Ajr%2 e98%2e2%2e343

OL. 98, No. 2
PULMONARY PARENCHYMAL FINDINGS IN BLUNT
TRAUMA TO THE CHEST*
liv V. M. ‘l’ING, M.I).
ElOISE, MICHIGAN
W ‘‘ tile increased rate of nlton1ol)ile
accidents during tile recent ears,
more 1)lunt tratiiit to the patient’s chest
has been encountered in the general hos-
pita! tilan ever. ‘I’wo hundred cases of pa-
tients who sustained blunt trauma to the
chest were reviewed and all were found to
have parench v m a! ch ailges. Ni netv-fou r
per ceilt of the cases had rib fractures, in-
dicating tilat tile tratiia was of a moder-
ately severe nature; 6$ per cent of the cases,
ill addition to having ru) fractures, also had
associ a ted pn ciiiii oth ora or ilefll otii orax.
In this stti(l’V attention was directed only to
the type of parenciivm a! i nvolvement pres-
ent.
lile 1)tre11cllY11tl changes ill l)lunt
trau 111 a to
the transmissionf1Eefheunderlving
lung1tTssuesof the thor
pt#{235}’siR3’ii and recoil phenomena r0f the
lu ng,mt
rencil vn al cilaflges encountered comprised:
(i) pulmonary edema and congestion, (2)
atelectasis, (,) ()
formation of traumatic lung cavities and
in trapu Imon arv hematoma. Often a com-
bination of the above mentioned cilanges
was noted on a single chest roentgenogram.
Usu a!iy, one tYpe predom mated.
ANIMAL EXPERIMENT
Our interest in the roentgen findings of
pulmonary contusions prompted us to do
tue foliowing experinlent. A dog, weighing
20 kg., was used for the experiilleilt of blunt
trauma to the chest. ihe dog was anes-
thetizcd and open thoracotom’ was per-
formed on the right. The right lung was
then contused with noncrushing, intestinal
rubber shods, the thoracotomy incision
closed and tile lung re-expanded. Two
hours later tile dog was sacrificed and tile
thoracic contents were removed en bloc. On
gross patilologv the contused rigilt lung
was markedly bogg’, edematous, and (115-
colored (Fig. i). There were areas of sub-
pleural hemorrhage. A roentgenogram of
the inflated lung showed varying sizes of
traumatic lung cavities from rupture of the
alveoli aild, also, (lifluse, hazy densities,
representing areas of ultra-alveolar, pen-
vascular and pen bronchial h enlorrhage
(Fig. 2). I)ue to the elastic recoil phenome-
non of tile alveoli,7 the ruptured or lacer-
ated alveoli assumed oval or rounded shape.
hen these lacerated alveoli were filled
with air, or partly filled with liquid blood,
tile appearance was that of a trauillatic
lung cavity. Vhen they were completely
filled with blood, the shape aild appearance
resem bled pulmon any 11cm atom as. Ihe
microscopic appearance of the sections of
tile representative areas of tile contused
‘I’’
‘. ;j
11G. 1. Ihe contused right lung of the (log is mark-
edly boggy and discolored with numerous areas of
subpleural hemorrhage. The left lung is normal.
* irom the I)epartment of Radiology, Wayne County General hospital, Eloise, iichigan.
343
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344 Y. M. Ting OCTOBER, 1966
Fic. 2. Roentgenogram taken of the inflated lungs
shown in Figure I. The contused right lung shows
various areas of traumatic cavities from ruptured
alveoli. Note also patchy areas of density due to
intra-alveolar hemorrhage.
lung of the dog revealed areas of intra-
alveolar ii em orrh age, edem a, beginning
form ation of ilenl atom a and congestion.
ROENTGEN FINDINGS
In the present series about i 5 pen cent of
the cases showed roentgenognaphic changes
of acute parench’mal edema and conges-
tion. This type of change, as described by
Daniel and Cate,2 is due to the presence of
edema fluid by dilated extravasculan and
lymphatic spaces and the presence of fluid
within the alveoli and bronchioles. Their
experimental study favors neunogenic fac-
tors of reflex mechanism through sympa-
thetic nerve suppk. Arteriole and capillary
dilatation has been described by Falla4 in
his microscopic study. These roentgen
changes usually clean up within 24 hours if,
in the meantime, no other complications
develop. Figure 3 shows the appearance of
acute edema and congestive changes.
Atelectasis was demonstrated in i6 per
cent of the series. In most cases the atelec-
tasis was not present on the initial roent-
genogram, rather it was observed on the
chest studies made i to 2 days after the
initial trauma. The mechanism of atelec-
tasis, as described b- DeTakats et al.,’ coil-
sists of obstruction of the broncilus with
massive secretion, insufficient movement of
tile cilia and suppressed cough mecilanism.
The atelectasis can also be caused by ob-
struction of the bronchus due to blood
clots on penibronchial hemorrhage. Rup-
tured bronchus, as described by Williams
and Bonte,’2 is a rare cause of atelectasis,
and we have not encountered sucil all in-
stance in our series. The atelectatic changes
usually follow a segmental distribution.
The atelectasis ma- persist for as long as 2
months.
In about 69 pen cent of the cases re-
viewed, the predom man t noen tgen findings
consisted of patchy, IllOttled, irregular, ill-
defined densities Ofl the initial chest roent-
genognams. Tilis roentgen appearance con-
FIG. 3. Roentgenogram illustrating the appearance
of acute edema a few hours following blunt trauma
to the chest.

#{149}1
VOL. 98, No. 2 Blunt Trauma to the Chest 345
relates with the microscopic findings of
pen vascular, pen bronchial and intra-alveo-
lan henlonnilage and transudate. These
changes often occurred on the same side as
the blunt traunla to the chest; they usually
cleared up in a few days to 2 weeks. How-
ever, tilere were 15 cases (about 7 per cent)
which silowed formation of traumatic
cavities and intnapulmonanv ilem atom a.
Tile intrapulmonarv hematoma can persist
in the chest roentgenogranl for a period of 2
to JO fllOfltilS.
A few cases are presented briefly to illus-
trate the appearance of traumatic cavities
and intrapulmonany ilematomas.
ILLUSTRATIVE CASES
CASE I, #141523. The initial roentgenograms
of this patient, following an autoniobile acci-
dent, revealed patchy, ill-defined densities in
tile right upper lobe due to penibronchial, pen-
vascular, intra-alveolar hemorrhage and trail-
sudate (Fig. 4). A roentgenogram made week
later demonstrated clearing of the patchy den-
sities and an air fluid level in the traumatic
cavities. This contained liquid blood and
FIG. 4. Case i. Note the localized, ill-defined densi-
ties in the right upper lobe at the site of the blunt
trauma. This roentgen appearance correlates with
microscopic findings of peribronchial, perivascular
and intra-alveolar hemorrhage and transudate.
FIG. 5. Case I. Roentgenogram made I week later
shows clearing of the hazy densities but now there
is formation of a traumatic cavity containing
liquid blood and trapped air.
trapped air (Fig. ). Chester’ demonstrated in
his case that such traumatic cavities have no
connection witil the bronchial tree. ‘I’he air in
tile trauIllatic cavities probably represents
trapped air in the alveoli. One month later the
air had completely resolved and a marked de-
crease in the size of the traumatic cavity with
formation of an in trapulmon ary hem atom a was
noted (Fig. 6).
CASE II, #125504. Tile initial admitting chest
roentgenogranl of this patient, following an
automobile accident, demonstrated ill-defined
densities in tile right lung (Fig. 7). Two weeks
later tilere was clearing of tile densities and a
slightly oval, more discrete, soft tissue density
in the right lower lobe (Fig. 8). This probably
represents the beginning of in trapulmonary
hematoma formation. Tile patient was lost to
follow-up until 3 months later. He returned to
the hospital after being rejected for employment
because of findings on a pre-employment chest
roentgenogram. He was told that he had a tu-
mor of the lung. A chest roentgenogram showed
a very discrete, sharply circumscribed, intrapul-

346 Y. M. Ting OCTOBER, 1966
Fic. 6. Case I. Roentgenogram obtained i month
later shows marked decrease in the size of the
traumatic cavity with complete resorption of air
and formation of an intrapulmonary hematoma.
monary hematoma in the right lower lobe (Fig.
9). No calcification was present. In the light of
the previous trauma and serial chest studies, a
diagnosis of in trapuimonary hematoma was
made and a thoracotomy was averted. Six
months later the follow-up chest roentgenogram
silowed furtiler decrease in the size of the hem a-
11G. 7. Case II. Admitting chest roentgenogram
shows patchy density in the right lung on the side
of the blunt trauma.
I’I(;. 8. Case n. Chest roentgenogram made 2 weeks
later shows an oval density in the right lower lobe,
representing in trapulmonary hematom a.
toma (Fig. io). A I year follow-up chest roent-
genogram demonstrated complete clearing of
tile hematoma.
CASE III, #93379. The initial chest study of
this patient showed a patchy density in tile
11G. 9. Case II. Roentgenogram made 3 months
later. Note considerable decrease in the size of the
in trapulmonary hematoma. The in trapulmonary
hematoma appears sharpi y circumscribed. No
calcification is present.

OL. 98, No. 2 Blunt Trauma to tile Chest 347
11G. 10. Case II. I”ollow-up chest roentgenogram
made 6 months later shows further decrease ill the
size of the in trapulnlonary hematoma.
rigllt lung with a suggestion of an area of radio-
iucency in tile center of tile density, probably
representillg tile site of alveolar laceration (Fig.
ii). Roentgenograms made 4 days later silowed
clearing of tile patclly density, but then re-
vealed a slightly lobulated soft tissue density
in tile right upper lobe (Fig. 12). On the follow-
up study i week later, the presence of a tilick-
‘4
Fio. II. Case III. Admitting chest roentgenogram
shows patchy density in the right lung. Note also
the presence of subcutaneous emphysema. Among
the densities of the right upper lobe, there is an
area of radiolucency, probably the site of alveolar
laceration.
11G. I 2. Case iii. lOllow-ul) chest roentgenogram
made 4 days later shows clearing of the patchy
densities. A lobulated, more defined density in the
right upper lOl)C suggests formation ot a traumatic
cavity’.
walled traunlatic cavity and also a small ultra-
P(1l111ztrY ileflatoI1la beilind the trauniatic
cavity was noted (Fig. 13). The wall of this
cavity’ appeared slightly irregular in outline.
lilis would be difticult to duflerentiate from
abscess or necrotic neopiasm without serial
roen tgenography. One mon til later the chest
roen tgenogram showed further decrease in the
size of the traumatic lung cavity and the hema-
toiili (Fig. 14).
CASE iy, #127612. In this case, the initial
roentgenogram of the cilest revealed a Ilazy ir-
regular density in the left lung (Fig. 15). A
follow-up study 4 days later demonstrated a
discrete, sharply outlined, subpleural, intrapul-
monary hematoma (Fig. i6). A roentgellografll
made 2 weeks later showed further decrease in
the size of tile hematonla. Oblique roentgeno-
grams denlonstrated tile subpleural location of
this henlatoma. Complete clearing resulted 2
months after the initial trauma.
DISCUSSION
In this study, the importance of obtain-
ing, at the earliest possible moment, chest

348 Y. M. Ting OCtOBER, 1966
11G. 13. Case III. Follow-up chest roentgenogram
made i week later reveals the presence of a well
defined, thick-walled, traumatic cavity. Note that
the wall appears slightly- irregular in outline.
Fic. 14. Case iii. One month later, a follow-up
roentgenogram shows further decrease in the size
of the traumatic cavity.
1IG. 15. Case iv. Admitting chest roentgenogram
shows increased haziness of the left lung following
an automobile accident.
roen tgenogram s after moderately severe
blunt trauma to the cilest is stressed. The
follow_up cilest roentgenognams, 24 to 48
hours later, are pertinent in detecting late
atelectatic changes on the cleIning of
edema, or tile development of pneumo-
thorax on hemotilorax. Follow-up chest
noentgenognams in i and 2 weeks are of
value, inasmuch as most of the cases re-
viewed showed that the density caused by
intra-alveolan, penibronchi al ilenlornil age
usually cleared up b that tulle. In the case
of hematoma formation, follow-up chest
noentgenogranls silould be obtained at I
month, 3 month, 6 month and i year in-
tervals.
11G. i6. Case iv. Roentgenogram made 4 days later
reveals a sharply 00 dined subpleural intrapul-
monary hematorna.

1) fec3”
OL. 98, No. 2 Blunt Trauma to the Chest 349
In 200 cases reviewed, the most preval-
ent roentgen parenchymal findings were the
changes caused by intra-alveolar, pen-
bronchial and perivascular hemorrhage. In
patients showing traumatic cavities with
intnapulmonary hem atom as, the differ-
ential diagnosis from abscess, granuloma or
neoplasm would be difficult if serial chest
roentgenograms and history were not
available. In this series, all of the cases (7
per cent showing traumatic cavities an
pul onar hematomas demonstrated de-
finite4ecrease to complete ceaning o t e
SUMMARY
Chest roentgenograms of 200 patients
who sustained blunt trauma to the chest
were reviewed.
The ulmonar oen n findin s con-
sisted e ema and congestion, ctsis,
patchy,monrhagic infiltration, formation
ottimaticlun cavities, and intrapiiL
monar)_erfla.tcpi
The importance of serial follow-up
roentgenognaphic studies of the chest is
stressed.
Department of Radiology
Wayne County General Hospital
Eloise, Michigan 48132
The author gratefully acknowledges the as-
sistance and advice of Dr. R. L. Tygart in the
experiment and Miss June Morris for the photo-
graphic illustrations.
)
REFERENCES
I. CHESTER, E. H. Chest injury resulting in bullae
in lung: report of case. New England 7. Med.,
1963, 268, 1068-1070.
2. DANIEL, R. A., JR., and CATE, W. R., JR. “Wet
lung”-experimental study: effect of trauma
and hypoxia; neurogenic factor. Ann. Surg.,
1948, 127, 836-857.
3. DETAKATS, G., FENN, G. K., and JENKINSON,
E. L. Reflex pulmonary atelectasis. 7.A.M.A.,
1942, 120, 686-690.
4. FALLA, S. T. Effect of explosion-blast on lungs:
report of case. Brit. M. 7., 1940, 2, 255-256.
. GREENING, R., KYNETTE, A., and HODES, P. J.
Unusual pulmonary changes secondary to
chest trauma. AM. J. ROENTGENOL., RAD.
THERAPY & NUCLEAR MED., 1957, 77, 1Q59-
io6.
6. JENSEN, N. K. Recovery of pulmonary function
after crushing injuries of chest. Dii. Chest,
1952, 22, 3 19-346.
7. MILNE, E., and DICK, A. Circumscribed intra-
pulmonary haematoma. Brit. 7. Radiol., 1961,
34, 587-595.
8. SALYER, J. M., BLAKE, H. A., and FORSEE, J. H.
Pulmonary hematoma. 7. Thoracic Surg.,
1953, 25, 336-340.
9. SEA LY, W. C. Contusions of lung from nonpene-
trating injuries to thorax. Arch. Surg., 1949,
59, 882-887.
10. SCHWARTZ, A., and BORMAN, J. B. Contusion of
lung in childhood. Arch. Dii. Childhood, 1961,
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ii. WESTERMARK, N. Roentgenological investiga-
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12. WILLIAMS, J. R., and BONTE, F. J. The Roent-
genological Aspects of Nonpenetrating Chest
Injuries. Charles C Thomas, Publishers,
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This article has been cited by:
1. O. Chan, M. Hiorns. 1996. Chest trauma. European Journal of Radiology 23, 23-34. [CrossRef]
2. Farhad Azimi, Alan H. Wolson, Murray K. Dalinka, Herman I. Libshitz. 1975. Unilateral Pulmonary Edema—Differential
Diagnosis. Australasian Radiology 19, 20-25. [CrossRef]
3. Emil Blair, Cemalettin Topuzlu, Robert S. Deane. 1969. Major blunt chest trauma. Current Problems in Surgery 6, 1-64.
[CrossRef]

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