This document discusses chest trauma and summarizes key information about various types of pulmonary and chest injuries that can occur from blunt or penetrating chest trauma. It covers topics like pneumothorax, hemothorax, pulmonary contusions and lacerations, rib fractures, tracheobronchial injuries, and imaging findings on chest x-rays and CT for evaluating these injuries. Imaging plays an important role in accurately assessing the nature and extent of pulmonary and chest wall injuries from trauma.

1. CHEST TRAUMA
DR ASHISH KUMAR
MODERATOR- DR CHANDAN KUMAR PAL

2. Trauma : leading cause of death under 40 years of age
pulmonary trauma : common in high-impact injuries.
most common types of lung parenchymal injury :contusions,
lacerations
hematomas.
Chest radiography : first-line imaging modality.
CT images :accurate for the assessment of the nature and extent of pulmonary injury.

3. TRAUMA MECHANISMS
More than two-thirds of blunt thoracic trauma is caused by motor
vehicle collisions (MVCs), while the remainder result from falls
from height or direct impact to the chest.
Penetrating injuries : gunshot/stab/blast injuries and penetration from
other objects.

4. ASSOCIATED INJURIES
Sternal fracture Heart injury
Rib fracture Pulmonary contusion, laceration
Upper rib fracture (first three ribs) Brachial plexus, subclavian vessels
Lower rib fractures (last four ribs) Intra-abdominal injury
Subcutaneous emphysema Airway injury, oesophageal injury
Pneumomediastinum Airway injury, lung injury, oesophageal injury
Sternoclavicular fracture (posterior sternoclavicular
dislocation)
Mediastinal vessels, tracheal injury, oesophageal injury
Scapular fracture Haemopneumothorax, lung injury, spine and clavicle
fracture, subclavian vessels, brachial plexus

5. IMAGING TECHNIQUES FOR PULMONARY TRAUMA
 The chest radiograph is the primary initial screening examination performed in thoracic
trauma, although some centers also perform extended focused assessment in sonography for
trauma (eFAST).
 FAST : rapid, deployed at the bedside, and it does not impart ionizing radiation. It can detect
pleural effusion/hemothorax or pericardial effusion/hemopericardium.
 Chest radiographs are widely used as screening examinations in thoracic trauma.
 Chest radiography :1]identify rib fractures
2]foreign bodies/ballistic fragments
3]Contusions,
4]pneumothorax
5]hemothorax &mediastinal injuries

6.  Contrast-enhanced CT :standard imaging tool in the evaluation of trauma
patients.
Moreover, CT provides greater sensitivity and specificity than chest
radiography in the detection and extent of pulmonary injuries.

8. TRAUMA CHEST RADIOGRAPH
Usually AP,
often supine,
frequently in
poor
inspiration.

9. LIMITATIONS OF PLAIN XRAY
A large hemothorax may be seen as pleural effusion.
It is almost impossible to differentiate a hemothorax from other causes
of pleural effusion.

10. PNEUMOTHORAX
Trauma-related pneumothorax occurs in 30–40% of cases. Most commonly
associated with rib fractures that lacerate the lung.
Tracheobronchial always associated with pneumothorax. CT is more sensitive.
Radiographic signs :
(1) Increased lucency at the affected hemidiaphragm,
(2) An abnormally deep costophrenic sulcus sign,
(3) A sharply defined radiolucent border of the mediastinum or heart, and
(4) The “double diaphragm sign” caused by the presence of air outlining the dome
and insertion of the diaphragm.

12. Normal lung USG : M mode

14. USG: barcode sign in pneumothorax

15. Pneumothorax following blunt chest trauma. (a) Supine AP chest radiograph shows displaced left rib fractures, subcutaneous
emphysema, and subtle pneumothorax. There is a significant basilar pneumothorax with several imaging clues: deep sulcus
sign, double diaphragm sign, and a well-defined left heart border with floating fat pad sign. Multiple opacities are depicted
throughout the left lung, compatible with a combination of contusions and lacerations in the setting of trauma. (b) Axial CT
image obtained on the same day as a shows a large pneumothorax; a radiograph can significantly underestimate
pneumothorax size. Two intraparenchymal lacerations are depicted in the left lower lobe, with pneumatocele and
hematopneumatocele.

16. TENSION PNEUMOTHORAX
A tension pneumothorax is due to a one-way valve mechanism that allows air
into but not out of the pleural space, thereby allowing the pleural pressure to
exceed atmospheric pressure.
Findings: collapse of the ipsilateral lung, contralateral mediastinal deviation,
and inversion of the ipsilateral diaphragm.
Since tension pneumothorax is a clinical diagnosis, and patients may have
mediastinal deviation without clinical signs of tension physiology (impaired
venous return to the heart), likely due to loss of negative intrapleural pressure
on the affected side.

17. TENSION PNEUMOTHORAX
 Erect AP/PA view is best
 Shift of mediastinum /heart/trachea away from pneumothorax side
 Depressed hemidiaphragm
 Degree of lung collapse is variable

18. Posteroanterior chest radiograph
in a 29-year-old man with
shortness of breath shows findings
of tension pneumothorax,
including collapse of the ipsilateral
lung, contralateral mediastinal
deviation, and inversion of the
ipsilateral diaphragm.

19. Tension haemopneumothorax. Axial contrast-
enhanced CT at mediastinal window shows a right
tension haemopneumothorax with heterogeneous
increased density due to presence of blood clots
and a significant shift of the mediastinum
contralaterally.

21. Tension pneumothorax. Sagittal reformatted CT
image at lung window showing tension
pneumothorax with significantly collapsed lung at
the posterior part of the hemithorax associated with
ipsilateral pleural effusion.

22. HEMOTHORAX
Haemothorax: In 50% of chest trauma cases. Blood pooling into the pleural
space from variable sources: the lung parenchyma, the chest wall, the great
vessels, the heart or even the liver and spleen through diaphragmatic
rupture.
Arterial bleeding more common.
CT: very sensitive in detecting even a small haemothorax.

23. Chest x-ray showing a massive left (L)
hemothorax following blunt trauma from a
motor vehicle crash.

24. Ultrasonography: Sagittal view of the right
upper quadrant and lower right hemithorax. The
dark area depicted by the arrow is diagnostic for
either fluid or blood in the right hemithorax.

26. TRACHEA/BRONCHI INJURY
 Tracheobronchial injuries are rare, occurring in 0.2–8% of all cases of chest trauma. 50% of
patients die at the trauma scene within the first 2 h from associated injuries and respiratory
insufficiency.
 Bronchial injuries: more commonly than tracheal, usually on the right side and within 2.5
cm from the carina.
 85% of tracheal lacerations occur 2 cm above the carina.
 A direct CT finding of tracheobronchial injuries is the cutoff of the tracheal and bronchial
wall with extraluminal air surrounding the airway. Indirect findings are the “fallen lung”
sign, corresponding to the collapsed lung resting away from the hilum towards the
dependent portion of the hemithorax.

27. Bronchial transection. A 22-year-old
man involved in a car accident.
Volume-rendered image of the
tracheobronchial tree showing
complete transection of the right
intermediate bronchus.

28. Tracheal injury in a 32-year-old man after a thoracic gunshot wound. (a) AP radiograph shows entry and exit
sites. The AP bullet trajectory would be expected to involve midline structures such as the trachea.
Paramediastinal haziness is depicted, reflecting pulmonary contusions. (b) Axial contrast-enhanced chest CT
image shows extensive diffuse pneumomediastinum. Note the small anterior tracheal wall defect. Tracheal
injury from a penetrating wound would likely be associated with injury to other adjacent mediastinal
structures as well. (c) Parasagittal contrast-enhanced reformatted CT image shows extensive anterior and
posterior pneumomediastinum from the visualized neck to the root of the aorta.

31. PULMONARY CONTUSION AND LACERATION
 Contusion: Blood in intact lung parenchyma
 Laceration: Blood in torn lung parenchyma
 Chest film cannot differentiate them.
Contusions peak in 2-3 days, begin to resolve in a week; lacerations
take much longer to resolve and may leave scars.

32. AAST
Organ
Injury
Scale for
Lung
Injury
Grade Injury Type Description of Injury
I Contusion Unilateral contusion, segmental or subsegmental involvement
II Contusion Unilateral contusion, lobar involvement
Laceration Peripheral laceration, with or without simple pneumothorax
III Contusion Unilateral contusion with more than single lobe involvement or bilateral contusions
Laceration Persistent laceration (>72 hours); injury to distal airways, with or without air leak
Hematoma Intraparenchymal hematoma (nonexpanding)
IV Laceration Major laceration (segmental or lobar) with imaging findings suggestive of air leak
Hematoma Expanding intraparenchymal hematoma (expanding over consecutive imaging
examinations or with active contrast material extravasation)
Vascular injury Primary branch intrapulmonary vessel disruption
V Vascular injury Hilar vascular injury (contained, without active contrast material extravasation)
VI Vascular injury Transection of pulmonary hilum or hilar vessel injury with uncontained bleeding
(active contrast material extravasation)

33. PULMONARY CONTUSION
Lung contusion is a focal parenchymal injury caused by disruption of the
capillaries of the alveolar walls and septa, and leakage of blood into the alveolar
spaces and interstitium.
It is the most common type of lung injury in blunt chest trauma.
Main mechanism: compression and tearing of the lung parenchyma at the site of
impact against osseous structures, rib fractures or pre-existing pleural adhesions.
Lung contusion occurs at the time of injury, but it may be undetectable on chest
radiography for the first 6 h after trauma.
The pooling of haemorrhage and oedema will occur at 24 h, rendering the
contusion radiographically more evident, although CT may readily reveal it from
the initial imaging.

34.  The appearance of consolidation on chest radiography after the first 24 h should
raise suspicion of other pathological conditions such as aspiration, pneumonia and
fat embolism.
 Contusions appear as geographic, non-segmental areas of ground-glass or nodular
opacities or consolidation on CT that do not respect the lobar boundaries and may
manifest air bronchograms if the bronchioles are not filled with blood.
 Subpleural sparing of 1–2 mm may be seen, especially in children. Clearance of an
uncomplicated contusion begins at 24 to 48 h with complete resolution after 3 to
14 days.
 Lack of resolution within the expected time frame should raise the suspicion of
complications such as pneumonia, abscess or ARDS.

35. Lung contusion. Axial (a, b) and
coronal (c) CT images at lung window
show nodular opacities of ground-
glass opacity that do not respect the
lung boundaries of the right upper
lobe. (a), diffuse areas of ground-glass
opacity in the upper lobes bilaterally
with subpleural sparing (b) and
multiple areas of consolidation with
air bronchograms and small
lacerations in both lungs consistent
with lung contusions.

36. PULMONARY LACERATIONS
 Pulmonary laceration occurs in major chest trauma when disruption and tearing of the lung
parenchyma follows shearing forces, caused by direct impact, compression or inertial
deceleration.
 Classified into the following four types according to the mechanism of injury:
• type I - compression rupture: most common type of laceration that usually occurs as a 2-8
cm lesion in the central lung.
• type II - compression shear: occurs after sudden compression of the lower chest when the
lung suffers from a shear injury to the spine; the lung is compressed by lateral compression,
against the spine leading to a paravertebral tubular lesion in lower part of the lung.
• type III - direct puncture / rib penetration: occur with a penetrating fractured rib; these
lesions are commonly multiple.
• type IV - adhesion tears: occurs in sudden injuries of the chest wall where
prior pleuropulmonary adhesions have been created.

37. Pulmonary laceration in a 38-year-old man after a thoracic gunshot wound. (a) AP chest radiograph
obtained at presentation shows a hazy opacity in the left upper lobe, reflecting laceration obscured by
pulmonary contusions. (b) Axial CT image obtained on the same day better shows the pulmonary
laceration cavity filled with blood and air, with surrounding contusion. (c) AP radiograph obtained 8
days later shows that the laceration is visible as a well-circumscribed opacity, as the contusions have
resolved. Note the persistent pneumothorax, possibly from a bronchopleural fistula, a potential
complication of large pulmonary lacerations.

38. Pulmonary laceration types 1–3. (a)
Axial CT image in a 27-year-old man
shows three centrally located
intraparenchymal lacerations type 1,
compression rupture (pneumatocele and
hematopneumatocele). The surrounding
ground-glass attenuation, reflecting
contusions and moderate
pneumothorax.
(b) Axial CT image in a 33-year-old
man shows a paravertebral air-filled
laceration (pneumatocele) type 2,
compression shear laceration
(pneumatocele).
(c) Axial CT image in a 24-year-old
man shows a peripheral air-filled
laceration (pneumatocele) subjacent to
the thoracic ribs, type 3, rib penetration
tear.

39. Lung laceration, type II. Coronal reformatted CT image at lung window (a) shows a lobulated paraspinal
pneumatocele surrounded by ground-glass opacity (contusion) in the right lung consistent with lung laceration
(type II?). On mediastinal window lung laceration is seen to have been complicated by acute pulmonary
embolism.

40. Lung laceration, type IV. Axial CT image of
the left lung at lung window shows a small
peripheral laceration beneath a rib fracture
surrounded by ground-glass opacity (lung
contusion) and associated with a small
ipsilateral pneumothorax.

41. PNEUMOMEDIASTINUM
 Usually from ruptured alveoli
 Can also be from trachea, bronchi,
esophagus, bowel and neck injuries

42. SIGNS
 Linear paratracheal lucencies
 Air along heart border
 “V” sign at aortic-diaphragm
junction
 Continuous diaphragm sign

43. Chest xray following trauma showing air outlining mediastinal structures and
subcutaneous emphysema

45. V sign of
neclerio

46. PNEUMOMEDIASTINUM: CT

47. PNEUMOMEDIASTINUM WITH SUBCUTANEOUS EMPHYSEMA

48. Pneumopericardium

49. HEMOPERICARDIUM
 Hemopericardium refers to the presence of blood within the pericardial cavity. Can occur
from blunt/penetrating/deceleration trauma.
 Plain radiograph
• enlargement of the cardiac silhouette may be present but chest x-rays are insensitive and
non-specific.
• the "straight left heart border" is an infrequent sign with low sensitivity (~40%) for
hemopericardium in penetrating trauma patients.
• ​the Oreo cookie sign on lateral CXR.

51. HEMOPERICARDIUM: CT

52. RIBS FRACTURE
 Rib fractures are the most common injury in blunt chest trauma. A single rib fracture is
usually not clinically significant, whereas multiple rib fractures indicate severe injury.
 Fractures of the first three ribs imply high-energy trauma that may be associated with
injury of the brachial plexus or subclavian vessels.
 Fractures of the fourth up to the eighth ribs are the most common, while fractures of
the last four ribs are usually associated with intra-abdominal injury.

53.  Flail chest: An injury that occurs typically
following a blunt trauma to the chest.
When three or more ribs in a row have
multiple fractures [atleast two] within
each rib, it can cause a part of your chest
wall to become separated and out of sync
from the rest of your chest wall.
 The diagnosis is clinical based on the
paradoxical motion during respiration,
which may result in ventilatory
compromise. More than 50% of cases
require surgical treatment and prolonged
mechanical ventilation.

54. Coronal MIP CT image
showing multiple
contiguous left rib
fractures.

55. Coronal (a) and sagittal (b) reconstructed CT images show fractures of three contiguous
right ribs (arrows) that were associated with paradox motion of the chest during
respiration. Flail chest was suspected clinically and verified on imaging.

56. SPINE INJURY
Thoracic spine fractures account for up to 30% of all spine fractures.
62% of spine fractures will result in neurological deficits. The most
vulnerable site is between the ninth and twelfth vertebra.
The main mechanism is hyperflexion and axial loading.
Sagittal and coronal MDCT reformats readily reveal even small spinal
fractures.
MDCT of the spine is highly indicated for spinal survey for possible
fractures and determine the type of fracture. However, in the case of
suspected compressive myelopathy, MRI is the method of choice.

57. Thoracic spine fracture.
Coronal (a) and sagittal
(b) CT reconstructed
images of two different
patients show fractures of
the upper thoracic
vertebrae.

58. Thoracic spine fracture and compressive
myelopathy. Sagittal T2-weighted MRI
of the cervicothoracic spine undertaken 1
week after a motor vehicle accident
verifies the presence of extensive
compressive myelopathy due to fractures
of the second and the third thoracic
vertebrae.

59. STERNUM FRACTURE
Sternal fractures: 3–8% in blunt chest trauma.
Main mechanism: deceleration injury/direct blow to the anterior chest wall.
Difficult to detect on lateral chest radiographs .
Almost always accompanied by anterior mediastinal haemorrhage, which has a
preserved fat plane with the aorta, as opposed to an anterior mediastinal
haemorrhage secondary to aortic injury, which will present with a lost fat plane
with the aorta.

60. Sternal fracture. Sagittal reconstructed
CT image shows multiple fractures of the
manubrium and the body of the sternum
accompanied by extensive retrosternal
haematoma.

61. Sternal fracture. Axial CT image at mediastinal window shows sternal fracture associated
with retrosternal haematoma. Note the preserved fat plane with the aorta, excluding the
presence of aortic injury.

62. CLAVICLE INJURIES

63. STERNO-CLAVICLE JOINT DISLOCATION

64. STERNO-CLAVICLE DISLOCATION: CT

65. SHOULDER INJURIES
Scapular fracture is uncommon,
occurring in 3.7% of cases of blunt chest
trauma.
It indicates a high energy force trauma
with a direct blow to the scapula or force
transmitted through the humerus.
Associated injuries are pneumothorax,
haemothorax, clavicular fracture and
injuries of the lung parenchyma,
subclavian vessels, brachial plexus or
spine.

66. CT Needed if Scapula Fracture Seen

67. DIAPHRAGM INJURIES
 5% of major blunt trauma.
 Left clinically injured more than right 60/40.
 CT is a sensitive modality.

68.  Signs of diaphragmatic injury:
• the collar sign (or hourglass sign) : a waist-like constriction of the herniating hollow viscus
from the abdomen into the chest at the site of the diaphragmatic tear, which is classical for
diaphragmatic rupture.
• the dependent viscera sign: when a patient with a ruptured diaphragm lies supine at CT
examination, the herniated viscera (bowel or solid organs) are no longer supported
posteriorly by the injured diaphragm and fall to a dependent position against the posterior
ribs.
• segmental non-recognition of the diaphragm.
• focal diaphragmatic thickening.

71. POSITION OF NG TUBE

73. VASCULAR
INJURY
Thoracic aortic injury can result from either blunt or penetrating trauma:
1. blunt trauma (more common)
1.rapid deceleration (eg. motor vehicle accident, fall from great height)
2.crush injury
2. penetrating trauma
1.stab wound
2.gunshot wound

74. THORACIC AORTIC INJURY
 Grading
 Thoracic aortic injury can be graded according to the severity of injury.
One grading system is
• grade 1: intimal tear
• grade 2: intramural hematoma
• grade 3: pseudoaneurysm formation
• grade 4: free rupture

75. VASCULAR INJURY: SIGNS
 Signs of mediastinal hematoma
 Widened mediastinum
 Indistinct or abnormal aortic contour
 Deviation of trachea or NGT to the right
 Depression of left main bronchus
 Widened paraspinal stripe

76. X RAY: VASCULAR
INJURY

77. CT
Indirect signs of aortic injury:
 Mediastinal hematoma
 Periaortic fat stranding
CT Angiography:
 100% sensitivity and specificity
 Signs of mediastinal hematoma
 Abnormal soft tissue density around mediastinal structures
 Location – periaortic hematoma than isolated mediastinal hematoma remote from
the aorta.

78. Signs of aortic injury:
 Intraluminal filling defect (intimal
flap or clot)
 Abnormal aortic contour (mural
hematoma)
 Pseudoaneurysm & extravasation
of contrast

82. TRAUMATIC ESOPHAGEAL RUPTURE
 Can occur secondary to both
blunt or penetrating trauma.
 CT is the preferred modality.
 Signs on CT:
• extraluminal gas locules in
the mediastinum or
abdominal cavity, adjacent to
the esophagus: highly
suggestive.
• pleural or mediastinal fluid.
• pneumomediastinum or pneu
mothorax.
• pericardial or pleural
effusions can be seen.

84. TRAUMATIC LUNG HERNIATION
herniation of the lung beyond the confines of the thoracic cage.
Usually associated with rib fracture.
Results in subcutaneous emphysema.

86. SUBCUTANEOUS EMPHYSEMA
Causes:
Usually from ruptured
alveoli
Can also be from
trachea, bronchi,
esophagus, bowel and
neck injuries

88. THANK YOU