922.
Pope TL, Bloem HL, et al. Acute osseous injuries to the hip and proximal femur. Imaging of the
musculoskeletal system. Philadelphia, PA: Saunders Elsevier, 2008:470498, Chapter 20.
Sankey RA, Turner J, Lee J, et al. The use of MRI to detect occult fractures of the proximal
femur: a study of 102 consecutive Cases over a ten year period. J Bone Joint Surg Br
2009;91-B:10641068.

STRESS AND INSUFFICIENCY FRACTURES OF THE FEMORAL

NECK
KEY FACTS
Stress fractures of the femoral neck occur due to abnormal stresses on normal bone,
while insufficiency fractures occur due to normal stresses on abnormal bone. Stress
fractures occur in long distance runners and military recruits. Insufficiency fractures
occur in osteoporotic individuals. Osteoporosis may be due to old age, disuse, renal
insufficiency, or steroid use.
Stress fractures encountered in athletes are more likely to occur at the inferior
base of the medial femoral neck near the calcar (basicervical). These are com-
pression fractures. Osteoporotic individuals sustaining insufficiency fractures
may have basicervical stress fractures as well. They are also prone to tensile frac-
tures at the lateral aspect of the femoral neck in a subcapital location similar to
femoral neck fractures encountered in osteoporotic individuals following minor
trauma.
Femoral neck stress fractures are bilateral in approximately 10% of cases.
The radiographic appearance is that of a band of sclerosis crossing the com-
pressile trabeculae for compression-type fractures and crossing the tensile tra-
beculae for tensile-type fractures. One may also see discontinuity of the cortex. A
radiolucent line appears when the fracture becomes displaced.
Radiographs are initially normal in up to 40% of cases and can lag 2 to 6 weeks
beyond the onset of symptoms. Under the appropriate clinical circumstances,

MRI could be performed to facilitate early diagnosis and to prevent progression
to a complete fracture.
MRI is superior to nuclear medicine bone scan in diagnosing stress fractures.
MRI will reveal the fracture in the immediate hours following injury. It will char-
acterize the fracture as compressile or tensile, incomplete or complete. It can
also identify other causes for the patients symptoms, such as other stress frac-
tures in the bony pelvis, osteonecrosis, or neoplasm.

The treatment of undisplaced incomplete compressile stress fractures at the

medial base of the femoral neck near the calcar is conservative with a period
of limited weight bearing and cessation of activities that brought on the stress
fracture. The treatment of undisplaced incomplete tensile fractures at the lateral
aspect of the femoral neck is orthopedic pins and screws because of the risk of
displacement.
Insufficiency fractures in osteoporotic patients may also occur in the superior
acetabulum, pubic rami, and femoral head. These insufficiency fractures can be
diagnosed on MRI.
Subchondral insufficiency fractures of the femoral head can be confused with
osteonecrosis and collapse. MR demonstrates a subcapital line in the superior
femoral head with decreased T1 and T2 signal with variable surrounding edema
(decreased T1, increased T2 signal, and gadolinium enhancement).

A. B.
C. D.
FIGURE 5.15. Occult insufficiency fracture of the femoral neck. Frontal (A) and lateral (B)
plain radiographs of the right hip show no evidence of fracture. There is vascular calcifica-
tion. The patient is an elderly woman with chronic hip pain. C and D. MRI of a subacute
insufficiency fracture of the right femoral neck. Coronal T1 (C) and STIR (D) images of
the pelvis and bilateral hips of an elderly woman with chronic right hip pain show a subacute
insufficiency fracture of the medial right femoral neck. There is mild bone marrow edema
in the right femoral neck with low signal intensity on T1 and high signal intensity on STIR.
There is a line of low signal intensity in the medial right femoral neck on T1 that is also
visualized on STIR (arrows) concerning for an incomplete fracture.

SUGGESTED READING
Bryant LR, Song WS, Banks KP, et al. Comparison of planar scintigraphy alone and with
SPECT for the initial evaluation of femoral neck stress fracture. Am J Roentgenol 2008;
191:10101015.
Egol K A, Koval KJ, Kummer F, et al. Stress fractures of the femoral neck. Clinical orthopae-
dics and related research. Number 348, March 1998:7278.
Gerot IL, Demondion X, Louville AB, et al. Subchondral fractures of the femoral head: a
review of seven cases. Joint Bone Spine 2004;71(2):131135.
Rafii M, Mitnick H, Klug J, et al. Insufficiency fracture of the femoral head: MR imaging in
three patients. Am J Roentgenol 1997;168:159163.

EXTRACAPSULAR PROXIMAL FEMUR FRACTURES:

INTERTROCHANTERIC FEMUR FRACTURE
KEY FACTS
Intertrochanteric femur fractures usually occur in the elderly patient, with
women and men equally affected. Most of these fractures are due to falls. Inter-
trochanteric fractures are seen in younger patients suffering high energy trau-
matic injuries.
In the setting of high energy trauma, up to 15% of these injuries can have an ipsi-
lateral femoral shaft fracture
Radiographs show that the main fracture line parallels the intertrochanteric
ridge. The simple classification is described in parts, the four parts defined as
the head/neck, shaft, greater and lesser trochanters. The AO classification is also
used.
The following are the simple classification of intertrochanteric femur fractures:
Two part: linear intertrochanteric
Three part: linear intertrochanteric with comminution of greater or lesser tro-
chanter
Four part: intertrochanteric with comminution of both trochanters
Multipart: comminution of both trochanters and intertrochanteric region
Like femoral neck fractures, intertrochanteric femur fractures can be occult and
MRI may be used to detect these injuries (see Occult Hip Fracture).
An incomplete intertrochanteric fracture extends from the greater trochanter
into the intertrochanteric region but does not disrupt the medial cortex. It is
best seen on MRI, as it may be occult or misinterpreted as an isolated greater
trochanter fracture on radiographs.
Nonunion and osteonecrosis are uncommon in this fracture because of the abun-
dant blood supply of the intertrochanteric region.
Isolated fractures of the greater trochanter may occur in elderly patients. They
are avulsion fractures of the greater trochanter.
Isolated fractures of the lesser trochanter may occur in children and adolescents
due to avulsion of the apophysis by the iliopsoas. Isolated avulsion fractures of
the lesser trochanter are unusual in older individuals and should raise concern
for a pathologic fracture due to bony metastatic disease.
Surgical treatment of intertrochanteric fractures is with a dynamic hip screw
that allows compression across the screw to prevent migration and failure of the
components.

A. B.
C. D.
FIGURE 5.16. A 48-year-old man sustaining a 35-foot fall. AP (A) and lateral (B) radiograph
show a linear intertrochanteric right femur fracture. Mildly comminuted fractures of the
right superior and inferior pubic rami are seen. There is contrast in the bladder from a recent
CT. Axial (C) and coronal reformatted (D) CT images of the right femur show comminution
of the lesser trochanter indicating a three part fracture.
SUGGESTED READING
Greenspan A. Lower Limb I: Pelvic Girdle and Proximal Femur. Orthopedic Imaging:
A Practical Approach. Philadelphia, PA: Lippincott Williams & Wilkins, 2004:231241,
Chapter 8.
Pope TL, Bloem HL, et al. Acute Osseous Injuries to the Hip and Proximal Femur. Imaging
of the Musculoskeletal System. Philadelphia, PA: Saunders Elsevier, 2008;20:470498,
Chapter 20.
Schultz E, Miller T, Boruchov SD, et al. Imcomplete intertrochanteric fractures: imaging fea-
tures and clinical management. Radiology 1999;211:237240.

EXTRACAPSULAR PROXIMAL FEMUR FRACTURES:

SUBTROCHANTERIC FEMUR FRACTURE
KEY FACTS
While definitions vary, it is generally accepted that a subtrochanteric femur frac-
ture involves a 3-inch segment of bone extending from the proximal margin of
the lesser trochanter to approximately 2 inches distal to the inferior margin of
the lesser trochanter.
Subtrochanteric femur fractures account for 10% to 34% of hip fractures and
tend to occur in three populations:
Under 50 yearsusually high energy trauma
Over 50 yearslow energy trauma (i.e., falls)
Pathologic fracturesPaget disease and metastatic disease
In the former two categories, the fracture orientation is oblique, often commi-
nuted and involves the intertrochanteric region.
A transverse subtrochanteric fracture is always concerning for a pathologic frac-
ture from metastatic disease or Pagets.
The strong pull of the adductor muscles on the distal fracture fragment in apposi-
tion to the pull of the hip abductors and external rotators on the proximal fracture
fragment results in medial displacement, foreshortening, and varus angulation
across subtrochanteric fractures. It is these strong muscle forces that place the
fracture at risk for nonunion and malunion.
Surgical fixation typically involves a long intramedullary rod or bladed nail that
can withstand the strong muscle forces.
A subtrochanteric fracture may extend into the intertrochanteric region or have
associated femoral neck fractures.

A.
B.
FIGURE 5.17. Frontal (A) and lateral (B) plain radiographs demonstrate a comminuted
subtrochanteric fracture of the proximal left femur. The fracture extends from above the lesser
trochanter to the subtrochanteric region with separation of the lesser trochanter. There is
varus and apex anterior angulation with lateral displacement of the distal fracture fragment.
SUGGESTED READING
Greenspan A. Lower Limb I: Pelvic Girdle and Proximal Femur. Orthopedic Imaging:
A Practical Approach. Philadelphia, PA: Lippincott Williams & Wilkins, 2004:231241,
Chapter 8.
Pope TL, Bloem HL, et al. Acute Osseous Injuries to the Hip and Proximal Femur. Imag-
ing of the Musculoskeletal System. Philadelphia, PA: Saunders Elsevier, 2008:470498,
Chapter 20.

FEMORAL SHAFT FRACTURE
KEY FACTS
The femur is the longest, strongest, and heaviest bone in the body; therefore, it
takes violent high energy trauma to cause a fracture.
Femur fractures are usually seen in young adults as the result of vehicular acci-
dents or gunshot wounds.
In elderly patients without high energy trauma, femur fractures are usually
pathologic fractures from metastatic disease.
Long-term complications of traumatic femur fractures include malunion with
foreshortening of the limb and rotational deformity and contractures at the knee
due to prolonged immobilization.
A commonly used classification scheme is that by Winquist and Hansen.
Type I: minimum or no comminution
Type II: small butterfly fragment comprising less than 50% the circumference
of the femoral shaft.

Type III: large butterfly fragment comprising 50% to 100% of the circumfer-
ence of the femoral shaft.

Type IV: circumferential comminution of the shaft with no contact of the cor-
tices of the major fragments after reduction

Treatment of femoral shaft fractures is with an intramedullary rod and proximal
and distal interlocking screws.
Children are treated with traction and hip spica casts. Overgrowth is a potential
complication of femoral shaft fractures in children. This is countered by not com-
pletely reducing the fracture and allowing 1 cm of overlap.
Approximately 15% are open injuries. These may be treated with traction and
delayed closure or immediate nailing after cleansing and debridement of the
wound depending on the severity of bone contamination.
Occasionally fracture fragments may be extruded through an open wound and
lost.
20% of femur fractures are associated with other injuries in the same leg. These
include fractures of the tibia; patellar fractures; supracondylar fractures of the
distal femur; and proximal injuries at the hip including femoral neck fractures,
intertrochanteric fractures, posterior dislocation of the hip, acetabular fractures,
and pelvic fractures.
An associated tibial fracture leads to the floating knee.
Knee ligamentous injuries occur in 17% to 33% of patients with femoral shaft
fractures.

Because of the associated lower extremity injuries, evaluation of these patients

must include radiographs of the hip, knee, and tibia.
Neurovascular structures of the leg are usually spared except in supracondylar
fractures and penetrating trauma (see Supracondylar Fracture).
Complications of the femoral shaft fracture include significant blood loss
(23 units), venous thromboembolic complications in 40% to 90% of patients
without appropriate prophylaxis, and fat embolism.
CNS, visceral, chest, and spine injuries often coexist.
(see Patella Fractures, Fig. 5.21B).
A. B.
FIGURE 5.18. Frontal (A) and lateral (B) plain radiographs demonstrate a comminuted
fracture of the distal femoral shaft with angulation apex posterior and posterior and lat-
eral displacement of the distal fracture fragment. The fracture is also externally rotated
90 degrees. There is an extruded butterfly fragment situated anterior that is subcutaneous
(arrow). There are also comminuted fractures of the proximal tibia and fibula resulting in a
floating knee.

A. B.
C. D.
FIGURE 5.19. Pathologic femur fracture. A 62-year-old woman with a newly unsteady gait
presented with a fracture of the femoral diaphysis after tripping in her living room. A. AP
radiograph of the left femur demonstrates a transverse fracture of the femoral diaphysis.
There is bone missing from the fracture site, and there is a permeative pattern at the frac-
ture ends. B. Whole body Tc-99 MDP bone scan reveals increased uptake in the pathologic
femoral fracture (arrowheads) in addition to several rib metastases. C. Axial CT of the chest
revealed the primary to be carcinoma of the lung with right hilar invasion (arrow). D. Axial T1
weighted post-gadolinium MRI of the brain reveals an enhancing left cerebellar metastasis
(arrow). Both this history and the radiographic appearance of the femoral fracture should
raise great suspicion for a pathologic fracture.

SUGGESTED READING
Bucholz RW, Jones A. Fractures of the shaft of the femur. J Bone Joint Surg Am 1991;73(10):1561
1566.
Cannada LK, Viehe T, Cates CA, et al. A retrospective review of high-energy femoral neck-shaft
fractures. Southeastern Fracture Consortium. J Orthop Trauma 2009;23(4):254260.
Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium 2007.
J Orthop Trauma 2007;21(Suppl):S1S133.

SUPRACONDYLAR FRACTURE OF THE FEMUR
KEY FACTS
Supracondylar fractures are high energy injuries, the usual mechanism being
direct trauma to the flexed knee, such as occurs when the knee violently strikes
the dashboard during a motor-vehicle accident.
Associated fractures include patella, tibia, femoral shaft or neck, and acetabulum
as well as posterior hip dislocation.
An associated tibial shaft fracture may isolate the knee joint leading to the so-
called floating knee.
Supracondylar fractures may be extra-articular or intra-articular, nondisplaced,
impacted, or displaced.
Intra-articular fractures may be unicondylar or intercondylar. Intercondylar frac-
tures are T or Y shaped and enter the joint vertically at the intercondylar notch.
Typically the distal fragment is angled posteriorly due to the pull of the gastroc-
nemius muscles.
Popliteal vascular disruption occurs in 10% to 40% of cases. Arterial injury may
also occur in the adductor canal.
Injury to soft tissue supporting structures of the knee is seen in up to 20% of
patients and includes cruciate and collateral ligament injuries, meniscal tears,
and capsular disruption.
The following are AO classification of distal femur fractures:
Type A: extra-articular
Type B: unicondylar fractures
Type C: bicondylar injuries
The Hoffa fracture is an isolated coronally orientated fracture of either femoral

condyle with intra-articular extension best appreciated on CT or MR.

A. B.
FIGURE 5.20. AP/oblique (A) and lateral (B) radiographs demonstrate a comminuted intra-
articular supracondylar fracture of the femur.
SUGGESTED READING
Jahangir A, Cross WW, Schmidt AH. Current management of distal femoral fractures. Curr
Orthop Pract 2010;21(2):193197.
Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium 2007.
J Orthop Trauma 2007;21(Suppl):S1S133.

PATELLA FRACTURE
KEY FACTS
Patellar fractures result from either direct blows or to tension forces from the
quadriceps muscle and tendon.
Most fractures (60%) are mid-body and transverse; 25% are stellate or comminuted;
and 15% are vertical.
Transverse fractures often require open reduction and internal fixation to over-
come the tendency of the quadriceps muscles to distract the fracture.
The knee striking the dashboard during a motor vehicle collision is a frequent
cause and may be associated with ipsilateral lower extremity, pelvic, and acetab-
ular injuries.
Bipartite and multipartite patella may mimic a patellar fracture. These develop-
mental anomalies of secondary ossification centers typically occur in the upper
lateral quadrant of the patella. If the fragments are put back together, they do
not form a normal patella.
If there is evidence of osteochondral injury on sunrise view of the patella, an MRI
should be considered.
Avulsion fractures at the superior pole are related to the quadriceps tendon inser-
tion, and those at the inferior pole are related to the patellar tendon origin.
Patella alta may occur with patellar tendon rupture or inferior pole avulsion
fracture.
To diagnose patella alta, examine a lateral radiograph with 30 degrees of knee
flexion. If the distance from the inferior pole of the patella to the tibial tuber-
osity is greater than 1.2 times the greatest diagonal length of the patella, the
diagnosis is patella alta.

A. B.
FIGURE 5.21. Three patients with patellar fractures. Patient 1: (A) and (B); Patient 2: (C);
Patient 3: (D) and (E). A. Lateral view of knee and distal femur shows a comminuted frac-
ture of the junction of the middle and distal thirds of the femur, as well as a transverse frac-
ture through the mid portion of the patella (black arrows). Note the gas in the soft tissues
(white arrows) as both fractures were open injuries. B. The AP view shows the fracture of
the patella (black arrows), as well as a nondisplaced fracture of the intercondylar region of
the distal femur (curved arrows). (continued )

C.
FIGURE 5.21. (continued ) C. The lateral radiograph of the knee shows avulsion of the infe-
rior pole of the patella (lower arrows) with upward displacement of the upper pole and
marked prepatellar edema. Note the wavy contour of the quadriceps tendon (upper arrows),
indicating laxity due to the loss of the tethering effect of the patellar tendon attached to the
distal fragment. (continued )

D.
E.
FIGURE 5.21. (continued ) D and E. AP and patellar views of the knee show a nondisplaced
vertical fracture of the patella (arrows).
SUGGESTED READING
Dupuis CS, Westra SJ, Makris J, et al. Injuries and conditions of the extensor mechanism of
the pediatric knee. RadioGraphics 2009;29:877886.
Pope TL, Bloem HL, et al. Acute Osseous Injuries to the knee. Imaging of the Musculoskeletal
System. Philadelphia, PA: Saunders Elsevier, 2008:543548, Chapter 23.

TIBIAL PLATEAU FRACTURE
KEY FACTS
The usual mechanism of injury for a tibial plateau fracture is either a valgus stress
or an axial load, creating a split, depression, or combination of the two through
the lateral tibial plateau.
The cancellous trabeculae are stronger on the medial side of the knee joint
because of its greater weight-bearing load. Lateral injuries are, therefore, more
common, accounting for 75% to 80% of cases of tibial plateau fractures.
Schatzker classification of tibial plateau fractures
Type I: lateral plateau fracture without depression (6%)
Type II: lateral plateau fracture with depression (25%)
Type III: compression fracture (36%)
Type IIIA: lateral plateau depression
Type IIIB: central plateau depression
Type IV: medial plateau fracture (10%). Split and/or depressed component
Type V: bicondylar plateau fractures (4%). Often inverted Y appearance
Type VI: plateau fracture with diaphyseal discontinuity (20%). One third are
open, often associated with significant soft tissue injury

Schatkzer Types I, II, and III typically result from low mechanism injuries, while
Schatkzer Types IV, V, and VI typically result from high mechanism injuries.
Osteoporotic patients may have more severe tibial plateau fractures from low
mechanism injury.
Treatment of Type I, II, and III fractures focuses on full evaluation and repair of
the articular cartilage.
Type IV fractures overall have the worst prognosis, and there is increased risk of
injury to the peroneal nerve or popliteal vessels, lateral collateral ligament (LCL)
or posterolateral corner injury, or proximal fibula dislocation.
Careful CT examination or routine MR can be used to evaluate for ligamentous
injury.

A. B.
FIGURE 5.22. A. AP radiograph of the

knee shows a 6-mm depressed and com-
minuted fracture of the lateral tibial plateau.
There is a split component of the articular
surface and widening of the lateral joint
space (arrow) (Schatzker II). A fibular head
fracture is also seen. B. Cross-table lateral
radiograph of the knee shows the depres-
sion of the lateral tibial plateau (arrow), mild
displacement of the fibular head fracture,
and a lipohemarthrosis (arrowhead). C. Cor-
onal CT of the knee again demonstrates the
Schatzker II injury with depression greater
than 4 mm of the lateral tibial plateau and
disruption of the lateral joint space.
C.

A. B.
FIGURE 5.23. AP (A) and oblique (B) radio-
graphs and (C) coronal CT of the knee show
mildly comminuted and depressed bicondylar
tibial plateau fractures. There are associated
fractures of the fibular head, lateral femoral
condyle, and the intercondylar notch of the
femur.
C.

FIGURE 5.24. The Schatzker classification of tibial plateau fractures. (From Koval KJ,
Zuckerman JD. Atlas of Orthopaedic Surgery: A Multimedia Reference. Philadelphia, PA:
Lippincott Williams & Wilkins, 2004.)
SUGGESTED READING
Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of
CT and MR imaging improves assessment. Radiographics 2009;29(2):585597.

ANTERIOR CRUCIATE LIGAMENT AVULSION FRACTURE
KEY FACTS
True avulsions of bone occur at sites of ligamentous attachment.
Avulsion of the anterior tibial spine usually occurs in children or adolescents and
is often associated with a fall from a bicycle.
Radiographs show a bony fragment near the tibial spines anteriorly in the inter-
condylar notch.
The intact anterior cruciate ligament (ACL) is attached to this fragment and if
nondisplaced may not require operation (Meyers and McKeever Type I); with
displacement, simple reattachment of the fragment may restore joint stability
(Meyers and McKeever Type IIIV).
Adults with high mechanism injuries may have associated injuries such as kiss-
ing bone contusions or injuries to the medial collateral ligament (MCL) and
posterior cruciate ligament (PCL).
Differential diagnosis of avulsion of the anterior tibial spine includes other bony
densities in the joint space, such as osteochondral fractures from the articular
surfaces.
A. B.

C. D.
E. F.
FIGURE 5.25. A 46-year-old man involved in a motorcycle crash. Oblique (A) and AP
(B) radiographs demonstrate a mildly displaced avulsion fracture of the tibial spine (arrow)
and a mildly displaced and comminuted fracture of the fibular neck with significant soft
tissue swelling. Axial (C) and sagittal reformatted (D) CT more clearly defines the avulsion
fracture involving the tibial spine. Sagittal STIR (E) and coronal T1 (F) MR images demon-
strate marked marrow edema of the tibial eminence (asterisk) and proximal tibial meta-
physis with abnormal signal of the anterior cruciate ligament (ACL) without complete tear
(arrow). Associated tear of the free edge of the medial meniscus is also seen (arrowhead).
The associated MCL injury is not completely visualized. The avulsion fracture of the tibial
eminence is again seen (arrow).
SUGGESTED READING
Gottsegen CJ, Eyer BA, White EA, et al. Avulsion fractures of the knee: imaging findings and
clinical significance. Radiographics 2008;28(6):17551770. Review.

POSTERIOR CRUCIATE LIGAMENT AVULSION FRACTURE
KEY FACTS
The posterior cruciate ligament inserts on the posterior aspect of the tibial
plateau.
Typically the result of a knee striking the dashboard during a motor vehicle col-
lision, forcing the tibia posteriorly, or from severe hyperextension during athletic
activities
On the lateral radiograph, an avulsed bony fragment is seen over the posterior
aspect of the tibial plateau or there is focal discontinuity of the posterior tibial
articular surface.
MR demonstrates a discrete fragment attached to the often retracted and redun-
dant posterior cruciate ligament (PCL).
Associated injuries include medial and lateral collateral ligament (LCL) tears,
meniscal tears, and focal bone contusions of the anterior tibia and lateral femo-
ral condyle.
Additional avulsion fractures about the knee also include avulsions of the arc-
uate complex (posterolateral corner), iliotibial band (Gerdy tubercle), biceps
femoris tendon, semimembranosus tendon, quadriceps tendon, patellar tendon
(Sinding-Larsen-Johansson syndrome, jumpers knee, patellar sleeve avulsion),
and Osgood-Schlatter disease (chronic avulsion injury of tibial tubercle).

A. B.
FIGURE 5.26. AP radiograph (A) demonstrates an avulsion fracture of the posterior tibial
spine (arrow). A lateral femoral condyle fracture is also present. Sagittal STIR MR (B) in a
different patient with prior anterior cruciate ligament (ACL) surgery demonstrates increased
signal abnormality in the posterior aspect of the tibial plateau (asterisk) and slight retraction
of the PCL (arrow) related to the avulsion fracture.
SUGGESTED READING
Miller LS, Yu JS. Radiographic indicators of acute ligament injuries of the knee: a mechanis-
tic approach. Emerg Radiol 2010 May 21.

COLLATERAL LIGAMENT INJURIES OF THE KNEE
KEY FACTS
The Unhappy Triad of ODonoghue was originally described as combined val-
gus stress with rotation injury involving the medial collateral ligament (MCL),
anterior cruciate ligament (ACL), and medial meniscus. Bone contusions of the
lateral femoral condyle and lateral tibial plateau are typically also seen on MR. A
reverse Segond fracture may also be seen.
Normal MCL and LCL (lateral collateral ligament) show continuity of the low
signal ligament and no signal between the ligament and the overlying subcutane-
ous fat.
Collateral ligament tears are classified as follows:
Grade I: sprainsoft tissue edema superficial to an otherwise normal liga-
ment
Grade II: partial tearsoft tissue edema with abnormal ligament signal and
ligament thickening with partial tear, and thinning with extensive partial tear
Grade III: complete teardiscontinuity of ligament with more extensive soft
tissue abnormalities
Radiographs may show a joint effusion.
Pellegrini-Stieda disease: Sequela of MCL liagment injury where there is post-
traumatic heterotopic ossification at the femoral attachment of the MCL.

A. B.
FIGURE 5.27. A 45-year-old woman

involved in an MVC. Coronal T1 (A) and STIR
images (B) demonstrate discontinuity of
the MCL (arrowhead) and a complete tear
of the proximal femoral attachment of the
MCL. There is also a tear of the deep fibers
of the MCL and superior meniscocapsular
separation. There is associated subchondral
bone contusion of the lateral tibial plateau
and lateral femoral condyle with decreased
T1 and increased STIR signal abnormality.
C. Associated complete ACL tear at the
C. femoral attachment (arrow).
SUGGESTED READING
Miller TT. Imaging of the medial and lateral ligaments of the knee. Semin Musculoskelet
Radiol 2009;13(4):340352.
Miller LS, Yu JS. Radiographic indicators of acute ligament injuries of the knee: a mechanis-
tic approach. Emerg Radiol 2010 May 21.

ANTERIOR CRUCIATE LIGAMENT TEAR
KEY FACTS
The anterior cruciate ligament (ACL) is intracapsular and extrasynovial. It arises
from the posteromedial aspect of the lateral femoral condyle in the intercondylar
notch and attaches on the anterior intercondylar eminence of the proximal tibia
anterior and lateral to the tibial spine between the anterior attachments of the
menisci.
The ACL resists anterior translation of the tibia and posterior translation of the
femur.
There are several mechanisms of ACL failure.
The pivot shift mechanism of injury in skiers and football players occurs when a
valgus force is applied to a flexed knee with external rotation of the tibia relative
to the femur.
Other mechanisms of injury include the dashboard injury, whereby a force is
applied to the anterior tibia with the knee flexed and the hyperextension injury
when a force is applied to the anterior tibia with the knee extended, such as
when a car bumper impales the anterior tibia of a pedestrian. These injuries are
associated with tears of the posterior cruciate ligament (PCL).
On MR scans, the ACL should be taut and straight, forming a line clearly extend-
ing from origin to insertion. The normal orientation is parallel to the roof of the
intercondylar notch (Blumensaat line). The ACL is composed of an anterior band
and posterior band. It has low signal intensity on T2. The posterior band demon-
strates more intermediate signal intensity on T1.
The ACL can tear in its proximal or distal aspect, but in most series, midsub-
stance tears predominate. Partial tears are seen in up to one quarter of patients.
Avulsions at the insertion are also seen. Complete and incomplete tears can be
difficult to distinguish.
Associated injuries include meniscal tears in up to 80% of cases, medial collateral
ligament and capsular disruptions, and osteochondral fractures.
MR findings of ACL tear include the following:
Horizontal orientation of the ACL relative to the roof of the intercondylar
notch (Blumensaat line)

Waviness, with loss of taut appearance
Discontinuity of ligament fibers with increased T2 signal intensity
Ill-defined mass replacing normal contours; a focal pseudomass may be seen
at the site of the tear.

FIGURE 5.28. Sagittal T2 FSE with fat saturation shows abnormal increased signal in the
expected location of the ACL with no discernable normal ACL fibers consistent with a com-
plete ACL tear (arrow). There is also abnormal signal in the partially visualized PCL (arrow-
head) due to a tear at the femoral insertion site (not shown). Increased signal in the patellar
tendon at the patellar insertion is seen consistent with tendinopathy.
Associated bone marrow edema is seen in up to 85% of ACL tears. Character-

istic kissing contusions involving the weight-bearing surface of the lateral
femoral condyle at the terminal sulcus and the posterior lateral tibial plateau
are strongly associated with ACL tears.
Anterior subluxation of the tibia relative to the femurthe MR drawer sign
Radiographic findings that may be seen with an ACL tear include depression
of the lateral femoral condyle at the terminal sulcus, the Segond fracture at the
anterolateral aspect of the lateral tibial condyle at the capsular insertion, and
fractures of the anterior tibial spine.
SUGGESTED READING
Mink JH, Reicher MA, Crues III JV, et al. MRI of the Knee. New York, NY: Raven Press, 1993:
141162.

MENISCAL TEARS
KEY FACTS
Normal meniscal characteristics are as follows:
Medial meniscus: Larger; C-shaped; posterior horn larger than anterior horn;
attached to deep capsular component of medial collateral ligament (MCL)
Lateral meniscus: Anterior and posterior horns of similar size; no lateral col-
lateral ligament (LCL) attachment

Bow tie configuration seen of the peripheral meniscus on two to three con-
tiguous sagittal MRI slices

Meniscal tears are not to be confused with normal meniscofemoral ligaments.
Meniscal signal grades are as follows:
Grade 0: normal meniscus; uniformly low in signal intensity on all MRI pulse
sequences
Grade I: globular or rounded signal focus within the meniscus, not commu-
nicating with a free intra-articular surface (mild mucinous degeneration at

pathologic correlation)
Grade II: linear signal within the meniscus, often extending to meniscocap-
sular junction but not involving a free surface (meniscal degeneration and/or
intrasubstance tear)
Grade III: linear signal that extends to a free intra-articular surface or distor-
tion of meniscal morphology; 2-touch slice ruleabnormality seen on two

slices
Types of meniscal tears are as follows:
Longitudinal: Parallels long axis of meniscus; equidistant from outer and inner
margins; primarily occurs with trauma

Horizontal: Free edge of meniscus extending to articular surface; associated
with meniscal cysts; primarily occurs with degenerative change

Radial: Free edge of the meniscus extending perpendicular to the meniscal
long axis; complete tear divides meniscus into anterior and posterior halves
and outer portion may extrude. Associated signs include truncated triangle
sign, cleft sign, marching cleft sign, and ghost meniscus.
Bucket handle tear: Longitudinal tear with central migration of inner seg-
ment. Associated signs include double posterior cruciate ligament (PCL) sign,
flipped meniscus sign, and absent bow tie sign.

A. B.
C. D.
FIGURE 5.29. Coronal (A) and sagittal (B) PD with fat saturation MR of the knee. There is a
complex tear of the posterior horn of the medial meniscus with deformity and an undersur-
face flap tear (long arrow in B). There is a subchondral fracture in the central weight bearing
surface of the medial femoral condyle with a band of subchondral low signal intensity and
surrounding bone marrow edema (arrowhead). Edema overlies the proximal femoral attach-
ment of the MCL which could be reactive or due to an MCL sprain (double arrow). A small
joint effusion is present. Sagittal T1 (C) and coronal PD with fat saturation (D) MR of the
knee in a different patient shows a bucket handle tear (arrow) the medial meniscus. A clas-
sic double PCL sign is seen (C) along with decreased size of the medial meniscus.
SUGGESTED READING
Fox MG. MR imaging of the meniscus: review, current trends, and clinical implications.
Radiol Clin North Am 2007;45(6):10331053, vii.
Rosas HG, De Smet AA. Magnetic resonance imaging of the meniscus. Top Magn Reson Imag-
ing 2009;20(3):151173.

SEGOND FRACTURE: LATERAL CAPSULAR AVULSION
KEY FACTS
Although often innocuous-appearing on conventional knee radiographs, this
avulsion represents a serious injury caused by varus force with internal rotation
in a flexed or extended knee. An anterior cruciate ligament (ACL) tear is usually
also present.
The avulsion fracture occurs at the anterolateral cortex of the lateral tibial con-
dyle, at the attachment of the lateral capsular ligament.
MR of the knee should be performed in all cases of Segond fracture due to the
high incidence of internal derangement of the knee.
Anterior cruciate ligament tears in 75% to 100%
Meniscal tears in up to 70%.
Posterolateral triangle structure injuries
Radiographs show an elliptical bone fragment typically 2 to 3 mm distal to the

lateral tibial plateau and an effusion.
Acutely, MR will show decreased T1 and increased T2 signal at the donor site.
Healed Segond fracture will form well-corticated bony excrescence at the lateral
tibial plateau.
Reverse (medial) Segond fracture:
Due to external rotation and valgus stress
Deep medial collateral ligament (MCL) avulsion from medial tibial plateau
attachment
May be associated with posterior cruciate ligament (PCL) and peripheral
medial meniscus injuries; therefore, MR is recommended

A. B.
C. D.
FIGURE 5.30. AP radiograph of the knee (A) shows a tiny avulsion fracture fragment adja-
cent to the lateral margin of the proximal tibia (arrow). Coronal T1 MR (B) and coronal proton
density FSE with fat saturation MR (C) of the knee shows marrow edema of the Segond
fracture donor site in the lateral proximal tibia at the anterolateral attachment of the joint
capsule (arrow). There is discontinuity of the overlying cortex with an overlying focus of
low signal intensity representing the bone fragment (arrowhead) and subchondral fracture
in the lateral femoral condyle (asterisk). There is a grade 2 sprain of the proximal femoral
attachment of the MCL (incompletely shown) (superior arrow in B). There is abnormal signal
in the tibial spine due to an avulsion fracture of the ACL insertion. Sagittal proton density
FSE MR (D) shows ACL disruption (arrow) and lipohemarthrosis with soft tissue edema
surrounding the knee.
SUGGESTED READING
Bathala EA, Bancroft LW, Ortiguera CJ, et al. Radiologic case study. Segond fracture. Ortho-
pedics 2007;30(9):689, 797798.

PATELLAR DISLOCATION
KEY FACTS
The patella normally sits in the trochlear sulcus of the anterior distal femur.
Mechanism of injury in patellar dislocation usually involves internal rotation of
the femur on a fixed foot, such as during an abrupt change of direction in athletic
activity.
The patella usually relocates prior to clinical presentation. The patient often does
not recognize the dislocation but offers a history such as the knee gave out.
The dislocation is almost always lateral, with disruption of the medial retinacu-
lum. A tear of the vastas medialis obliquus (VMO) muscle may also occur. The
medial facet of the patella impacts upon the anterior lateral femoral condyle.
The diagnosis may be uncertain in up to 50% of cases prior to MRI scanning.
Patients may present clinically as anterior cruciate ligament (ACL) tears or
medial joint injuries.
Radiographs are usually unremarkable except for a joint effusion.
MR findings in patients with lateral patellar dislocation may include the
following:
Medial retinacular disruption in 76%
Medial patellofemoral ligament injury in 49%
Disruption of the medial stabilizers (VMO) in 48%
Joint effusions in 55% of patients, with only 7% of these demonstrating
hemarthrosis
Lateral patellar tilt in 43%, and 15% with lateral subluxation
Bone contusions, typically in lateral femoral condyle anterolaterally (80%) and
in the medial facet of the patella (61%)

Osteochondral injuries to the patella in 60%
Associated injuries to major ligaments (notably the medial collateral ligament
[MCL] in 11%) or menisci (11%)

FIGURE 5.31. Axial T2 with fat saturation MR of the left knee shows abnormally increased
signal in the anterior lateral femoral condyle and the medial patella consistent with bone
marrow edema and contusion from a lateral patellar dislocation (short arrows). There is a
fluid filled fissure in the articular cartilage of the median ridge of the patella (arrowhead).
Tears of the medial patellofemoral ligament and of the medial patellar retinaculum at the
patellar attachment are present (long arrow). A joint effusion is also present.
SUGGESTED READING
Elias DA, White LM, Fithian DC. Acute lateral patellar dislocation at MR imaging: injury
patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inf-
eromedial patella. Radiology 2002;225(3):736743.

KNEE DISLOCATION
KEY FACTS
The classic definition of a knee dislocation involves clinical or radiographic
evidence of displacement of the tibia relative to the femur.
Using this definition, anterior and posterior dislocations account for 50% to 75%
of cases. Medial, lateral, and rotary types also occur.
Knee dislocations can go unrecognized because of spontaneous reduction dur-
ing initial rescue or resuscitation; the marked laxity that results from extensive
capsular and ligamentous injury appears to predispose to this spontaneous
reduction.
The mechanism of knee dislocation usually involves violent forces such as motor
vehicle collision or falls from a significant height; multisystem traumatic injuries
are often coexistent.
Knee dislocation results in instability of the knee due to disruptions of the soft
tissue supporting structures.
Radiographs may show gross displacement of the tibia relative to the femur,
although minor degrees of suluxation or even normal alignment may be noted.
The unstable knee in a patient with high energy trauma may be best evaluated
with MRI to fully assess for ligamentous injury.
Peroneal nerve injury occurs in 33% of knee dislocations.
Serious vascular injury to the popliteal vessels occurs in 20% to 40% of knee dis-
locations. CTA and catheter angiographic manifestations of arterial injury from
a knee dislocation include vasospasm (typically smooth tapered narrowing),
nonocclusive narrowing (extrinsic compression by hematoma or intrinsic com-
pression by mural hematoma), intimal flap, pseudoaneurysm, or abrupt/tapered
occlusion. CT angiography is typically performed for diagnosis but catheter
angioplasty and rarely stent placement may be useful.
See case Peripheral Vascular Injuries, p. 138, Chapter 3.

A. B.
FIGURE 5.32. AP (A) and lateral (B) views of the knee show anterior and lateral dislocation
of the tibia and fibula on the femur.
SUGGESTED READING
Henrichs A. A review of knee dislocations. J Athl Train 2004;39(4):365369.
Kapur S, Wissman RD, Robertson M, et al. Acute knee dislocation: review of an elusive entity.
Curr Probl Diagn Radiol 2009;38(6):237250.
Redmond JM, Levy BA, Dajani KA, et al. Detecting vascular injury in lower-extremity ortho-
pedic trauma: the role of CT angiography. Orthopedics 2008;31(8):761767.

TIBIAL STRESS FRACTURE
KEY FACTS
Tibial stress fractures account for approximately 73% of all stress fractures.
In children, the classic stress fracture occurs in the proximal tibia, but in adult
runners it often occurs at the junction of the middle and distal thirds.
Radiographs show a zone of sclerosis with periosteal reaction and cortical thick-
ening. The fracture line may never be visible on radiographs, or may appear dur-
ing the convalescent period.
Stress fractures in the medial tibial plateau are also seen and can mimic internal
derangement clinically.
One must distinguish the terms stress and insufficiency fracture. Stress frac-
tures are due to abnormal stress on normal bone; insufficiency fractures are due
to normal weight-bearing stresses on abnormal (usually osteoporotic) bone.
Radiographic findings can lag behind symptoms by 2 to 6 weeks. MRI scanning
or radionuclide bone scanning can expedite the diagnosis.
Failure to recognize a stress fracture can lead to complete fracture.
A.

FIGURE 5.33. Axial T2 with fat saturation

MR (A) of the lower leg shows a sagit-
tally oriented fracture (arrow) through the
anterior cortex of the middle third of the
tibia and stress-related marrow edema
in the underlying central medullary cav-
ity. Coronal STIR MR (B) of the lower
leg again shows stress-related marrow
edema in the underlying central medul-
lary cavity of the middle third of the tibia
as well as in the overlying periosteum
and edema of the anterior soft tissues.
B.
SUGGESTED READING
Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am 2002;
40(2):313331.

TIBIAL AND FIBULAR SHAFT FRACTURES
KEY FACTS
Fractures of the tibial and fibular shafts are classified by anatomic location,
pattern of fracture lines, and number of fragments.
As a general rule, AP and lateral views are sufficient to diagnose and characterize
these fractures.
The radiographic findings are rarely subtle, even in nondisplaced fractures.
As with the forearm, the tibia, fibula, and the proximal and distal tibiofibular
joints represent a fibro-osseous ring. Fractures involving both bones are unsta-
ble, while isolated tibial or fibular shaft fractures are stable.
Proximal fibular shaft fractures and fibular neck fractures can be associated with
injuries to the ankle mortise (Maisonneuve fracture).
Whenever an isolated injury to one bone is seen, careful clinical and radiologic
assessment of the ankle joint and proximal tibiofibular joint should be made.
In small children, nondisplaced spiral fractures (toddlers fractures) of the tibial
shaft may be difficult to see on some views. Two perpendicular plane, good qual-
ity, radiographs are therefore essential.
Indications for angiographic evaluation include diminished ankle brachial index
or loss of dorsalis pedis and posterior tibial pulses.

A. B.
FIGURE 5.34. Toddlers fracture. The spiral tibial shaft fracture is shown well on (A) the
lateral view, but is almost invisible on (B) the AP view. No fibular fracture was detected in
this child.
SUGGESTED READING
11111222.

TIBIAL PLAFOND FRACTURE (PILON FRACTURE)
KEY FACTS
Supramalleolar fractures of the distal tibia that extend into the tibial plafond are
known as Pilon fractures. They are usually associated with fractures of the distal
fibula and/or disruption of the distal tibiofibular syndesmosis.
These fractures are a combination of injuries to the ankle and the distal tibial
metadiaphysis, usually with intra-articular comminution.
The mechanism of injury is vertical loading (e.g., jumpers, snowboarders). The
forces from impact upon the foot drive the talus upward through the tibial
plafond.
The compressive nature of the force usually results in articular cartilage damage
and outcomes are often poor, in spite of anatomic reductions. Persistent pain
and early osteoarthritis are common.
Almost all of these injuries require internal fixation and they frequently present a
major surgical challenge to the orthopedist.
It is important to identify the extent and severity of the tibial plafond injury,
including degree of impaction, comminution, and displacement of fracture frag-
ments.
Standard AP, lateral, and mortise views of the ankle are adequate for initial
evaluation. CT scan is useful for preoperative planning.
A. B.

C.
D. E.
FIGURE 5.35. AP (A) and lateral radiographs (B) show the comminuted tibial fracture
extending into the articular surface. Axial (C), coronal (D), and sagittal (E) CT images show
proximal displacement of tibial fragments as a result of impaction of the talus on the pla-
fond. Orthopedically placed traction on the foot distracts the talus from the tibial articular
surface on the coronal and sagittal CT images. Gas (arrow) was introduced during traction
pin placement.
SUGGESTED READING
Browner BD, Levine AM, Jupiter JB, et al., eds. Skeletal Trauma, 4th ed. Philadelphia, PA: WB
Saunders, 2009.
Rogers LF. Radiology of Skeletal Trauma, 3rd ed. Philadelphia, PA: Churchill Livingstone,
2002:12701273.

ANKLE MORTISE INJURIES: CLASSIFICATION
KEY FACTS
There are two popular classification systems for fractures involving the ankle
mortise: the Danis-Weber classification and the Lauge-Hansen classification.
Whichever classification is used, the most important consideration is ankle sta-
bility. The fibro-osseous ring of the ankle consists of medial elements (medial
malleolus and deltoid ligament), lateral elements (lateral malleolus and lateral
collateral ligament [LCL]), and the tibiofibular syndesmosis. A single break in the
fibro-osseous ring of the ankle mortise is stable. Two or more breaks will render
the ankle unstable. Unstable fractures usually need operative fixation.
Whenever instability is suspected but not demonstrated radiographically or clin-
ically, stress radiographs of the ankle should be performed.
Danis-Weber Classification
This classification describes ankle fractures by the position of the level of the
fibular fracture (if there is one) relative to the distal tibiofibular syndesmosis:
Type A: fracture below the syndesmosis
Type B: fracture at the level of the syndesmosis
Type C: fracture above the syndesmosis which tears the syndesmotic ligaments
Lauge-Hansen Classification
This classification describes the sequence of events that occurs during ankle
injury to predict ligamentous injury. This is an important classification for radiol-
ogists to understand given that it allows for more accurate diagnosis and appro-
priate selection of additional investigations.
The first word describes the position of the foot at the time of injury, and the
second word describes the motion of the foot (talus) with respect to the leg.
Supination-Adduction (10% to 20% of Ankle Fractures)

Stage 1: transverse fracture of lateral malleolus below the tibial plafond or a tear
of LCL structures
Stage 2: oblique or vertical fracture of medial malleolus
Pronation-Abduction (5% to 20% of Ankle Fractures)

Stage 1: rupture of the deltoid ligament or transverse fracture of the medial
malleolus
Stage 2: rupture of the anterior and posterior inferior tibiofibular ligaments or
bony avulsion
Stage 3: oblique fracture of the fibula at or just above the syndesmosis

SupinationExternal Rotation (40% to 70% of Ankle Fractures)

Stage 1: rupture of anterior inferior tibiofibular ligament and/or avulsion fracture
at its attachment
Stage 2: oblique or spiral fracture of the lateral malleolus at the level of the syn-
desmosis
Stage 3: rupture of post tibiofibular ligament or fracture of posterior malleolus
Stage 4: transverse (sometimes oblique) fracture of medial malleolus or tear of
the deltoid liagment
PronationExternal Rotation (5% to 20% of Ankle Fractures)

Stage 1: rupture of the deltoid ligament or transverse fracture of the medial
malleolus
Stage 2: rupture of the anterior inferior tibiofibular ligaments or bony avulsion
Stage 3: spiral/oblique fracture of the fibula (typically 67 cm) above the tibial
plafond
Stage 4: rupture of the posterior inferior tibiofibular ligament or fracture of the
posterior malleolus
A. B.
FIGURE 5.36. AP views of two different patients with supination-adduction injuries. In

stage 1 (A), the direct pull on the lateral malleolus produces a transverse fracture (arrow).
In stage 2 (B), the direct push on the medial malleolus produces a vertical fracture at the
junction of the malleolus and the plafond (arrow). In this patient, the lateral injury manifests
as an avulsion fracture at the tip of the lateral malleolus at the site of attachment of a com-
ponent of the LCL (arrowhead).

A. B.
FIGURE 5.37. AP views of two different patients with typical pronation-abduction injury.
In both of the cases shown here, the transverse medial malleolar fracture (curved arrows)
is displaced, the talus is shifted laterally, and the syndesmosis is wide. In both patients,
the bending fracture of the fibula shows its characteristic spike of bone (straight arrows)
pointing directly at the upper margin of the tibiofibular syndesmosis. The presence of this
spike is the most reliable method for recognizing a pronation-abduction injury. Both of these
injuries are stage 3.

A. B.
FIGURE 5.38. AP (A) and lateral (B) radio-

graphs of a Stage 4 supinationexternal rota-
tion injury. There is a spiral fracture of the
lateral malleolus (white arrow), a fracture of
the posterior malleolus (black arrows), and a
transverse fracture of the medial malleolus
(arrowhead). C. In a different patient with a
Stage 4 supinationexternal rotation injury,
there is widening of the medial clear space
(arrow) indicating disruption of the deltoid
ligament.
C.

A.
B. C.
FIGURE 5.39. A. AP view of a typical pronationexternal rotation injury. The initial force
pulls down on the medial malleolus, twisting it outward. Stage 1 is a medial malleolar frac-
ture (long arrow). Stage 2 is an anterior tibiofibular ligament rupture and tear of the distal
interosseous membrane. Stage 3 is a fracture through the distal fibular shaft. The fibular
fracture is usually oblique and is often comminuted (curved arrow). Stage 4 is a posterior
malleolar fracture or posterior tibiofibular ligament rupture. Note the syndesmosis widening
(short arrows) and lateral talar shift. B. In some patients, the initial force will result in a tear
of the deltoid ligament rather than a medial malleolar fracture. This may cause widening of
the medial clear space (arrow). C. A high fibular fracture (arrow) should be suspected in any
patient with a medial malleolar fracture or widening of the medial clear space and no fibular
fracture visible on the ankle films.

FIGURE 5.40. Avulsion of the anterior

tubercle of the tibia (arrows) can occur in
external rotation injuries as an alternative to
rupture of the anterior tibiofibular ligament.
This is known as the Tillaux-Chaput fracture.
Similar avulsions of the anterior tubercle
of the fibula can also occur. These injuries
can be isolated or associated with the other
characteristic fractures and dislocations of
external rotation injuries.
SUGGESTED READING
Rogers LF, ed. Radiology of Skeletal Trauma. Philadelphia, PA: Churchill Livingstone; 2002:
12221317.

CALCANEAL FRACTURE
KEY FACTS
The calcaneus is the most commonly fractured bone of the adult foot. The injury
is intra-articular in 75% and extra-articular in 25% of adults; in children, the frac-
tures are usually extra-articular.
The usual mechanism involves a fall onto the heel, often off a ladder or roof.
Associated injuries include the following:
Ipsilateral lower extremity fracture in 20% to 46%
Spine fractures in 10% to 30%, particularly involving the lumbar spine
Peroneal tendon entrapment in the lateral wall fracture
Extra-articular fractures include fractures of the tuberosity, Achilles avulsions (in

children and in some diabetic adults), and anterior process avulsions.
Intra-articular fractures include joint depression and tongue-type injuries. Both
involve the posterior facet of the subtalar joint, but the latter has a horizontal frac-
ture line that exits through the dorsum of the tuberosity, often below the Achilles
tendon insertion. This tongue fragment contains at least a portion of the posterior
facet of the subtalar joint, which may be displaced by the pull of the Achilles ten-
don. In the more common joint depression injury, the posterior facet is separated
from the tuberosity.
Intra-articular fractures result from an axial load, which drives the lateral pro-
cess of the talus into the underlying calcaneus, creating three fracture fragments:
the tuberosity, lateral fragment containing one half to two thirds of the poste-
rior facet, and the sustentaculum tali, including middle facet and remaining part
of the posterior facet. The fracture often extends into the calcaneocuboid joint.
Injury to the talus is rare.

A.
B.
FIGURE 5.41. Tongue-type fracture: A. The tongue fragment (black arrow) extends to the
posterior margin of the calcaneal tuberosity and includes the posterior facet of the subtalar
joint (white arrow). B. CT in the sagittal plane demonstrates the tongue fragment formed
by a horizontal fracture line exiting the posterior wall of the tuberosity (black arrows). The
intra-articular component extends into the posterior facet (white arrow). There is a small
intra-articular loose body.

A.
B.
FIGURE 5.42. Joint depression fracture: A. There is loss of Beohler angle with a subtle fracture
extending posterior to the posterior subtalar joint (black arrows). A second fracture line extends
into the posterior subtalar joint (black arrowhead). B. CT in the sagittal plane shows the fracture
line (black arrows) posterior to the posterior subtalar joint separating the posterior facet from
the tuberosity. There is a fracture extending into the calcaneocuboid joint (white arrow) and intra-
articular bone fragments in the calcaneocuboid and subtalar joints (white arrowheads).

FIGURE 5.43. Anterior process fracture: A lateral radiograph of the ankle shows an avul-
sion of the anterior process of the calcaneus (arrow).
SUGGESTED READING
2002:13321348.
Wechsler RJ, Schweitzer ME, Karasick D, et al. Helical CT of calcaneal fractures: technique
and imaging features. Skeletal Radiol 1998;27:16.

TALUS FRACTURE
KEY FACTS
Articular cartilage covers 60% of the talus; in addition, there are no muscle or
tendon insertions. As a result, dislocation is frequent.
The main arterial supply to the talus enters laterally via the tarsal tunnel, near
the inferior margin of the neck. It supplies part of the neck of the talus and most
of the body.
Fractures through the neck of the talus can compromise the blood supply in a
manner analogous to scaphoid waist fracture, leaving the body of the talus at risk
for avascular necrosis (AVN).
Mechanism of injury usually involves abrupt dorsiflexion of the foot with delivery
of high energy forces as in motor vehicle collisions or falls.
Associated injuries include ipsilateral fractures of foot and ankle in 16% of
patients. Approximately one quarter of patients will have fractures elsewhere,
reflecting the high energy nature of the injury.
Approximately one half of fractures of the body and neck involve subtalar dislo-
cation or posterior talar dislocation from the ankle mortise.
Most orthopedic surgeons use the Hawkins classification, which describes the
injuries in terms of displacement of the fractures and associated joint disloca-
tions. It is useful in predicting the likelihood of AVN.
Hawkins Classification of Talar Neck Fractures

Type Description AVN Incidence
I Nondisplaced vertical fractures < 10%
II Fractures with subtalar subluxation or dislocation 40%
III Fracture with tibiotalar and subtalar dislocation > 90%
IV Features of type III with extrusion of the body, often nearly 100%
through an open wound and talonavicular dislocation

A.
B.
FIGURE 5.44. Non/minimally displaced fracture of the body of the talus (arrows) is seen on
a lateral radiograph (A) and CT (B) in the sagittal reformation in another patient. The poste-
rior component extends to the tibiotalar and posterior subtalar joints.

A.
B.
FIGURE 5.45. Non/minimally displaced fracture of the neck of the talus (arrows), (Hawkins
Type I), is seen on a lateral radiograph (A) and CT (B) in the sagittal plane. (continued )

C.
D.
FIGURE 5.45. (continued ) C. Talar neck fracture with subtalar subluxation (arrows) (Hawkins
Type II). D. Talar neck fracture with subtalar and tibiotalar dislocations (black arrows) and talo-
navicular subluxation (white arrow) (Hawkins Type IV).

FIGURE 5.46. Mortise (oblique) view of the ankle shows a nondisplaced fracture of the
lateral process of the talus (arrow). Fractures of this region may mimic routine ankle sprains
clinically and can be missed if not sought.

SUGGESTED READING
Digiovanni CW, Benirschke SK, Hansen ST. Foot injuries. In: Browner BD, Jupiter JB, Levine
AM, et al., eds. Skeletal Trauma, 3rd ed. Philadelphia, PA: WB Saunders, 2003:23792384.
2002:13481358.

TALAR AND SUBTALAR DISLOCATIONS
KEY FACTS
Most dislocations are associated with talar fractures.
Pure subtalar dislocation without fracture requires simultaneous dislocation of
the talonavicular joint. Total talar dislocation is rare and includes the tibiotalar
joint.
Subtalar dislocations are distributed as follows: medial (56%); lateral (34%); pos-
terior (6%); and anterior (4%).
Medial subtalar dislocations are the result of an inversion force with the calca-
neus and navicular lying medial to the talus and an intact ankle mortise.
Lateral subtalar dislocations result from eversion forces, with the navicular and
calcaneus lateral to the talus.
Associated osteochondral injuries are common; CT should be considered in
all such dislocations to detect any loose bodies in the subtalar or talonavicular
joints. At times, an entrapped fragment can prevent anatomic reduction.
Subluxations are more subtle and may involve only the subtalar joint. Careful
examination of the alignment of the posterior facet of the subtalar joint on the
lateral radiograph and the relationship of the talus to the calcaneus on the AP
radiograph is essential in making the diagnosis.

A. B.
FIGURE 5.47. A. Lateral radiograph of the hindfoot shows a fracture dislocation of the
talus at the subtalar joint and a talonavicular dislocation. The fracture extends into the sub-
talar articular surface (straight black arrows) with comminuted pieces of the posterior talus
(white arrows) and the normal calcaneal side of the posterior facet of the subtalar joint
(curved black arrows). B. AP radiograph of the foot shows medial dislocation with the navic-
ular (N) and calcaneus (C) displaced medially in relationship to the talus (T); the tibiotalar
joint is intact.
SUGGESTED READING
Berquist TH, Johnson KA. Trauma. In: Berquist TH. ed. Radiology of the Foot and Ankle. New
York, NY: Raven Press, 1989:174175.
2002:13581364.

TARSAL NAVICULAR FRACTURE
KEY FACTS
Three types of tarsal navicular fractures occur: avulsion, tuberosity, and body.
Capsular avulsions at the dorsal margin at the talonavicular joint are common
and account for about half of navicular fractures.
The medial aspect of the navicular is the tuberosity; it serves as site of insertion
for the posterior tibial tendon. Avulsion of the tuberosity may occur with forced
eversion or abduction of the foot.
Fractures of the body of the navicular are often associated with midfoot fracture
dislocation and account for about one fourth of navicular fractures.
Both horizontal and vertical fracture patterns are noted in the body of the navic-
ular. Displacement of fragments is common in these injuries.
The talonavicular, subtalar, and tibiotalar joints are essential joints for normal
biomechanical function of the foot. Anatomic restoration following navicular
body fracture often requires surgical stabilization.
Stress fractures and nondisplaced acute body fractures can be difficult to detect
on conventional radiographs. MRI is the procedure of choice for suspicion of non-
displaced stress fracture, and CT in multiple planes is the procedure of choice for
nondisplaced acute fractures.

A.
B.
FIGURE 5.48. AP (A) and lateral (B) views of the foot show a subtle fracture line (arrows)
through the navicular. (continued )

C.
D.
FIGURE 5.48. (continued ) An oblique view (C) did not show the fracture, but it was con-
firmed on CT (curved arrows, D). The density proximal to the navicular in (D) (white arrow)
proved to be an accessory ossicle. These fractures can be quite subtle and often require
additional radiographs or CT as in this case. (N, navicular.)

SUGGESTED READING
AM, et al., eds. Skeletal Trauma, 3rd ed. Philadelphia, PA: WB Saunders, 2003:2379
2384.

CUBOID AND CUNEIFORM FRACTURES
KEY FACTS
Cuboid fracture due to indirect compressive forces is designated the nutcracker
fracture.
This fracture occurs when abduction of the forefoot compresses the cuboid
between the bases of the fourth and fifth metatarsals (MTs) distally and the cal-
caneus proximally like a nut in a nutcracker.
These fractures are significant clinically because they can interfere with the
mechanical alignment of the foot or involve displacement of articular surfaces.
The valgus stress typically crushes the cuboid articular surface and may avulse
the insertion of the posterior tibial tendon on the navicular medially. Other com-
pressive injuries may involve the calcaneus or bases of the fourth and fifth MTs.
Fractures secondary to direct trauma or associated with dislocation, stress frac-
tures, and toddlers fractures have also been reported. Isolated fractures of the
cuboid are uncommon injuries with avulsion fractures of the cuboid most fre-
quently encountered.
Avulsions are usually periarticular, proximally at the calcaneocuboid joints or
distally in association with Lisfranc injuries.
Isolated cuneiform fractures are rare. When identified, a careful search for con-
comitant injuries, including Lisfranc injury, should be sought.
A.

B.
C. D.
FIGURE 5.49. AP (A) radiograph of the foot shows poor definition of the calcaneocuboid
joint (black arrows) as well as an avulsion of the insertion of the posterior tibialis tendon
medially off the navicular (white arrow). The lateral radiograph (B) shows a fracture of the
body (curved arrow) and compression of the articular surface of the cuboid (arrows). This
is further highlighted by the axial CT (arrows in C). Axial CT through the talonavicular (T, N)
joint in (D) demonstrate the avulsion fracture (curved arrow) and the distal posterior tibialis
tendon (open white arrow).
SUGGESTED READING
2384.

TARSOMETATARSAL (LISFRANC) FRACTURE DISLOCATION
KEY FACTS
The tarsometatarsal (TMT) joint is also known as the Lisfranc joint. Injuries at
this location typically involve their stabilizing ligaments with or without associ-
ated fracture.
The mechanism of TMT fracture dislocation is usually forced plantar flexion. The
bunk bed fracture in children is an example. Twisting and crush injuries can
also result in TMT injuries.
The transverse metatarsal (MT) ligaments span the MT bases II to V; the medial
aspect of MT II is attached to the medial cuneiform by the oblique Lisfranc liga-
ment, but there is no ligament attaching MT I to MT II.
The middle cuneiform is shorter than the medial and lateral cuneiforms, creating
a mortise or recess for the base of the second MT, locking the latter between the
surrounding tarsal bones.
This unique osseous and ligamentous anatomy predisposes to separation of MTs
I and II under high stress. Higher energy injuries result in even greater degrees of
disruption and involvement of more MTs.
There are multiple classifications systems to describe Lisfranc injury patterns.
However, most are not helpful to guide treatment or predict prognosis. Two main
patterns are frequently described:
DivergentMT I is displaced medially, and MTs II to V are displaced laterally.
There may occasionally be only medial displacement of the first MT.

HomolateralAll MTs are displaced laterally. This is more common than the
divergent pattern.
The plantar ligaments and tendons provide more support than the dorsal soft
tissues and, therefore, dorsal displacement is more common.
Imaging includes AP, lateral, and medial oblique views of the foot. On the normal
AP view, the lateral border of MT I aligns with the lateral border of the medial
cuneiform and the medial border of MT II aligns with the medial border of the
middle cuneiform. On the normal oblique view, the lateral border of MT III aligns
with the lateral border of the lateral cuneiform and the medial border of MT IV
aligns with the medial border of the cuboid. On the normal lateral view, the TMT
joints are clearly visible.
Stress views are used to diagnose purely ligamentous lesions. Displacement or
distraction of the involved TMT joint by greater than 2 mm is usually an indica-
tion for surgical stabilization.
Comparison radiographs can be useful for subtle ligamentous injury. CT scan-
ning can be used to detect occult injuries, although physical examination and
stress views under anesthesia usually suffice.

A.
B.
FIGURE 5.50. AP (A) and lateral (B) views of the foot show a homolateral Lisfranc fracture
dislocation. A. Lateral subluxation of all of the MTs is typical of the homolateral pattern.
The small bony fragment (arrow) has avulsed from the base of the second MT at the site
of attachment of the ligament to the medial cuneiform. B. The lateral view looks unremark-
able at first glance but note the lack of normally visualized TMT joints (arrows) as the only
evidence of the injury.

A. B.
C. D.
FIGURE 5.51. Signs of Lisfranc injury: A. Offset of the lateral margin of the first MT base in
relation to the lateral margin of the medial cuneiform (arrow). B. Transverse fracture of the
second MT base. There is also a fracture of the third MT base. C. MT base avulsion fracture
(black arrow) and cuboid avulsion or impaction fractures (white arrow). D. Dorsal subluxation
of the MT bases can occur without fracture, visible only on the lateral view (arrow).

SUGGESTED READING
2244.
2002:1369.

METATARSAL FRACTURE
KEY FACTS
Direct injury is the most common mechanism of metatarsal (MT) fracture.
Typically, a heavy object falls on the foot.
Indirect forces can be applied by twisting injuries, resulting in spiral fractures of
the MT shafts, particularly the first three.
Twisting injuries can also result in avulsions of tendon or ligament insertions.
The most common of these occurs at the base of the fifth MT at the insertion of
peroneus brevis and lateral plantar aponeurosis. This is sometimes referred to as
a pseudo-Jones fracture, to distinguish it from the Jones fracture
A Jones fracture is an extraarticular transverse fracture of the fifth metadiaphy-
seal junction. These more commonly lead to delayed healing than the pseudo-
Jones fracture.
AP, oblique, and lateral radiographs are usually adequate to characterize MT
fractures.
A.

B. C.
FIGURE 5.52. Fifth MT base (pseudo-Jones) fracture. Often misinterpreted clinically as

ankle injuries, these fractures (arrows) are often visible on lateral views of the ankle. In this
patient, the nondisplaced fracture is much easier to see on (A) the lateral view of the ankle
than on (B) the oblique view of the foot. C. Nondisplaced Jones fracture (arrow) in another
patient.
SUGGESTED READING
AM, et al., eds. Skeletal Trauma, 3rd ed. Philadelphia, PA: WB Saunders, 2003:2466.
2002:13861394.

TOE INJURIES AND LOWER EXTREMITY FOREIGN BODIES
KEY FACTS
Injuries to the toes usually result from direct blows. Either objects are dropped on
the unprotected foot or the toe is stubbed against a hard object.
Most great toe fractures are minimally displaced.
Lesser toe fractures will often involve multiple toes and are frequently displaced,
angulated, or rotated.
The interphalangeal or metatarsophalangeal joints are often involved in toe
fractures.
Dislocations of the metatarsophalangeal or interphalangeal joints occur when
axial loads are applied to the toes. These dislocations are most commonly dorsal.
AP, lateral, and oblique radiographs of the affected toes are usually sufficient to
evaluate these fractures and dislocations.
Foreign bodies are common in the toes and feet. Sonography may be of value for
localization of wood and plastic as they are frequently invisible on radiographs.
Metal and glass are readily demonstrated radiographically.

A.
B.
FIGURE 5.53. Foreign body in the dorsum of the foot. Concern for foreign body after the
patient cut dorsum of his foot with glass 1 month ago. A. Lateral radiograph of the foot
shows soft tissue swelling over the dorsum of the foot and a small radio-opaque foreign
body (arrow). B. Ultrasound of this area clearly shows the glass fragment as an echogenic
line in the subcutaneous tissues (arrow). The arrowheads indicate the location of the tarso-
metatarsal joint. Ultrasound is useful both to find radiolucent foreign bodies and to evaluate
for associated abscesses. Using ultrasound, the skin over the foreign body can be marked
to assist the surgeon.

A. B.
FIGURE 5.54. Foreign body in the leg. AP (A) and lateral (B) views demonstrate a large
piece of glass (arrows) in the soft tissues adjacent to the fibular shaft, which was present
for 3 weeks. The laceration had been sutured at the time of injury and radiographs were
not obtained. The patient presented 3 weeks postinjury with a wound infection. Note the
periosteal new bone (curved arrows in B) surrounding the foreign body.
SUGGESTED READING
Horton LK, Jacobson JA, Powell A, et al. Sonography and radiography of soft-tissue foreign
bodies. Am J Roentgenol 2001;176(5):11551159.

Index BMT
Note: Page numbers in italics refer to illustrations; those followed by t indicate tables.
A diffuse axonal injury, 32, 33, 62, 63

Abbreviated Injury Scale (AIS), 8, 10t diffuse anoxia, 32, 33, 62, 63
Acetabulum epidural hematoma, 34, 35
anatomy, 314, 315 gunshot injury, 48, 48, 49
fracture intraventricular hemorrhage, 54, 55
both column, 326, 327329 perfusion SPECT, 64, 64, 65
transverse, 322, 323324 subarachnoid hemorrhage, 54, 55
Acromioclavicular joint dislocation, 258, 259 subdural hematoma, 36, 37, 38, 39
Active bleeding, 182, 183 subfalcine herniation, 58, 59
Adrenal gland, hemorrhage, 214, 215 uncal herniation, 56, 57
Adverse reactions, acute Breathing, 6
premedication, 2829 Bronchus
risk of, 28 laceration of, 116
Airway, 56 tooth in, 166
injury, 116, 117 Bullet injury
Angiographic indications, 200201, 201202 to arm, 18, 20
Ankle to head, 18, 19, 48, 48, 49
injury, 378, 379383 to leg, 22, 23
pronation-abduction injury, 378, 380 Bullet, kinetic energy of, 18
pronation-external rotation injury, 379, 382, 383
supination-adduction injury, 378, 379 C
supination-external rotation injury, 379, 381 Cardiac rupture, 142, 143
TillauxChaput fracture, 383 Carotid artery, acute dissection, 5051, 50, 51t, 5253
Anterior cruciate ligament (ACL) Cerebral anoxia, diffuse, 32, 33, 62, 63
avulsion, 356, 356357 Cerebral blood flow, 66, 67
tear, 362363, 363 Cerebral contusion, 30, 31
Aortic injury Cerebral perfusion SPECT, 64, 64, 65
traumatic aortic injury, 122, 123 Cerebrospinal fluid leak, 104, 105
chest radiography, 124, 125 Cervical spine
computed tomography, 128129, 129131 atlanto-occipital dissociation, 76, 77
endovascular repair, 132, 133134 axis, spondylolisthesis, 84, 85
minimal aortic injury, 126, 127 bilateral perched facet, 90, 90, 91
burst fracture, 94, 95
B dens fracture, 82, 82t, 83
Biffl grading cerebrovascular vascular injury, 51t hyperflexion fracture, 86, 87
Biliary injury, 192, 193194 Jefferson fracture, 78, 79
bilomas, 192, 193194 occipital condyle fracture, 74, 74t, 75
Bladder rupture posterior ligamentous injury, 92, 93
CT cystogram, 235, 237238, 240, 241242 spondylolisthesis, 84, 85
extraperitoneal, 234235, 236238 transverse atlantal ligament injury, 80, 81
intraperitoneal, 240, 241242 unilateral overriding facet, 88, 88, 89
Bleeding, computed tomography, 182, 183 Chance fracture, thoracic/lumbar spine, 98, 98, 99
Blunt cerebrovascular injury, 50, 50, 51t, 5253 Child abuse, 46, 47
Bowel injury, 206, 207 Clavicle
Brachiocephalic artery injury, 136, 137 dislocation, 112, 112
Brain fractures, 256, 257
anoxia, diffuse, 32, 33, 62, 63 Colles fracture, 281, 282
cerebellar hemorrhage, 60, 61 Colon, extraperitoneal injury, 178
child abuse, 46, 47 Colorectal injury, 212, 212, 213
contusion of, 30, 31 Contrast extravasation, 29
death of, 66, 67 Contrast media, acute adverse reactions, 2829
411
Bittle_Index.indd 411 4/15/2011 12:58:28 PM

412 Index
Contrast reactions, 2829 Flexion/distraction fracture,

Contusion hyperflexion fracture, of cervical spine, 86, 87
cerebral, 30, 31 thoracic/lumbar spine, 98, 98, 99
myocardial, 140 Flexion-Teardrop fracture of cervical spine, 86, 87
pulmonary, 148, 149 Focused assessment with sonography for trauma
Cortical rim sign, in renal injury, 227 (FAST), 174, 175177
Cruciate ligament Foot
anterior calcaneus fracture, 384, 385387
avulsion, 356, 356357 glass in, 410
tear, 362363, 363 Foreign body, aspiration, 166, 166167
posterior avulsion, 358, 359 Fractures
Cuboid, nutcracker fracture, 400, 400401 acetabular
Cuneiform fracture, 400, 400401 both column, 326, 327329
Cystogram posterior wall, 320, 321
technique for fluroscopic, 16 transverse, 322, 323324
bladder injury, 234, 237238, 240 Bartons, 281, 283
Bennetts, 290, 290
D Boxers, 292, 294
Danis-Weber classification, ankle mortise injuries, burst
378, 379383 cervical spine, 94, 95
Dens fracture, 82, 82t, 83 lumbar spine/thoracic spine, 96, 96t, 97
Depressed skull fracture, 42, 42, 43 calcaneus, 384, 385387
Diaphragm injury, 144, 145146 carpal bone, 284, 285287
Diffuse axonal injury, 32, 33 Chance, thoracic/lumbar spine, 98, 98, 99
Ductus diverticulum, 129 clavicle, 256, 257
Duodenal perforation, 210, 210, 211 Colles, 281, 282
E cuneiform, 400, 400401
Elbow dens, 82, 82t, 83
dislocation, 274, 274, 275 distal radius, 280281, 280283
injury, 272, 273 extension-distraction, thoracic/lumbar spine,
Embolism, after shotgun injury, 26 100, 101
Emphysema, subcutaneous, 164, 164 femoral
Endotracheal tube, 5 intertrochanteric, 338, 339
Epicondyle injury, 272, 273 subtrochanteric, 340, 341
Epidural hematoma, 34, 35 supracondylar, 346, 347
Esophageal rupture, 118, 119 intracapsular, 330, 331
Esophagram, 17 stress-insufficiency, 334335, 336
Extraperitoneal fluid, 178179, 178179 shaft, 342343, 343, 344
Extravasation, contrast, 29 fibula, 374, 375
flexion/distraction, thoracic/lumbar spine, 98,
F 98, 99
Face Galleazzis, 278, 279
LeFort fracture, 72, 72, 73 Hangmans fracture, 84
orbital floor fracture, 68, 69 Hill-Sachs fracture, 260, 261, 262
tripod fracture, 70, 70, 71 hip, occult, 332, 333
Facet override humerus
bilateral, of cervical spine, 90, 90, 91 distal, fracture, 370, 271
unilateral, of cervical spine, 88, 88, 89 proximal, fracture, 266267, 266267
Femoral neck fracture shaft, fracture, 268, 269
intracapsular, 330, 331 Jefferson, 78, 79
stress-insufficiency, 334335, 336 Jones fracture, 406, 407
Femoral shaft fracture, 342343, 343344 LeFort, 72, 72, 73
Femur fracture Lisfrancs, 402, 403, 404
intertrochanteric, 338, 339 metatarsal, 406, 406407
subtrochanteric, 340, 341 Monteggia, 278, 278
supracondylar, 346, 347 navicular, tarsal, 396, 397398
Fetus, trauma, 250, 251252 nutcracker, 400
Fibular shaft fracture, 374, 375 occipital condyle, 74, 74t, 75
Finger, fracture, 296, 297298 orbital floor, 68, 69
Flail chest, 110 patella, 348, 349351

Index 413
pelvic acute, 36, 37

anteroposterior compression, 306, 307 chronic, 38, 39
lateral compression, 304, 305 Hemidiaphragm rupture, 144, 145146
vertical shear, 308, 309 Hemoperitoneum, 170171, 171172
pilon, 376, 376377 Hemorrhage
radial head, 276, 277 adrenal gland, 214, 215
radiocarpal joint, 281, 283 cerebellar, 60, 60, 61
radius, 278, 278, 279, 280, 281 intracranial
rib, 110, 111 delayed, 44, 45
Rolandos, 290, 291 hyperacute, 34, 35
Scaphoid, 284, 285287 intraperitoneal, 170175, 171172
scapula, 108, 109 intraventricular, acute, 54, 55
Segond, 366, 367 subarachnoid, acute, 54, 55
skull subdural hematoma, 36, 37
depressed, 42, 42, 43 Herniation
linear, 40, 40, 41 subfalcine, 58, 59
Smiths, 281, 283 uncal, 56, 57
sternum, 114, 115 upper (cerebellar hemorrhage), 60, 60, 61
of talus, 388, 388t, 389392 Hill-Sachs fractures, 260, 261, 262
tarsal navicular, 396, 397398 Hip
tibia, 372, 372373 dislocation of
tibia1 plateau, 352, 353355 anterior, 316, 317
tibia1 shaft, 374, 375 posterior, 318, 319
TillauxChaput, 383 occult fracture, 332, 333
Toddlers, 374, 375 Humerus
torus, 280, 280281 fracture of distal, 270, 271
tripod, 70, 70, 71 fracture of proximal, 266267, 266267
triquetrum, 284, 285 fracture of shaft, 268, 269
ulna, 276, 277, 278, 278279 epicondyle injury, 272, 273
volar plate, 296, 297 Hyperflexion fracture, of cervical spine, 86, 87
G I
Gallbladder injuries, 192 Injury scales (AAST), 216, 216t
Galleazzi fracture, 278, 279 Injury Severity Score, 8, 9t, 10t
Gamekeepers thumb, 296, 297298 Internal carotid artery, injury of, 5051, 50, 51t, 5253
Gastric perforation, 120, 121 Intertrochanteric femur fracture, 338, 339
Gastrointestinal perforation, 206, 207208 Intracapsular femoral neck fracture, 330, 331
Glasgow Coma Scale (GCS), 8, 9t Intracranial hemorrhage
Gravid uterus, trauma, 250, 251252 acute
Great vessel injury, 136, 137 intraventricular, 54, 55
Gunshot wounds subarachnoid, 54, 55
to arm, 18, 20 delayed, 44, 45
to head, 18, 19, 48, 48, 49 hyperacute, 34, 35
to leg, 22, 23 Intraperitoneal fluid, 170171, 171172
Intraperitoneal gas, 180181, 180181
H Intrathoracic ectopic air collection, 164, 164165
Hand fractures, 290, 290292, 292, 292294 Intraventricular hemorrhage, 54, 55
bennett fracture, 290, 290 Intubation, esophageal, 120, 121
boxers fracture, 292, 294
Hangmans fracture, 84, 85 J
Head, gunshot wound, 48, 48, 49 Jefferson fracture, 78, 79
Heart rupture, 142, 143 Jejunal perforation, 208
Hematoma Jones fracture, 406, 406407
duodenal, 210, 210, 211
K
epidural, 34, 35
Kidney. See Renal injuries.
perinephric, 217, 220
Kidney Injury Scale, 216t
pulmonary, 156, 156157
Knee
renal injuries, 217
capsular ligament avulsion, 366, 367
splenic, 196
collateral ligament injuries, 360, 361
subdural
dislocation, 370, 371

414 Index
Knee (Continued) Near-drowning, 168, 169

posterior cruciate ligament (PCL) avulsion, Nutcracker fracture, 400, 400401
358, 359
floating knee, 342, 343 O
lateral capsular ligament avulsion, 366, 367 Occipital condyle fracture, 74, 74t, 75
meniscal tear, 364, 365 Occult hip fracture, 332, 333
tibial plateau fracture, 352, 353355 ODonoghue, triad of, 340, 341
supracondylar fracture, of femur, 346, 347 Orbital floor fracture, 68, 69
patella dislocation, 368, 369 blowout fracture, 68
patella fracture, 348, 349351
anterior cruciate ligament injury, 356, 356357 P
posterior cruciate injury, 358, 359 Pancreatic injury, 204, 205
collateral ligament injury, 360, 361 Patella
Segond fracture, 366, 367 alta, 348
posterior corner, 358 dislocation, 368, 369
triad of ODonoghue, 360, 361 fracture, 348, 349351
Pelvic apophyseal avulsion, 302, 303
L Pelvic fracture, anteriorposterior compression,
Lateral capsular ligament avulsion, 366, 367 306, 307
Lateral compression pelvic fracture, 304, 305 Pelvic ring disruption, 310, 311
Lauge-Hansen classification, ankle mortise injuries, Pelvis
378, 379383 apophyseal avulsion, 302, 303
LeFort fractures, 72, 71, 73 angiography, acetabular anatomy, 314, 315
Legal issues, 1113 anteroposterior compression fracture, 306, 307
Linear skull fracture, 40, 40, 41 arterial injury, 310, 311
Lisfrancs fracture dislocation, 402, 403, 404 both column acetabular fracture, 326, 327329
Liver lateral compression fracture, 304, 305
angiography, 200 ring disruption, 310, 311
injury, 184185 vertical shear fracture, 308, 309
complications, 190 Perinephric hematoma, 217, 220
computed tomograpy, 184185 Peripheral vascular trauma, 138139, 139
grading scale, 185t Phalangeal fractures, 296, 297298
nonsurgical management, 190, 191 Pilon fracture, 376, 376377
scale, 185t Pneumothorax, 160161, 162
laceration, 184185, 185t, 186189 Pneumomediastinum, 116, 117, 118, 180, 180
Lumbar spine Posterior cruciate ligament (PCL) avulsion, 358, 359
burst fracture, 96, 96t, 97 Posterior hip dislocation, 318, 319
extension-distraction fracture, 100, 101 acetabular fracture and, 320, 321
flexion/distraction fracture, 98, 98, 99 Posterior ligamentous injury of cervical spine, 92, 93
fracture/dislocations, 102, 102t, 103 Posterior urethral injuries, classification of, 244t
Lungs Posttraumatic intracranial hemorrhage, delayed, 44, 45
barotrauma, 164, 164165 Pregnancy, trauma during, 250, 251252
blast injury, 158, 159 Pulmonary contusion, 148, 149
contusion, 148, 149 Pulmonary hematoma, 156, 156157
hematoma, 156, 156157 Pulmonary laceration
laceration, 150151, 151152, 154, 155 blunt trauma, 150151, 151152
hematoma, 156, 156157
M penetrating trauma, 154, 155
Mediastinal widening, 124, 125
Medical-legal issues, 1113 R
Meniscal tears, 364, 365 Radial head fracture, 276, 277
Mesenteric injury, 206, 207208 Radius
Metacarpal fractures, 290, 290291, 292, 292294 distal fracture, 280281, 280283
Metatarsal fractures, 406, 406407 proximal fracture, 278, 278279
Minimal aortic injury (MAI), 126, 127 Rectal injuries, 212
Monteggia fracture, 278, 278 Renal injuries
Myocardial contusion, 140 angiographic indications, 200201
clinical management issues, 226, 227
N computed tomography, 220221, 222224
Naclerio V-sign, 118 grading scale, 216t, 216217, 217219
Navicular fracture, 396, 397398 hematoma, 217

Index 415
laceration of, 217 T

urinary extravasation and laceration, 228, 229 Talus
Retroperitoneal gas, 180181, 180181 dislocation, 394, 395
Revised Trauma Score (RTS), 8, 9t fracture, 388, 388t, 389392
Rib fractures, 110, 111 Testicular, trauma, 254, 255
Rolando fracture, 290, 291 Thoracic/lumbar spine
Runners stress fracture, 372, 372373 burst fracture, 96, 96t, 97
chance fracture, 98, 99
S extension-distraction fracture, 100, 101
Sacral fracture, 312, 312313 flexion/distraction fracture, 98, 98, 99
Scaphoid fracture, 284, 285287 fracture/dislocations, 102, 102, 103
Scapula fracture, 108, 109 Tibia
Scapulothoracic dissociation anterior tubercle avulsion, 383
CT angiography, 106107, 107 stress fracture, 372, 372373
magnetic resonance imaging, 107 Tibial plafond fractures, 376, 376377
radiography, 106, 107 Tibial plateau fracture, 352, 353355
Scrotum, trauma, 254, 255 Tibial shaft fractures, 374, 375
Segond fracture, 366, 367 Tibial spine, avulsion, 356, 357
Shotgun wound, 24, 25, 26. See also Gunshot Tillaux-Chaput fracture, 383
wounds. Toddlers fracture, 374, 375
Shoulder Toe injury, 408, 409410
acromioclavicular joint dislocation, Tooth, aspirated, 166
258, 259 Torus fracture, 280, 280281
anterior dislocation, 260, 261262 Trachea
posterior dislocation, 264, 264265 laceration, 116, 117
luxatio erecta, 260, 262 pneumomediastinum, 116, 117
humeral head fracture, 266, 266, 267 rupture, 116
Skull Tracheostomy tube, 56
depressed fracture, 42, 42, 43 Trans-scaphoid-perilunate dislocation, 288, 289
linear fracture, 40, 40, 41 Transverse acetabular fracture, 322, 323324
occipital condyle fracture, 74, 74t, 75 Transverse atlantal ligament injury, 80, 81
Smith fracture, 281, 283 Trauma
Smiths fracture, 281 epidemiology of, 24, 3t
Sonography, focused assessment in trauma, 174, severity scoring, 8, 9t, 10t
175177 Traumatic aortic injury, 122, 123
SPECT, of cerebral blood flow, 64, 64, 65 chest radiography, 124, 125
Spine. See Cervical spine; Lumbar spine; Thoracic computed tomography, 128129, 129131
spine. endovascular repair, 132, 133134
Spleen Injury Scale, 197t minimal aortic injury, 126, 127
Splenic cleft, 196 Traumatic brain injuries (TBI), 8, 9t
Splenic trauma, 196, 197t, 198 Traumatic pneumothorax
angiographic indications, 200 CT scan, 161, 162
computed tomography, 196 pleural sonography, 160161
grading scale, 197t radiography, 160
Sternal fracture, 114, 115 tension pneumothorax, 161
Sternoclavicular dislocation Triad of ODonoghue, 360, 361
anterior, 112, 112 Tripod fracture, 70, 70, 71
posterior, 112, 113 Triquetral fracture, 284, 287
Straddle injury of urethra, 248, 249
Stress fracture U
femoral neck, 334335, 336 Ulna fracture, 278, 278279, 280, 281
of tibia, 372, 372, 373 Uncal herniation, 56, 57
Subclavian artery injury, 136, 137 Unilateral facet dislocation, cervical spine, 88, 88, 89
Subdural hematoma (SDH) Upper (cerebellar hemorrhage), 60, 60, 61
acute, 36, 37 Ureteral injuries, 230231, 231232
in child abuse, 46, 47 Ureteropelvic junction injury, 217
chronic, 38, 39 Urethra
Subfalcine herniation, 58, 59 anterior, injuries to, 244, 246
Subtrochanteric femur fracture, 340, 341 laceration, 248, 249
Supracondylar femur fracture, 346, 347 posterior, injuries to, 244, 245

416 Index
Urethra (Continued) Volar plate fracture, 296, 297

rupture V-sign of Naclerio, 118, 145
type 1, 244t, 245
type 2, 244t, 246 W
type 3, 244t, 247 Windswept pelvis, 304
Urethrogram, 15 Wrist
Urinoma, 228, 229 barton fracture, 281, 283
Uterus gravid, trauma, 250, 251252 carpal bone
dislocations, 288, 289
V fracture, 284, 285287
Vascular trauma, peripheral, 138139, 139 trans-scaphoid-perilunate dislocation,
Vertebral artery injury, 50, 5053, 51t, 5253 288, 289
Vertical shear pelvic fracture, 308, 309

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Trauma Radiology

Martin L. Gunn, M.B.Ch.B., FRANZCR.

Joel A. Gross, M.S., M.D.

Michelle M. Bittle, M.D.

Eric J. Stern, M.D.

Bittle_FM.indd i 4/30/2011 4:01:19 PM

Library of Congress Cataloging-in-Publication Data

Bittle_FM.indd ii 4/30/2011 4:01:20 PM

Bittle_FM.indd iii 4/30/2011 4:01:21 PM

Blunt Trauma Resuscitation Imaging: The Radiologic ABCs 5

Trauma Severity Scoring 8

Medical-Legal Issues in Trauma and Emergency Radiology 11

Special Procedures in the Emergency Room 15

Gunshot Wounds: Low-Velocity Bullet Injury 22

Gunshot Wounds: Shotgun Injury 24

Contrast Reactions and Extravasation 28

2 Brain and Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Diffuse Axonal Injury 32

Epidural Hematoma/Hyperacute Intracranial Hemorrhage 34

Acute Subdural Hematoma 36

Chronic Subdural Hematoma/Acute Rehemorrhage 38

Linear Skull Fracture 40

Delayed Posttraumatic Intracranial Hemorrhage 44

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Gunshot Wound to Head 48

Blunt Carotid and Vertebral Artery Injuries 50

Acute Intracranial Hemorrhage: Intraventricular Hemorrhage

Herniation: Upward (Cerebellar Hemorrhage) 60

Diffuse Anoxic Changes 62

Cerebral Perfusion SPECT in Traumatic Brain Injury 64

Cerebral Blood Flow Imaging for Brain Death 66

Facial Trauma: Orbital Floor Fracture 68

Facial Trauma: Tripod Fracture 70

Facial Trauma: Le Fort Fracture 72

Cervical Spine Injury: Occipital Condyle Fractures 74

Cervical Spine Injury: Atlanto-Occipital Dissociation 76

Cervical Spine Injury: Jefferson Fracture 78

Cervical Spine Injury: Transverse Atlantal Ligament Injury 80

Cervical Spine Injury: Dens Fracture 82

Cervical Spine Injury: Traumatic Spondylolisthesis of the Axis 84

Cervical Spine Injury: Flexion-Teardrop Fracture (aka Hyperflexion

Lower Cervical Spine Injury: Unilateral Jumped Facet 88

Lower Cervical Spine Injury: Bilateral Jumped Facets 90

Bittle_FM.indd v 4/30/2011 4:01:21 PM

Lower Cervical Spine Injury: Isolated Posterior Ligamentous Injury 92

Lower Cervical Spine Injury: Burst Fracture 94

Thoracic/Lumbar Spine Injury: Compression and Burst Fractures 96

Thoracic/Lumbar Spine Injury: Flexion-Distraction and Chance

Thoracic/Lumbar Spine Injury: Hyperextension Injuries 100

Thoracic/Lumbar Spine Injury: Fracture-Dislocations 102

Radionuclide Detection of Cerebrospinal Fluid Leaks 104

Scapula Fracture 108

Rib Fractures 110

Sternoclavicular Dislocation 112

Sternal Fractures 114

Airway Rupture/Laceration 116

Esophageal Rupture/Laceration 118

Esophageal Intubation with Gastric Perforation 120

Traumatic Aortic Injury: Overview 122

Traumatic Aortic Injury: Chest Radiography 124

Traumatic Aortic Injury: Minimal Aortic Injury 126

Traumatic Aortic Injury: Computed Tomography 128

Traumatic Aortic Injury: Endovascular Repair 132