Laurie A. Romig, MD, FACEP

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Shades of Black and White
Reading Trauma X Rays

• Laurie A. Romig, MD, FACEP
• Executive Medical Director
• LifeNet Florida
• Medical Director
• Pinellas County (FL) EMS

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Good News/Bad News

• Bad News
• We wont be able to cover all of the material in
  the handout
• Good News
• What we will cover is going to be terrific!

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Objectives

• Most common initial X rays in the adult trauma
  patient
• Normal and abnormal findings on
• cervical spine
• chest
• Examples of some ancillary studies

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Why should you know about all this stuff?
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Why should you know about all this stuff?

• Flight and critical care crew members might
  intervene based on X rays
• Feedback on your clinical patient evaluation
• Catch some problems early (even before the doc)
• Makes you a better trauma team member
• Impress almost anybody

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The BIG 3

• Cervical spine films
• lateral
• AP
• odontoid (open mouth)
• Supine chest film
• AP pelvis film

Some trauma teams routinely include a lateral
lumbosacral spine film, to make the BIG 4
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Ancillary Radiographic Studies

• Extremity X rays
• Other plain films
• Retrograde urethrogram
• Abdominal ultrasound
• CT
• Arteriography

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Approach to Reading X rays

• Know what normal anatomy looks like
• Always take a systematic approach
• A little distance can be a good thing
• Experience counts

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A Systematic Approach
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Cervical Spine X rays
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The Lateral Film

• Is the film satisfactory?
• Nothing obscured by jewelry or other opaque
  objects?
• Penetration OK?
• An adequate film?

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• A-O junction obscured by nameplate
• Occiput and palate not seen
• At least the top edge of T1 should be seen

Not an adequate film!
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Curves to Follow
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Abnormalities in Curves

• Malalignment of post. vertebral bodies more
  significant than ant.
• Spinal canal diameter is significantly narrowed
  if lt 14 mm
• Anterior subluxation caused by facet dislocation
• lt 50 VB width unilateral
• gt 50 VB width bilateral
• widening interspinous spaces

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Symmetry

• Symmetry of bones
• Intervertebral disc spaces

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Abnormal Symmetry

• Often due to compression
• Compression of gt 40 normal VB height usually
  indicates a burst fx with possible fragments into
  spinal canal
• Anterior compression may cause a teardrop
  shaped fx

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Measurements

• Soft tissue spaces
• Retropharyngeal space
• 7 mm at C2
• lt 50 of width of VB at C4 and above
• may be 100 width of VB below C4
• Retrotracheal space
• 22 mm at C6
• 14 mm in children

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Soft Tissue Measurements
Abnormal measurements may indicate soft tissue
swelling from obvious or occult fxs, hematomas,
or abscesses
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Anterior Atlanto-dens Interval

• 3 mm in adults
• 5 mm in children
• gt3.5 mm T. L. injury
• gt 5 mm T.L. rupture instability

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Intervertebral Disc Spaces

• Decreased IVD space may indicate herniated disc

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Atlanto-Occipital Distance

• Distance from atlas (C1) to occiput should always
  be lt 5mm
• Increased distance may indicate atlanto-occipital
  dislocation

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Anterior-Posterior View

• Symmetry/size
• Alignment of spinous processes
• Smooth, rolling lateral edges

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Odontoid (Open mouth) View
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Odontoid View Close-up
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(No Transcript)
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Abnormal Cervical Spine Films
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Atlanto-occipital Disassociation Fx C1
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(No Transcript)
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Unilateral Facet Dislocation
Bilateral Facet Dislocation
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C2 fx/dislocation
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(No Transcript)
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Odontoid (C2) fx
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(No Transcript)
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(No Transcript)
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Lateral view of odontoid fx on CT
C1
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C5 compression fx
C5 compression fx
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C6 burst fx/dislocation
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C 5-6 fracture/dislocation on CT
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C4 Teardrop Fx
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Chest X rays
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A Systematic Approach

• The systematic approach involves evaluating
• adequacy of the film
• bony structures
• mediastinum/major vessels
• lung fields
• soft tissue
• diaphragm/portion of abdomen visible

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Adequacy of the Film

• Do you have it hung up right?
• Appropriate X ray penetration
• Too light, cant separate out subtle changes
• Too penetrated, cant evaluate lung fields well
• Able to see both costophrenic angles and both
  apices

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Bony Structures

• Ribs
• Fx of first and second ribs imply great force and
  potential for underlying great vessel, lung and
  airway damage
• Sternum
• Clavicles
• Scapula
• Fx may also imply great force and underlying
  injuries
• Cervical and thoracic spine

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Mediastinum and Major Vessels

• Width of mediastinum
• Aortic rupture
• Size of cardiac shadow
• Hemo or pneumopericardium
• Underlying medical problem
• Air in mediastinum
• Trachea
• Tracheal shift

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Lung Fields

• Pneumothorax/Tension Pneumothorax
• Hemothorax
• Pulmonary Contusion
• Atelectasis
• Infection
• Pulmonary Edema

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Soft Tissue

• Subcutaneous emphysema
• Foreign bodies/impaled objects

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Diaphragm/Abdomen

• Diaphragm position
• Position of gastric air bubble and/or NG tube
• Ruptured diaphragm
• Free air under the diaphragm
• Ruptured abdominal viscous organ

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Normal Chest X ray

• Adequacy
• Bones
• Mediastinum/major vessels/trachea
• Lung fields
• Soft tissue
• Abdomen

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Abnormal Chest X rays
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Bony Abnormalities

• Rib fxs
• Mediast. OK
• Pulmonary contusion
• Subcu air
• Chest tube
• NG tube

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MVC victim
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(No Transcript)
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Mediastinal Abnormalities
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Deep Right Mainstem Intubation
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Pneumomediastinum
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Pneumomediastinum
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Potential X ray findings

• wide mediastinum
• obliteration of aortic knob
• Rt mainstem shift up and right
• NG deviate to right
• pleural cap

Major Vessel Injury
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Mediastinal Hematoma
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(No Transcript)
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(No Transcript)
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Pneumothoraces
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(No Transcript)
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Expiration reduces lung volume, making a small
pneumo easier to see
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(No Transcript)
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Tension Pneumothorax on CT
Tension Pneumo
Mediastinum
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Hemothoraces
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Hemothorax
Supine
Upright
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Tension Hemothorax
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Hemopneumothorax
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Diaphragm Injuries
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Indistinct diaphragm
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Elevated, irregular hemidiaphragm
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Close-up
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Crushed right chest
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After ventilated with PEEP
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Internal fixation
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After fixation
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Hemo/pneumo/diaphragmo/stomacho
DISASTER
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Trauma and Radiology Internet Resources
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Before we finish
You can download this Powerpoint from
www.jumpstarttriage.com Go to the The Other Dr.
Romig page from the home page and click on the
appropriate link at the bottom of the page Youre
also welcome to any of the other lectures listed.
I just ask that appropriate attributions are made
if you use them for presentation or research
purposes. Please contact me with any questions or
corrections.
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Summary

• The key to ANY X ray interpretation is knowledge
  of anatomy, normal appearance and a systematic
  approach
• The most common plain films used for adult
  multiple trauma patients are cervical spine,
  chest, and pelvis films

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Summary

• Plain films can be very effective at detecting
  many major injuries
• Sometimes even better than fancier technology
• Plain films can suggest further needed diagnostic
  modalities
• You can read X rays!

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Questions?
drromig_at_medcontrol.com