Radiology in Trauma

1. ICM
Bagian Radiologi
Fakultas kedokteran Universitas Pelita Harapan

2. Used In Trauma ?
• Plain X-Ray  used for basic fracture, available in emergency
department
• USG  Hemoperitoneum, portable in emergency department,
Keuntungan :
1.Noninvasif
2.Tidak menimbulkan rasa sakit
3.Dapat dilakukan dengan cepat dan aman serta tidak
memiliki kontraindikasi.
• CT Scan  Unstable patient, major trauma cases
• MRI  CNS trauma, stable patient, not available in emergency
department

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

4. BEFORE SENDING PATIENT FOR X-RAYS
• 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
TRANSPORTING DEVICES FOR X-RAY

5. TRAUMA IMAGING ON ADMISSION
IMAGING STUDY INJURY BEING ASSESSED
Lateral Cervical spine
(& or L Spine):
Fracture or dislocation
(to prevent paralysis)
Chest X-ray (AP view) Aortic rupture / pneumothorax
Abdominal US Check for hemoperitoneum
(major solid organ injury)
OPTION
CT
If available in Emergency Dept
Assess major CNS, Vascular & Solid
organ injuries

6. APPROACH TO IMAGING OF TRAUMA
TYPES OF TRAUMA
A: ORGAN SPECIFIC
1. 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:
1. Penetrating
2. Blunt trauma

7. 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
APPROACH TO IMAGING OF TRAUMA
IMAGING OF ORGAN SPECIFIC TRAUMA

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

9. 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

10. Splenic
hematoma
Liver
Spleen
SINGLE ORGAN TRAUMA

11. Abdomen

12. Morrison’s Pouch
• probe is placed in the right mid- to posterior
axillary line at the level of the 11th and 12th
ribs

13. ULTRASOUND
Used in Emergency Department
to detect free fluid – specifically blood
Liver
Ascites

14. Blunt abdominal trauma. Normal Morison pouch (ie, no free
fluid).

15. Blunt abdominal trauma. Free fluid in the Morison pouch.

16. RUQ
• Image on screen:
• Liver cephalad
• Kidney inferiorly
• Morison’s Pouch*:
space between
Glisson’s capsule and
Gerota’s fascia
*
*
*
*

17. Normal RUQ
• Image kidney
• Longitudinally
• Transversely
• Two toned structure
• Cortex/medulla
• Renal sinus

18. Appearance of blood
• Fresh blood
• Anechoic (black)
• Coagulating blood
• First hypoechoic
• Later hyperechoic

19. Normal
Morison’s Pouch
Free fluid in
Morison’s
Pouch

20. Blunt abdominal trauma. Normal splenorenal recess.

21. Blunt abdominal trauma. Free fluid in the splenorenal
recess.

23. To Evaluate the Thorax
• Move probe
• cephalad
• longitudinal
• Image
Liver
Diaphragm
Pleural space

24. Hemothorax
liver
diaphragm
fluid

25. Small Pleural Effusion
Large Pleural Effusion

26. Normal
Transverse
pelvic
Fluid in pelvis

27. Pelvic View – Sagittal
• Fluid in front of the
bladder
• If bladder is empty
or Foley already
placed:
Trick of trade
• IV bag on abdomen
• Scan through bag
clot bladder

28. Blood in the Pelvis

31. Free fluid in the pelvis

34. How good is FAST?
As a decision making tool for identifying the need for laparotomy in
hypotensive patients (Systolic BP < 90), FAST has:
 a sensitivity of 92%,
specificity of 96%
Accuracy 93%

35. Plain film radiograph
Hepatic angle
Spenic angle
Renal shadow
Psoas muscle
Properitoneal fat
strip

36. Normal

37. Normal CT anatomy
1.LHV, left hepatic vein
2.MHV, middle hepatic
vein;
3.RHV, right hepatic vein;
4.IVC, inferior vena cava
5.Ao,aorta
6.Stomach
1
2
3 4 5 6

38. 1.LPV, left portal vein
2.Stomach
3.Speen
4.IVC, inferior vena
cava
5.Ao,aorta
5
2
3
1
4

39. 1.Gallbladder
2.RPV, right portal vein
3.antrum
4.duodenal bulb
3
4
1
1

40. 1.CA,celiac axis
2.Splenic artery
3.common hepatic artery
4.Duodenum
5.Kidney
6.Pancreas
7.Portal vein
8.Adrenal gland
1
2
3
4
5
5
6
7

41. CTA
SMA, superior
mesenteric artery
CA,celiac axis
Splenic artery
common hepatic
artery

42. main portal trunk;
right portal branch;
splenic vein;
inferior mesenteric
vein;
superior mesenteric
vein

43. RHV, right hepatic vein;
MHV, middle hepatic vein;
LHV, left hepatic vein
IVC, inferior vena cava

44. Organ specific injuries
 Spleen
 Liver
 Kidneys
 Bowel and mesentery

45. ABDOMINAL ANATOMY
Liver
Kidney
Traumatic injuries to
1. LIVER
2. SPLEEN
3. KIDNEYS

46. CT
Ultrasound
IMAGING STUDIES BEST FOR ABDOMINAL TRAUMA
Liver

47. Traumatic splenic injury
 Commonly injured in blunt trauma
 Clinical findings:
 Often no/non-specific symptoms
 Peritoneal irritation
 Signs/symptoms of acute hemorrhage

48. Traumatic splenic injury
 Imaging
 Plain film: not useful
 US: hemoperitoneum
 Contrast-enhanced CT: imaging modality of choice
 Angiography: therapeutic embolization

49.  Hematoma
 Laceration
 Infarction

50. 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

53. Splenic
hematoma
Liver
Spleen
Contrast enhanced CT:
splenic hematoma

54. 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”

56. Pseudo-aneurysm
Splenic laceration
Liver
L kidney

57. 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)

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

59. TYPES OF LIVER INJURIES
 Contusions
 Subcapsular hematoma
 Intraparenchymal hematoma
 Lacerations
 Complete hepatic fracture

62. Severe
intraparenchymal
bleeding
No enhancement
with contrast
Intraparenchymal
hematoma
stomach
spleen
liver

63.  Peripherally located
 Least common form of liver injury

64.  Peripherally located
 Least common form of liver injury
Subcapsular hematoma
Low attenuation,
lentiform collection
displacing &
compressing the liver
stomach
spleen
liver

65.  Most common liver injury
 The Liver capsule can be Intact or disrupted
 Intact liver capsule – stable injury
 Disrupted capsule – can result in Hemoperitoneum

67. Hepatic laceration Descending
aorta
Spleen

68.  Mechanism:
 Blunt trauma (80%)
 Laceration by lower ribs
 Torn by rapid acceleration & deceleration
 Clinical findings:
 Back pain
 Hematuria
 Can be hemodynamically unstable

69. Can affect:
 Renal Parenchyma
 Renal collecting system
 Renal vessels

70. Classification Description Treatment
Minor Type I Contusion
Superficial laceration
Observe
Serial
hematocrits
Major Type II Deep laceration
Involvement of collecting
system
Conservative
(majority)
Surgery
Catastrophic Type III Major laceration
Laceration involving pedicle
Shattered kidney (multiple
lacerations)
Surgery
(majority)
Conservative
Catastrophic Type IV Avulsion from ureteropelvic
junction
Nephrectomy
(majority)

71.  US:
 Limited use
 Contrast enhanced CT:
 Study of choice
 Delayed images important to differentiate
between hematoma & leakage from collecting
system

72. 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

73. Contrast-enhanced CT:
Low density areas in
kidney parallel to
intervascular tissue planes
Kidney Kidney

74. Renal laceration
Small perirenal
hematoma
Contrast-enhanced CT:
Low density areas in
kidney parallel to
intervascular tissue planes

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

76. Collecting system
leak
R kidney

77. 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

79. R kidney:
Absence of contrast
enhancement

81. Laceration
Perirenal
hematoma
Contrast extravasation

82. quick quiz what organ is injured?

83. Cases

92. 15%-20%ofgallstones
containsufficientcalcium
tobeidentifiedonplain
filmrightupperquadrant
(RUQ)laminated
appearance

94. calcification
in the wall
of the
gallbladder

95. Discontinuous
mural calcification
diffuse

103. FI

110. BU

111. Polypoid GC

114. Lymphatic spread

115. GIST (ekstragastric)

116. Small GIST

117. Large GIST

118. FL

120. LC

122. H

128. Appendicitis: CT findings
Abscess, fat
stranding
Cecum

147. IA