Foundations of Medical Practice: Trauma Imaging

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Foundations of Medical Practice Trauma Imaging
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Trauma Imaging
Acknowledgements Richard Aviv Robert
Bleakney TaeBong Chung Tim Dowdell Paul
Hamilton Nasir Jaffer Lara Richardson Harry
Shulman Lyne Noel de Tilly Bill Weiser
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TRAUMA IMAGING - OBJECTIVES

• Learn about
• Types of Imaging (X-ray) studies used for trauma
  patients
• Understand their uses
• Examples of organ and skeletal injury and
  typical findings
• Test Cases

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MAJOR TRAUMA CENTRES

• Have a dynamic team of specialists
• Emergency Physicians
• ICU Physicians
• Surgeons (Ortho, Neuro, Abdominal)
• Radiologists
• Have Well Equipped Emergency Department
• Resuscitation Centre
• Mini OR
• X-ray Department (Plain X-ray, CT US)

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• WHAT ARE THE DIFFERENT TYPES OF
• RADIOLOGIC (IMAGING) TESTS
• AVAILABLE FOR THE TRAUMA
• PATIENT ?

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PLAIN X-RAY UNIT

• Used for basic fractures and CXR
• Always located in the Emergency Department

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ULTRASOUND
ascites
LIVER
Right Kidney
Diaphragm
Sagittal Ultrasound of Liver showing ascites

• Small portable units in Emerg Dept
• Check for hemoperitoneum

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CT SCANNER

• Some major Trauma Centers have in Emerg Dept
• Important for unstable patient

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MRI SCANNER

• Used mostly for CNS trauma
• Done in a hemodynamically stable patient
• Not available in Emerg Dept

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Approach to trauma patient

• Primary survey (ABCDs)
• A Airway maintenance with cervical spine control
  
• B Breathing and ventilation
• C Circulation
• D Disability (neurological status)

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• WHAT ARE THE BASIC IMAGING
• TESTS THAT SHOULD BE DONE
• INITIALLY FOR MAJOR TRAUMA
• PATIENT?

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BEFORE SENDING PATIENT FOR X-RAYS
TRANSPORTING DEVICES FOR X-RAY

• Patient needs to be hemodynamically stable
• Stabilising devices
• Neck brace (C-spine injuries)
• Spinal board (Lumbar spine injuries)
• Facial and C-spine fractures can be deadly if
  neck flexed during CT scan positioning

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TRAUMA IMAGING ON ADMISSION
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APPROACH TO IMAGING OF TRAUMA

• TYPES OF TRAUMA
• A ORGAN SPECIFIC
• MULTIPLE ORGAN INVOLVEMENT
• e.g motor vehicle, bicycle involved with major
  motor vehicle
• 2. LOCALISED ORGAN INVOLVEMENT
• e.g. Abdominal, chest, head injury
• B TYPE OF INJURY
• Penetrating
• Blunt trauma

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APPROACH TO IMAGING OF TRAUMA
IMAGING OF ORGAN SPECIFIC TRAUMA

• A) MULTI ORGAN TRAUMA
• Requires aggressive imaging
• CT located in the Emergency Room
• Head. Chest and Abdomen CTs can be done quickly
• To triage the patient
• Do a Contrast CT of whole body
• Then refer patient to
• Neurosurgeon or Vascular surgeon or Orthopedic
  or Abdominal surgeon

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MULTI ORGAN TRAUMA
Liver
Stomach
Kidney
Kidney
A Liver laceration
B Renal laceration
Hyper enhancing bowel wall
C Shock Bowel
Small aorta
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SINGLE ORGAN TRAUMA

• Careful Clinical analysis before Imaging
• Since patient usually stable
• Can become unstable quickly
• E.g. delayed rupture of organs e.g spleen
• Also include the facial trauma and fractures
• May need specialised care
• Sent to other hospitals
• Complex Pelvic, C-spine fractures,
• Patients sent to Sunnybrook for special surgery
  where there is expertise

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SINGLE ORGAN TRAUMA
Liver
Spleen
Splenic hematoma
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SINGLE ORGAN TRAUMA
Liver
Spleen
Splenic hematoma
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TYPE OF INJURY

• PENETRATING
• Can be life threatening
• Instrument best left in patient
• Surgery best treatment
• IMAGING
• Plain Film
• CT scan to assess internal organ damage
• MRI cannot be performed!

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TYPES OF IMAGING

• Plain films
• Fractures
• May require CT for more complex fractures (e.g
  pelvis
• Sometimes 3D CT imaging done for surgeon
• CT
• Assessing Organ injury
• Ultrasound
• Abdominal injury (assessing for hemoperitoneum)
• Angiography
• For patients with bleeding requiring embolization
• MRI
• For neurological assessment especially for spinal
  cord injury

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PLAIN FILMS IN TRAUMA

• C Spine/L spine
• Used as initial investigation
• May need CT or MRI
• Long bone fractures
• Plain films sufficient

NORMAL
FRACTURE OF C2 POSTERIOR ELEMENTS
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CT SCAN FOR FRACTURES

• Important for complex fractures
• Facial fractures
• Spinal fractures
• Pelvic fractures
• Defines fractures better
• Shows associated complications
• Useful for surgeon

• Right maxillary sinus filled with blood
• Fractures of maxillary sinus

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3D RECONSTRUCTION OF CT IMAGES OF FACIAL FRACTURE

• Advantages
• 3D perspective for surgeon
• Can plan type of surgery
• Assess Post surgery reults

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ROLE OF MRI IN TRAUMA

• Used for CNS trauma
• Assess cord brain injury
• For
• Planning surgery
• Assess prognosis

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ULTRASOUND
Ascites
Used in Emergency Department to detect free
fluid specifically blood
Liver
Kidney
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ANGIOGRAPHY

• Two types
• CONVENTIONAL ANGIOGRAPHY
• Invasive
• Artery punctured
• CT ANGIOGRAPHY
• Not invasive
• Only antecubital vein punctured
• CT scan done

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CONVENTIONAL ANGIOGRAM
Fractured Humerus
Severed Brachial artery

• ANGIOGRAM TECHNIQUE
• Femoral artery punctured
• Catheter inserted into artery to be studied
• X-rays are taken

Angiogram X-ray of left Arm
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CT ANGIOGRAM
CT Angiogram (with bones removed)
CT Angiogram of Dislocated shoulder
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WHICH X-RAY TEST TO ORDER

• Clinical history of type of trauma important
• Blunt trauma
• Contra coup injury (e.g. brain)
• Organ traumatized difficult to locate
• May require global imaging ( i.e CT scan)
• Penetrating trauma injured organ easily
  identified

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TYPE OF INJURY

• FALL FROM HEIGHT
• Fractures of
• Calcaneum
• Pelvis
• Lumbar spine
• Must x-ray many areas

3D Reconstruction of CT Images of Lumbar spine
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Cervical Spine
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The Lateral Cervical Spine X-Ray

• Is it adequate?
• ABCS of C-Spine Lateral
• Alignment
• Bones - Vertebral Bodies
• Cartilage (Disc)
• Soft Tissue
• Open Mouth (Odontoid) View

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The Lateral Cervical Spine X-RayAdequacy

• MUST visualize the entire cervical spine, from
  the skull base to the cervico-thoracic junction.
• a film that does not show the upper border of T1
  is INADEQUATE

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3
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5
6
7
T1
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ABCS of Cervical Spine

• Alignment
• Bones
• Cartilage (Disc)
• Soft Tissue

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Alignment
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Alignment
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• Alignment
• Bones
• Cartilage (Disc)
• Soft Tissue

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C1
C2
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ABCS of Cervical Spine

• Alignment
• Bones
• Cartilage (Disc)
• Soft Tissue

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ABCS of Cervical Spine

• Alignment
• Bones
• Cartilage (Disc)
• Soft Tissue

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4-7mm (1/2 vertebral body)
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6
16-20mm (full vertebral body)
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Abnormal C-Spine Cases
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Abnormal Alignment
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normal more subtle findings
Which of the ABCS are abnormal?
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normal more subtle findings
Alignment
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Wheres the fracture?
Normal
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Odontoid fracture
Normal
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C6 wedge compression fracture
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avulsed teardrop fragment
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clay shovelers fracture avulsion fracture of
spinous process of C7
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normal where is the fracture?
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normal fracture of C2
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Open Mouth (Odontoid) View
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Open Mouth (Odontoid) View
C1
C1
C2
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Axial compression

• open mouth view

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normal Fracture of C1
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normal Fracture of C1
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quick quiz where is the injury?
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quick quiz where is the injury?
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quick quiz where is the injury?
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quick quiz where is the injury?
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injury normal
Which of the ABCS is abnormal?
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Head
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Head
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Head

• bleeds
• epidural haemorrhage
• subdural haemorrhage
• subarachnoid haemorrhage
• intracerebral haemorrahge

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bone dura
dura thick dense inelastic closely adherent to
the inner surface of the bone
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epidural haemorrhage lenticular biconvex
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epidural haematoma
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epidural haematoma
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bone dura arachnoid pia brain
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bone dura arachnoid pia brain
subdural haemorrhage crestentic concave
inner margin
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fluid / fluid level
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bone dura arachnoid pia brain
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bone dura arachnoid pia brain
subarachnoid haemorrhage subtle diffuse
inter-hemispheric inter-ventricular
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normal
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normal
subarachnoid haemorrhage
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bone dura arachnoid pia brain
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bone dura arachnoid pia brain
intra-cerebral haemorrhage
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normal
haemorrhagic contusions frontal lobes
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ICH
intraventricular extension
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quick quiz where is the bleed?
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quick quiz where is the bleed?
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quick quiz where is the bleed?
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quick quiz where is the bleed?
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Chest

• Aortic Injury
• low survival if untreated
• Fractures
• Lung Injury
• Contusion
• Lacerations
• Pleural Injury
• Pneumothorax
• Hemothorax

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Imaging Assessment in Trauma

• CXR
• Usual method of initial screening in trauma
• CT
• Often needs CT for assessment of other regions
  (abdomen, head)
• Angiography
• Becoming less commonly used but still gold
  standard for aortic injury

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CXR Findings in Aortic Injury

• CXR sensitive but not specific for aortic injury
• Over 95-98 sensitive i.e. normal CXR should
  preclude further assessment
• CXR Findings
• Mediastinal and paraspinal line widening
• Indistinct aorta
• Apical cap
• Displacement of NG tube and left bronchus

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• 30 year old male involved in high speed MVA
  presents to a trauma centre.
• What are the findings on the CXR?
• What would the next imaging investigation for the
  thorax?

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Normal
Indistinct Aorta
Widened mediastinum
Increased Density Behind Heart
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Apical Cap
Displaced NG Tube
Indistinct Aorta Widened Mediastinum
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CT Findings
patient
normal
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CT Findings

• Indirect signs
• Mediastinal hematoma
• Direct Signs
• Sign of aortic injury

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CT Findings

• Indirect signs
• Mediastinal hematoma
• Direct Signs
• Sign of aortic injury

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• Life threatening events
• Tension pneumothorax
• Flail chest
• Large hemothorax
• Aortic dissection/rupture
• Great vessel rupture

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Normal CXR
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Haemothorax Complete opacification of right
hemi thorax Shift of mediastinum to left
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Sub pleural haematoma Rib fractures
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Flail chest
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normal
Tension pneumothorax
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Tension pneumothorax post chest drain insertion
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normal
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Traumatic diaphragmatic rupture
Distended stomach in chest
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What sort of tube is this? Where should it be?
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Endotracheal tube In right main bronchus
Carina
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ET tube should be 5 cm (/- 2 cm) proximal to the
carina
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ET tube should be 5 cm (/- 2 cm) proximal to the
carina
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quick quiz abnormality?
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quick quiz abnormality?
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quick quiz abnormality?
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Abdomen
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Abdomen

• Hemodynamically stable
• Complete clinical and radiological workup

• Hemodynamically unstable
• Minimal radiologic investigations (eg F.A.S.T. -
  Focused Assessment with Sonography for Trauma)
• Immediate surgery or interventional radiology
  treatment

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Abdominal trauma mechanism

• Blunt
• MVA
• Pedestrian
• Bike
• Falls
• Assaults
• Falling objects

• Penetrating
• Gunshot
• Stab wound

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Organ specific injuries

• Spleen
• Liver
• Kidneys
• Bowel and mesentery

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ABDOMINAL ANATOMY

• Traumatic injuries to
• LIVER
• SPLEEN
• KIDNEYS

Liver
Spleen
Kidney
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IMAGING STUDIES BEST FOR ABDOMINAL TRAUMA
Liver
kidney
Ultrasound
CT
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Traumatic splenic injury

• Commonly injured in blunt trauma
• Clinical findings
• Often no/non-specific symptoms
• Peritoneal irritation
• Signs/symptoms of acute hemorrhage

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Traumatic splenic injury

• Imaging
• Plain film not useful
• US hemoperitoneum
• Contrast-enhanced CT imaging modality of choice
• Angiography therapeutic embolization

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Imaging of splenic injury

• Hematoma
• Laceration
• Infarction

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Splenic hematoma

• CT
• The BEST IMAGING STUDY
• CT Findings
• On Plain CT High Density (Blood)
• With IV Contrast No enhancement
• Density of hematoma decreases with time

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Contrast enhanced CT splenic hematoma
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Contrast enhanced CT splenic hematoma
Liver
Spleen
Splenic hematoma
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Splenic Laceration

• Contrast-enhanced CT
• Findings often undetectable
• CT Findings
• Perisplenic fluid
• Low-density linear defects, within the spleen
  (usually
• extending from the lateral border towards the
  hilum)
• Blood clot - sentinal clot sign

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Contrast enhanced CTSplenic Laceration
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Contrast enhanced CTSplenic Laceration
Pseudo-aneurysm
Liver
L kidney
Splenic laceration
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Traumatic liver injury

• Commonly injured in blunt trauma
• R lobe, post segment most often injured
• Clinical findings
• RUQ pain
• Hypotension
• Shock
• Symptoms of bile peritonitis (bile duct injury)

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Traumatic liver injury imaging

• Plain film not useful
• US hemoperitoneum
• CT imaging modality of choice
• Angiography to detect vascular complications and
  for therapeutic embolization

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CT imaging of liver injury

• TYPES OF LIVER INJURIES
• Contusions
• Subcapsular hematoma
• Intraparenchymal hematoma
• Lacerations
• Complete hepatic fracture

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Intraparenchymal hematoma
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Intraparenchymal hematoma
Intraparenchymal hematoma
liver

• Severe intraparenchymal bleeding
• No enhancement with contrast

stomach
spleen
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Subcapsular hematoma

• Peripherally located
• Least common form of liver injury

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Subcapsular hematoma

• Peripherally located
• Least common form of liver injury

Subcapsular hematoma Low attenuation, lentiform
collection displacing compressing the liver
liver
stomach
spleen
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Hepatic laceration

• Most common liver injury
• The Liver capsule can be Intact or disrupted
• Intact liver capsule stable injury
• Disrupted capsule can result in Hemoperitoneum

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Hepatic Laceration
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Hepatic Laceration
Hepatic laceration
Descending aorta
Spleen
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Traumatic kidney injury

• Mechanism
• Blunt trauma (80)
• Laceration by lower ribs
• Torn by rapid acceleration deceleration
• Clinical findings
• Back pain
• Hematuria
• Can be hemodynamically unstable

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Traumatic kidney injury

• Can affect
• Renal Parenchyma
• Renal collecting system
• Renal vessels

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Classification and management of renal injuries
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Imaging of renal trauma

• US
• Limited use
• Contrast enhanced CT
• Study of choice
• Delayed images important to differentiate between
  hematoma leakage from collecting system

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Imaging of renal trauma

• Angiography
• Not done routinely
• Now CT Angiography better study
• CTA done with IV contrast and during arterial
  phase
• Done only when embolization of bleeding site is
  required

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Renal Laceration
Contrast-enhanced CT Low density areas in
kidney parallel to intervascular tissue planes
pancreas
Kidney
Kidney
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Renal Laceration
Contrast-enhanced CT Low density areas in
kidney parallel to intervascular tissue planes
pancreas
Renal laceration
Small perirenal hematoma
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Lacerations transecting the collecting system

• Contrast-enhanced CT
• Contrast extravasation
• around the kidney

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Lacerations transecting the collecting system
Collecting system leak
R kidney
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Renal Artery Injury

• Uncommon injury
• CT BEST TEST
• CT Findings
• Absence of contrast enhancement (no flow)
• Hematoma surrounding the kidney
• Abrupt cut-off of contrast filled renal artery
• Sometimes contrast leaks out from artery into
  tissues

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RENAL ARTERY INJURY
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RENAL ARTERY INJURY
R kidney Absence of contrast enhancement
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MAJOR ARTERIAL INJURY
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MAJOR ARTERIAL INJURY
Perirenal hematoma
Contrast extravasation
Laceration
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quick quiz what organ is injured?
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Trauma Imaging - objectives

• Imaging Methods
• C-spine evaluate lateral c spine
• Head know patterns of intracranial bleeds
• Chest identify life threatening injuries
• Abdomen know organ specific injuries