Imaging Pearls ❯ Musculoskeletal ❯ Trauma
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- “Historically, computer-assisted detection (CAD) in radiology has failed to achieve improvements in diagnostic accuracy, decreasing clinician sensitivity and leading to unnecessary further diagnostic tests. With the advent of deep learning approaches to CAD, there is great excitement about its appli- cation to medicine, yet there is little evidence demonstrating improved diagnostic accuracy in clinically-relevant applica- tions. We trained a deep learning model to detect fractures on radiographs with a diagnostic accuracy similar to that of senior subspecialized orthopedic surgeons. We demonstrate that when emergency medicine clinicians are provided with the assistance of the trained model, their ability to accurately detect fractures significantly improves.”
Deep neural network improves fracture detection by clinicians
Lindsey R et al.
PNAS | November 6, 2018 | vol. 115 | no. 45 | 11591–11596 - “We trained a deep learning model to detect fractures on radiographs with a diagnostic accuracy similar to that of senior subspecialized orthopedic surgeons. We demonstrate that when emergency medicine clinicians are provided with the assistance of the trained model, their ability to accurately detect fractures significantly improves.”
Deep neural network improves fracture detection by clinicians
Lindsey R et al.
PNAS | November 6, 2018 | vol. 115 | no. 45 | 11591–11596
- “Sacral fractures are a common component of pelvic fracture patterns and are an increasingly diagnosed injury both due to increased utilization of CT in trauma evaluation as well as an increasing rate of sacral fragility fractures as a result of an increase in general population age. Innovations in minimally invasive surgical techniques have also resulted in an increasing number of sacral fractures undergoing surgical management. It is vital that physicians practicing in an emergency setting are aware of the injury patterns and management of this increasingly injured and treated component of the bony pelvis.”
Sacral fractures: classification and management Nicholas M. Beckmann, Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617 - “The incidence of osteoporotic sacral insufficiency fractures is not well studied, but these fractures occur almost exclusively in older women with a report inci- dence of 1–5% in at-risk populations such as patients with steroid-induced osteoporosis, pelvic radiation therapy, hyperparathyroidism, or rheumatoid arthritis . Even though sacral fractures are uncommon in the general population, sacral fractures become very common in patients presenting with trauma and pelvic fractures.”
Sacral fractures: classification and management Nicholas M. Beckmann, Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617 - “The incidence of osteoporotic sacral insufficiency fractures is not well studied, but these fractures occur almost exclusively in older women with a report incidence of 1–5% in at-risk populations such as patients with steroid-induced osteoporosis, pelvic radiation therapy, hyperparathyroidism, or rheumatoid arthritis.” Sacral fractures: classification and management Nicholas M. Beckmann, Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617
- “CT has become the mainstay for diagnosing and characteriz- ing sacral fractures due to the low sensitivity of radiographs. Noncontrast CT imaging with 2-mm-thick slices in the axial, coronal, and sagittal planes is generally adequate for diagnos- ing sacral fractures. For complex sacral fractures or sacral fractures that are part of a pelvic ring injury pattern, additional three-dimensional reformatted images are often helpful for surgeons to conceptualize fracture patterns and morphology for preoperative planning. Sacral morphology can preclude
afe placement of transacral screws, particularly at the S1 lev- el; and preoperative CT can be assessed for sacral dysmorphism and adequate osseous pathway for sacral screw placement.”
Sacral fractures: classification and management Nicholas M. Beckmann,Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617 - “Longitudinal fractures are by far the most common type of sacral fracture; isolated longitudinal fractures have been reported to comprise almost 90% of all sacral fracture patterns . Approximately 90% of longitudinal fractures is associated with an additional pelvic ring injury, most commonly pubic rami fractures . Longitudinal fractures can occur with any mechanism of injury but are most commonly seen with lateral compression in which the longitudinal fracture may be incomplete and stable or complete and unstable.”
Sacral fractures: classification and management Nicholas M. Beckmann1,2 & Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617 - “Sacral fractures are an increasingly recognized pathology in patients presenting with pelvic trauma, and these injuries are important for both the structural instability and neurologic com- plications that can result. Management of sacral fractures re- mains a challenge as significant variability exists regarding what constitutes an unstable sacral fracture and which neuro- logic injuries require surgical intervention. The lumbosacral injury classification system represents the first attempt to create a specific classification system to guide management of sacral fractures and may find utility in treating complex sacral frac- tures in the future. However, this classification system is novel and requires further validation before gaining widespread use.”
Sacral fractures: classification and management Nicholas M. Beckmann, Naga R. Chinapuvvula Emerg Radiol (2017) 24:605–617
- BACKGROUND: The interpretation of CT scans for the evaluation of calcaneal fractures is difficult. Three-dimensional (3D) reconstruction (volume rendering technique [VRT]) has been valuable in the evaluation of irregularly shaped bones. However, their value for the analysis of calcaneal fractures is still debated. Therefore, the objective of this study was to assess the effect of additional use of 3D CTs in calcaneal fractures.
CONCLUSION: The evaluation of CT scans of calcaneal fractures was improved by the additional use of 3D images (VRT).
Value of 3D Reconstructions of CT Scans for Calcaneal Fracture Assessment. Roll C et al. Foot Ankle Int. 2016 Nov;37(11):1211-1217 - METHODS: In a prospective multicenter study, the CT data set of 5 different fractures was presented to 57 evaluators. First, the participating surgeons were asked to assess the fractures on the basis of axial, coronal, and sagittal reconstructions using a multiple-choice questionnaire. Second, 3D reconstructions (VRT) were presented. The CT scans were validated by the intraoperative findings and the results were compared to the model solution of 3 foot and ankle surgeons. Intra- and interrater reliabilities were calculated.
Value of 3D Reconstructions of CT Scans for Calcaneal Fracture Assessment. Roll C et al. Foot Ankle Int. 2016 Nov;37(11):1211-1217
- “Traumatic sternoclavicular joint dislocation is an uncommon condition whose diagnosis is often missed.The posterior version of this dislocation has been associated with multiple complications, including respiratory compromise, vascular injury, brachial plexopathy, pneumothorax, dysphagia and even death, and should be managed by timely closed or open reduction.”
Posterior sternoclavicular joint dislocation Hoekzema N et al. Can J Surg. 2008 Feb; 51(1): E19–E20. - “Posterior dislocations of the sternoclavicular joint (SCJ) are rare events, occurring most commonly from motor vehicle accidents, athletic injuries, and falls. Due to the vital structures that lie posterior to the medial clavicle, namely the innominate artery, innominate vein, trachea, esophagus, and thoracic duct, this injury is a true emergency.”
Posterior Sternoclavicular Dislocations: A Brief Review and Technique for Closed Management of a Rare But Serious Injury Deren ME et al. Orthop Rev (Pavia). 2014 Jan 20; 6(1): 5245. - “Posterior SC dislocations are rare but serious injuries due to the proximity of the medial clavicle to the vital structures of the thorax. Open techniques for fixation have associated risks and mixed outcomes for patient satisfaction based mainly on case studies and series.”
Posterior Sternoclavicular Dislocations: A Brief Review and Technique for Closed Management of a Rare But Serious Injury Deren ME et al. Orthop Rev (Pavia). 2014 Jan 20; 6(1): 5245.
- CT with three-dimensional reconstruction has been compared with knee radiographs and shown to be more sensitive for fracture (100% versus 83% for radiographs), and to reflect the severity of tibial plateau fractures more accuratel. In severely injured patients, diagnostically sufficient radiographs are sometimes difficult to obtain, and therefore a negative radiograph is not reliable in ruling out a fracture. In these patients, multidetector CT is a fast and accurate examination for evaluating tibial plateau fractures and other complex knee injuries. Mui et al concluded that in the acute setting, CT offers 80% sensitivity and 98% specificity for depicting osseous avulsions, and a high negative predictive value for excluding ligament injury. Spiro et al found that the amount of articular surface depression on CT is a predictor of meniscus and ligament injuries and can identify cases that can benefit from MRI.
ACR Appropriateness Criteria Acute Trauma to the Knee. Tuite MJ et al. J Am Coll Radiol. 2015 Nov;12(11):1164-72 - “CT with three-dimensional reconstruction has been compared with knee radiographs and shown to be more sensitive for fracture (100% versus 83% for radiographs), and to reflect the severity of tibial plateau fractures more accuratel. In severely injured patients, diagnostically sufficient radiographs are sometimes difficult to obtain, and therefore a negative radiograph is not reliable in ruling out a fracture. In these patients, multidetector CT is a fast and accurate examination for evaluating tibial plateau fractures and other complex knee injuries. Mui et al concluded that in the acute setting, CT offers 80% sensitivity and 98% specificity for depicting osseous avulsions, and a high negative predictive value for excluding ligament injury.”
ACR Appropriateness Criteria Acute Trauma to the Knee. Tuite MJ et al. J Am Coll Radiol. 2015 Nov;12(11):1164-72 - “Dislocation of the knee is uncommon, representing about 0.1% of orthopedic injuries. The injury typically results from a motor-vehicle accident, but it can occur from contact sports, a vehicle striking a pedestrian, falls, or even a spontaneous dislocation in morbidly obese individuals. In 14% to 44% of patients, the dislocation is part of multiple traumatic injuries. This injury, which may reduce spontaneously, constitutes a true orthopedic emergency because of possible nerve or arterial damage. Vascular injury may be found in approximately 30% of patients after posterior knee dislocation. Physical signs of clinically significant vascular injury are the absence of pulses, ischemia, active bleeding, and bruit/thrill. Although angiography is considered the gold standard for assessing for vascular injury, debate continues over whether it should be obtained for all knee-dislocation patients or be used more selectively. CT angiography is being used increasingly because it is less invasive, is similar in having high accuracy, and involves a lower radiation dose.”
ACR Appropriateness Criteria Acute Trauma to the Knee. Tuite MJ et al. J Am Coll Radiol. 2015 Nov;12(11):1164-72 - “Vascular injury may be found in approximately 30% of patients after posterior knee dislocation. Physical signs of clinically significant vascular injury are the absence of pulses, ischemia, active bleeding, and bruit/thrill. Although angiography is considered the gold standard for assessing for vascular injury, debate continues over whether it should be obtained for all knee-dislocation patients or be used more selectively. CT angiography is being used increasingly because it is less invasive, is similar in having high accuracy, and involves a lower radiation dose.”
ACR Appropriateness Criteria Acute Trauma to the Knee. Tuite MJ et al. J Am Coll Radiol. 2015 Nov;12(11):1164-72 - “Dislocation of the knee is uncommon, representing about 0.1% of orthopedic injuries. The injury typically results from a motor-vehicle accident, but it can occur from contact sports, a vehicle striking a pedestrian, falls, or even a spontaneous dislocation in morbidly obese individuals. In 14% to 44% of patients, the dislocation is part of multiple traumatic injuries. This injury, which may reduce spontaneously, constitutes a true orthopedic emergency because of possible nerve or arterial damage. Vascular injury may be found in approximately 30% of patients after posterior knee dislocation. Physical signs of clinically significant vascular injury are the absence of pulses, ischemia, active bleeding, and bruit/thrill.”
ACR Appropriateness Criteria Acute Trauma to the Knee. Tuite MJ et al. J Am Coll Radiol. 2015 Nov;12(11):1164-72
- "Scapular fractures are uncommon, accounting for only 3-5% of shoulder girdle fractures and few- er than 1% of all fractures . High-energy trauma is the most common cause, and scapular fractures are frequently associated with other acute injuries, including rib fracture (53%), lung injury (47%), head injury (39%), spinal fracture (29%), and clavicle frac- ture (25%) . The initial diagnosis of scapular fracture is often delayed or ignored, because clinical care in the acute setting is focused on patient resuscitation after one or more life-threatening injuries."
Scapular Fractures: What Radiologists Need to Know
RoppAM, Davis DL
AJR 2015; 205:491-501 - "CT allows detailed characterization of bone, joint, muscle, or ligament injury at the shoulder girdle and is particularly helpful with identification of radiographically occult injuries. Thus, CT is more reliable and accurate for the detection and staging of scapular injuries than radiographs are; this is especially true for coracoid process, glenoid, and scapular neck fractures ."
Scapular Fractures: What Radiologists Need to Know
RoppAM, Davis DL
AJR 2015; 205:491-501 - "Anterior shoulder dislocation is an additional mechanism associated with intraarticular fracture of the anterior glenoid. These Ideberg type 1 fractures of the glenoid are the most typical scapular fracture pattern encountered after shoulder dislocation, with shoulder dislocations accounting for two thirds of type 1 fractures ."
Scapular Fractures: What Radiologists Need to Know
RoppAM, Davis DL
AJR 2015; 205:491-501 - "The scapula is a flat triangular bone with several distinct regions. The glenoid fossa forms the articular surface of the scapula and connects to the scapular body via the neck of the scapula. The scapula serves as an attachment site for 17 muscles, which facil- itate movement and form a functional soft- tissue envelope for the shoulder girdle. These muscles are subdivided into scapulothoracic and scapulohumeral groups. The rotator cuff muscles are a subcomponent of the scapulohumeral group."
Scapular Fractures: What Radiologists Need to Know
RoppAM, Davis DL
AJR 2015; 205:491-501 - Ideberg Classification of Intraarticular Glenoid Fractures
- “Classically, anterior sternoclavicular dislocation is seen much more frequently, with a 20:1 ratio. This is, in part, due to a greater strength of the posterior sternoclavicular ligament compared with the anterior ligament. Four strong ligaments (intra-articular disk and costoclavicular, interclavicular, and capsular ligaments) anchor the clavicle to the sternum in a saddle-type joint that allows for both articulation and stability of the clavicle.”
Radiologic case study. Posterior Sternoclavicular Dislocation.
O'Laughlin MC et al.
Orthopedics. 2011 Jul;34(7):498, 556 - “Although rare, a posterior sternoclavicular dislocation is considered a medical emergency and requires immediate attention due to the vital structures and organs that lie immediately posterior to the joint. The innominate artery and vein lie posterior to the right sternoclavicular joint, and the trachea and esophagus lie posteromedially. On the left side, the common carotid artery and left subclavian vein are located directly posterior to the sternoclavicular joint. Compression or damage to the great vessels, trachea, esophagus, or lungs that arise from sternoclavicular dislocations could result in significant morbidity and mortality, if not properly managed.”
Radiologic case study. Posterior Sternoclavicular Dislocation.
O'Laughlin MC et al.
Orthopedics. 2011 Jul;34(7):498, 556 - “Computed tomography scanning allows for better characterization of a posterior sternoclavicular dislocation and can detect fractures that may not be appreciated on radiographs. Computed tomography angiography is recommended for the evaluation of any acute vascular injuries that may accompany a posterior sternoclavicular dislocation, and magnetic resonance imaging (MRI) can assess for neurovascular injuries if symptoms after reduction or complicated cases.”
Radiologic case study. Posterior Sternoclavicular Dislocation.
O'Laughlin MC et al.
Orthopedics. 2011 Jul;34(7):498, 556 - “Treatment methods aim to restore proper articulation of the sternoclavicular joint and are most commonly assessed by proximity of the dislocated clavicle to vital structures. However, reports in the literature differ on preferential treatment methods for posterior sternoclavicular dislocation. If there is no associated vascular compression or disruption demonstrated on CT angiography, then closed reduction within 48 hours of the injury is typically performed.”
Radiologic case study. Posterior Sternoclavicular Dislocation.
O'Laughlin MC et al.
Orthopedics. 2011 Jul;34(7):498, 556
- “ CT findings in cutaneous T-cell lymphoma are related to the pathophysiology of the disease: cutaneous plaques and diffuse peripheral adenopathy that spare the mediastinal and paraaortic lymph nodes. Although the skin lesions can be easily evaluated clinically, secondary malignant neoplasms arising in treated skin lesions can be found with CT by their extension into the subcutaneous fat.”
Cutaneous T-cell lymphoma: value of CT in staging and determining prognosis.
Miketic LM et al.
AJR Am J Roentgenol. 1993 May;160(5):1129-32. - “Cutaneous T-cell lymphomas are rare, distinct forms of non-Hodgkin's lymphomas. Of which, mycosis fungoides (MF) and Sézary syndrome (SS) are two of the most common forms.”
A practical approach to accurate classification and staging of mycosis fungoides and Sézary syndrome.
Thomas BR, Whitaker S
Skin Therapy Lett 2012 Dec; 17(10):5-9 - “Approximately one-fourth of cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle-center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL, LT).”
Cutaneous B-cell lymphomas: 2013 update on diagnosis, risk-stratification, and management
Wilcox RA
Am J Hematol 2013 Jan;8891);73-76 - “The term extranodal disease refers to lymphomatous infiltration of anatomic sites other than the lymph nodes. Almost any organ can be affected by lymphoma, with the most common extranodal sites of involvement being the stomach, spleen, Waldeyer ring, central nervous system, lung, bone, and skin. The prevalence of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease has increased in the past decade. The imaging characteristics of extranodal involvement can be subtle or absent at conventional computed tomography (CT). Imaging of tumor metabolism with 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) has facilitated the identification of affected extranodal sites, even when CT has demonstrated no lesions. More recently, hybrid PET/CT has become the standard imaging modality for initial staging, follow-up, and treatment response assessment in patients with lymphoma and has proved superior to CT in these settings.”
FDG PET/CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease
RadioGraphics 2010 Jan;30(1):269-91 - “The term extranodal lymphoma has been used to describe this uncommon form of lymphoid malignancy, in which there is neoplastic proliferation at sites other than the expected native lymph nodes or lymphoid tissues. Distribution among the non-lymphoid tissues is uneven, with greater predilection for some organs than for others, and includes the gastrointestinal tract, head and neck (Waldeyer ring), orbit, central nervous system (CNS), lung, bone, and skin. The prevalence and distribution among organs vary significantly depending on histologic type and disease stage.”
FDG PET/CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease
RadioGraphics 2010 Jan;30(1):269-91 - “Cutaneous lymphomas may manifest either as primary tumors or as secondary to disseminated disease. Primary cutaneous lymphoma is the second most prominent group of NHLs (67), whereas primary or secondary skin involvement is very rare in patients with Hodgkin disease. Almost 65% of primary cutaneous lymphomas are T-cell lymphomas (Fig 13), with the remainder being B-cell lymphomas. About 25% of primary cutaneous lymphomas demonstrate extracutaneous involvement at the time of diagnosis. The presence of extracutaneous disease in primary cutaneous lymphoma is important in treatment planning and in predicting prognosis at initial staging and posttherapy restaging. Cutaneous lymphoma is a heterogeneous group of diseases.”
FDG PET/CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease
RadioGraphics 2010 Jan;30(1):269-91
- “Up to 10% of proximal femur fractures may be missed on initial radiographs. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative hip radiographs. Our findings show that modern multislice CT may be comparable with MRI for detecting occult fracture.”
Investigation of occult hip fractures: the use of CT and MRI.
Gill SK et al.
ScientificWorldJournal 2013;2013:830319 - “Although 64-slice CT detected the majority of occult fractures, it missed four (2%) significant fractures detected by MRI. CT scan is helpful in the diagnosis of occult hip fracture, but one should not completely exclude the diagnosis based on a negative 64-slice CT scan in a patient with persistent, localized hip pain who cannot bear weight.”
Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography
Hakkarinen DK et al.
J Emerg Med 2012 Aug;43(2) 303-7 - “Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3-4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging.”
Imaging choices in occult hip fracture
Cannon J et al.
J Emerg Med 2009 Aug;37(2):144-52 - Neurofibromatosis Website
“Neurofibromatosis type 1 (NF1) is a hereditary condition commonly associated with multiple café-au-lait spots on the skin. Café-au-lait spots are light brown in color, like the color of “coffee with milk.” About 10% to 25% of the general population has café-au-lait spots; NF1 is suspected when a person has six or more. People with NF1 also tend to develop varying numbers of neurofibromas (benign [noncancerous] tumors on the covering of the nerves). Neurofibromas are often seen as raised bumps on the skin and can occur anywhere on the body. While these skin changes do not have serious medical consequences, they can affect a person’s appearance. Plexiform neurofibromas (which form under the skin or deeper in the body) are also benign tumors. However, these can grow quite large and can cause significant medical problems, and can affect the structure of nearby bone, skin, and muscle.”
Cancer.net
http://www.cancer.net/cancer-types/neurofibromatosis-type-1 - Tumors in Neurofibromatosis 1 Include
- Benign eye tumors (Lisch nodules growing on the iris of the eye) and cancerouseye tumors (glioma growing in the optic nerve
- Brain tumors
- Adrenal gland tumors
- Muscle tumors
- Spinal cord tumors
- Peripheral nerve sheath tumors (tumors that grow on nerves)
- Six or more café-au-lait spots (the spots must be more than five millimeters [mm] in diameter in young children and more than 15 mm in diameter after puberty.)
- Two or more neurofibromas or one plexiform neurofibroma
- Freckling around the arm pits or groin
- Optic glioma (tumor on the optic nerve in the brain which effects vision)
- Two or more Lisch nodules (tumors on the iris of the eye)
- Specific bone changes, including sphenoid dysplasia (abnormality of one of the bones forming the skull) or thinning of the long bones
- A parent, sibling (brother or sister), or child with NF1 - NF1 is diagnosed when a person meets the official diagnostic criteria for NF1 that was developed at a National Institutes of Health Consensus Conference in 1987. Based on these criteria, a person who has at least two of the following features is considered to have NF1:
- Six or more café-au-lait spots (the spots must be more than five millimeters [mm] in diameter in young children and more than 15 mm in diameter after puberty.)
- Two or more neurofibromas or one plexiform neurofibroma
- Freckling around the arm pits or groin
- Optic glioma (tumor on the optic nerve in the brain which effects vision)
- Two or more Lisch nodules (tumors on the iris of the eye)
- Specific bone changes, including sphenoid dysplasia (abnormality of one of the bones forming the skull) or thinning of the long bones
- A parent, sibling (brother or sister), or child with NF1
- “ Most clinically important vertebral body compression fractures in nontrauma patients at risk for low bone mineral density may go unreported at abdominal multidetector CT if sagittal reconstructions are not routinely evaluated.”
Unreported Vertebral Body Compression Fractures at Abdominal Multidetector CT
Carberry GA et al.
Radiology 2013; 268:120-126 - “ After review of 2015 abdominal multidetector CT scans in patients who underwent dual-energy x-ray absorptiometry (DXA) within 6 months of CT, prospective diagnosis of a moderate or severe vertebral body compression fracture was not determined in 84% (81 of 97).”
Unreported Vertebral Body Compression Fractures at Abdominal Multidetector CT
Carberry GA et al.
Radiology 2013; 268:120-126 - “ The study showed that MRI was substantially better than CT in detecting insufficiency fractures. In addition two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease.”
MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur
Cabarrus MC et al.
AJR 2008; 191:995-1001
- “ Spinal fractures represent 3% to 6% of all skeletal injuries. Spine trauma is a complex diagnostic area in which the radiological assessment is crucial. Plain radiography is often used as the initial diagnostic modality. However, stabilization of the acutely injured spine is a primary concern. In this respect, computed tomography (CT) is vastly superior to plain film in terms of speed and accuracy. In many trauma centers, CT has replaced plain film as the primary modality for evaluation of spinal trauma.”
Spinal Trauma
Looby S, Flanders A
Radiol Clin North Am 2011 Jan;49(1);129-63 - “In the last 10 years, on a total of 55 patients treated in our institution for benign lesions of the major airway, 20 were with an acute injury; eleven females and nine males with a mean age of 58 years (range of 24–92). Twelve lesions were iatrogenic (orotracheal intubation) and eight were post-traumatic (three blunt traumas, five penetrating traumas). The cervical trachea was involved in 13 cases (one associated to an incomplete esophageal transection and two associated to laryngeal injuries), the thoracic trachea in six cases (four extended to the right mainstem one and to the left).”
Acute major airway injuries: clinical features and management
Mussi A et al.
European j Cardio-Thoracic Surg
Vol 20, issue 1, July 2001; pages 46-52 - “Tracheobronchial injuries are relatively uncommon, often require a degree of clinical suspicion to make the diagnosis, and usually require immediate management. Most penetrating injuries occur in the cervical area. Most blunt injuries occur in the distal trachea or right mainstem, and are best approached by a right posterolateral thoracotomy.”
Traumatic Injury to the Trachea and Bronchus
Karmy-Jones R, Wood DE
Thorac Surg Clin
2007 Feb; 17(1):35-46 - “Tracheobronchial injuries are relatively uncommon, often require a degree of clinical suspicion to make the diagnosis, and usually require immediate management. The primary initial goals are twofold: stabilize the airway and define the extent and location of injury. These are often facilitated by flexible bronchoscopy, in the hands of a surgeon capable of managing these injuries. Most penetrating injuries occur in the cervical area. Most blunt injuries occur in the distal trachea or right mainstem, and are best approached by a right posterolateral thoracotomy.”
Traumatic Injury to the Trachea and Bronchus
Karmy-Jones R, Wood DE
Thorac Surg Clin
2007 Feb; 17(1):35-46 - Sternal Fractures are Associated With
- Pulmonary contusion
- Retrosternal hematoma
- Pneumothorax
- Cardiac contusion (least common) - “Sternal fracture is a common injury in a population where restraints are frequently used. Patients with an isolated sternal fracture do not require cardiac monitoring and those under 40 years of age may be cared for in a short stay ward.”
Sternal fractures: a retrospective analysis of 272 cases.
J Trauma 1993; 35(1):46-54
Brookes JG; Dunn RJ; Rogers IR - “ A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the ab- sence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients.”
Blunt Thoracic Trauma: An Analysis of 515 Patients
Shorr RM et al
Ann Surg Vol 206, No 2,pp 200-205 - “ MDCT cystography should be done when pelvic fluid is present, especially when there are fractures or gross hematuria, to define which of the patients has a bladder rupture and to define the type of bladder rupture.”
Bladder trauma: multidetector computed tomography cystography
Ishak C, Kanth N
Emerg Radiol (2011) 18:321-327 - Indications for CT Evaluation of Pediatric Trauma Patients
- High speed MVA with potential for skeletal trauma and organ injury
- Pelvic fractures
- Intraarticular fractures in the extremities
- Spine fractures
- GSW with suspected vascular and bone injury
- Radiologically occult fractures "In our experience, the role of 3D volume imaging in the evaluation of pediatric fractures and soft tissue injuries continues to evolve as this technique increasingly enables the detection and characterization of abnormalities and provides data that alter decisions about patient care."
Pediatric Skeletal Trauma: Use of Multiplanar Reformatted and Three-dimensional 64-Row Multidetector CT in the Emergency Department
Fayad LM, Corl F, Fishman EK
RadioGraphics 2009; 29:135-150"Given that trauma is a leading cause of morbidity and mortality in children, MDCT plays an important role in the evaluation of potential injury in the pediatric trauma patient."
Pediatric Skeletal Trauma: Use of Multiplanar Reformatted and Three-dimensional 64-Row Multidetector CT in the Emergency Department
Fayad LM, Corl F, Fishman EK
RadioGraphics 2009; 29:135-150"The role of three dimensional volume imaging in the evaluation of fractures and soft tissue injuries in pediatric patients continues to evolve as this technique increasingly enables detection and characterization of abnormalities and provides results that affect decisions about patient care."
Pediatric Skeletal Trauma: Use of Multiplanar Reformatted and Three-dimensional 64-Row Multidetector CT in the Emergency Department
Fayad LM, Corl F, Fishman EK
RadioGraphics 2009; 29:135-150- Complications of Missed Carpal Bone Fractures
- Osteonecrosis
- Nonunion
- Degenerative arthritis
- Persistent pain
- Functional comprimise - "In the proximal carpal row, lumate and triquetrum fractures were often radiographically occult (0% and 20% respectively detected at radiography); whereas in the distal carpal row. Trapezoid, capitate, and hamate fractures were often occult (0%,0%, and 40% detected at radiography respectively)."
MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns
Wellong RD et al.
AJR 2008; 190:10-16 - "Thirty percent of wrist fractures were not prospectively diagnosed on radiography, suggesting that CT should be considered after a negative radiographic finding if clinically warranted. The location of a dorsal scaphoid avulsion fracture emphasizes the need for specific radiographic views or cross sectional imaging for diagnosis."
MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns
Wellong RD et al.
AJR 2008; 190:10-16 - "Thirty percent of wrist fractures were not prospectively diagnosed on radiography, suggesting that CT should be considered after a negative radiographic finding if clinically warranted."
MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns
Wellong RD et al.
AJR 2008; 190:10-16