Imaging in major trauma

Dr Paul Middleton
Medical Adviser
Chair, Clinical Advisory Committee
Ambulance Service of NSW

Imaging in major trauma

Dr Paul Middleton
Senior Lecturer in
Emergency Medicine
Prince of Wales Hospital / UNSW

Imaging in major trauma

Dr Paul Middleton
Retrieval Specialist
CareFlight

Imaging in major trauma - perspective

{

Primary survey - ATLS/EMST

z A
Airway with cervical spine control
z B
Breathing and ventilation
z C
Circulation and haemorrhage control
z D
Disability
z E
Exposure, environment and
everything else
z Radiology comes at E trauma series
z Radiology also comes in the Secondary
survey

Imaging in major trauma - perspective

{

Trauma series of X-rays

z Chest X ray
z Pelvis X ray
z Lateral cervical spine X ray

Additional views
z AP cervical spine X ray
z Open mouth odontoid peg X ray
z Oblique views of cervical spine
z CT
z FAST

Imaging in major trauma - perspective

{

Trauma series of X-rays

z Chest X ray
z Pelvis X ray
z Lateral cervical spine X ray

Additional views
z AP cervical spine X ray
z Open mouth odontoid peg X ray
z
z Oblique views of cervical spine
z
z CT
z
z FAST

Imaging in major trauma - perspective

{
{

Spinal immobilisation is a priority in multiple

trauma, spinal clearance is not.
The spine should be assessed and cleared
when appropriate, given the injury and
physiological state.
Imaging the spine does not take precedence
over life-saving diagnostic and therapeutic
procedures.

Imaging in major trauma

Chest X ray

Imaging in major trauma - interpretation

How do we examine a CXR?

Imaging in major trauma - interpretation

How do we examine an XR?
AABCs
A
A
B
C
S

Adequacy
- Alignment
- Bones
- Cartilage
Soft tissues

Imaging in major trauma - interpretation

Normal CXR

Imaging in major trauma - interpretation

How do we examine a CXR?

Imaging in major trauma - interpretation

How do we examine a CXR?

Imaging in major trauma - interpretation

{
{
{
{
{
{

Some
B*****d
Pinched
My
Toy
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
B*****d
Pinched
My
Toy
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
Bones
Pinched
My
Toy
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
Bones
Pleura / Parenchyma
My
Toy
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Toy
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Trachea
Dinosaur

Imaging in major trauma - interpretation

{
{
{
{
{
{

Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Trachea
Diaphragms

Imaging in major trauma - interpretation

Normal
CXR

Soft
tissues

Imaging in major trauma - interpretation

Normal CXR

Bones

Imaging in major trauma - interpretation

Normal CXR

Pleura

Imaging in major trauma - interpretation

Normal CXR

Parenchyma

Imaging in major trauma - interpretation

Normal CXR

Mediastinum

Imaging in major trauma - interpretation

Normal CXR

Trachea

Imaging in major trauma - interpretation

Normal CXR

Diaphragms

Imaging in major trauma

Pathology

Imaging in major trauma - pathology

Subcutaneous
emphysema

Imaging in major trauma - pathology

Multiple rib
#s

Imaging in major trauma - pathology

Flail chest

Imaging in major trauma - pathology

Simple
pneumothorax

Imaging in major trauma - pathology

Simple
pneumothorax
- detail

Imaging in major trauma - pathology

Simple
pneumothorax
- detail

Imaging in major trauma - pathology

L tension
pneumothorax

Imaging in major trauma - pathology

Erect
haemothorax

Imaging in major trauma - pathology

Supine
haemothorax

Imaging in major trauma - pathology

Massive
haemothorax

Imaging in major trauma - pathology

Pulmonary
contusion

Imaging in major trauma - pathology

Widened
mediastinum

Imaging in major trauma - pathology

Oesophageal
rupture

Imaging in major trauma

Pelvis X ray

Imaging in major trauma - interpretation

How do we examine a PXR?

Imaging in major trauma - interpretation

How do we examine a PXR?
AABCs
{
{
{
{
{

A
A
B
C
S

Adequacy
- Alignment
- Bones
- Cartilage
Soft tissues

Imaging in major trauma - interpretation

Normal AP
pelvis

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Normal AP
pelvis

Imaging in major trauma - interpretation

Normal AP
pelvis

Imaging in major trauma - interpretation

Normal AP
pelvis

Imaging in major trauma - interpretation

Normal AP
pelvis

Imaging in major trauma - interpretation

Dont forget!

Imaging in major trauma - interpretation

Dont forget!

Imaging in major trauma - interpretation

Dont forget!

Imaging in major trauma

Pathology

Imaging in major trauma - pathology

Open book
pelvic #

Imaging in major trauma

Open book
pelvic #

Imaging in major trauma

Malgaigne
pelvic #

Imaging in major trauma - pathology

Lateral
compression
pelvic #

Imaging in major trauma - pathology

Lateral
compression
pelvic # CTR

Imaging in major trauma - pathology

Lateral
compression
pelvic # CTR

Imaging in major trauma

Central
dislocation
of hip

Imaging in major trauma

Vertical
shear #

Imaging in major trauma

Anterior +
posterior hip
dislocations

Imaging in major trauma

Shear# +
central
dislocation

Imaging in major trauma

Sacral #

Imaging in major trauma

Widened SI
joint

Imaging in major trauma - interpretation

Cervical spine X ray

Imaging in major trauma

Cervical spine why is it a problem?

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

{

Pathology
z Serious head and neck injuries 35mph
z 2001 Daytona 500 fatal accident - change in
velocity ~ 43 mph
z Resultant load in neck (tension + shear
loading) exceeds injury threshold.
z Also leads to base of the skull (basilar)
fractures - most common cause of death in
racing drivers (and lots of other drivers!)

Imaging in major trauma

{

Pathology
z Severe flexion, extension, and rotational
forces
z Atlanto-occipital disarticulations occur in
high-energy impacts and collisions
z Associated with
{ aortic laceration in 25%
{ basilar skull fracture in 21%

WHY DOES THIS ALL HAPPEN?

Imaging in major trauma

{

Anatomy
z 7 vertebral bodies connect head to torso
z C1 (atlas) & C2 (axis) - special shape
{ Supports the head
{ Permits head turning
{ Permits upward and downward tilting
z Lower 5 vertebrae similar in appearance &
function
{ Permit flexion / extension / rotation, lateral
bending

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

Imaging in major trauma

FORCES ACTING ON CERVICAL SPINE

Tension
loading

Imaging in major trauma

FORCES ACTING ON CERVICAL SPINE

Tension
loading

Compressive
loading

Imaging in major trauma

FORCES ACTING ON CERVICAL SPINE

Tension
loading

Compressive Shear
loading
forces

Imaging in major trauma

FORCES ACTING ON CERVICAL SPINE

Tension
loading

Compressive Shear
loading
forces

Torsional
forces

Imaging in major trauma - interpretation

How do we examine a lateral cervical
spine XR?

Imaging in major trauma - interpretation

How do we examine a lateral cervical
spine XR?
AABCs
{
{
{
{
{

A
A
B
C
S

Adequacy
- Alignment
- Bones
- Cartilage
Soft tissues

Imaging in major trauma - interpretation

A - Adequacy
Inadequate
lateral cervical
spine view

Imaging in major trauma - interpretation

A - Adequacy
Adequate
(just!) lateral
cervical spine

Imaging in major trauma - interpretation

A - Alignment

Imaging in major trauma - interpretation

B - Bones

Imaging in major trauma - interpretation

B - Bones

Imaging in major trauma - interpretation

B - Bones

Imaging in major trauma - interpretation

C - Cartilage

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Additional views

Imaging in major trauma - interpretation

How do we examine an AP cervical spine
XR?

Imaging in major trauma - interpretation

Normal AP
cervical spine

Imaging in major trauma - interpretation

How do we examine an AP cervical spine
XR?
AABCs
{
{
{
{
{

A
A
B
C
S

Adequacy
- Alignment
- Bones
- Cartilage
Soft tissues

Imaging in major trauma - interpretation

A
- Adequacy
Normal
AP
cervical spine
Adequate AP
cervical spine

Imaging in major trauma - interpretation

A - Alignment

Imaging in major trauma - interpretation

B - Bones

Imaging in major trauma - interpretation

B Bones
Space
Invader Sign

Imaging in major trauma - interpretation

C Cartilage

Imaging in major trauma - interpretation

How do we examine an odontoid peg XR?

Imaging in major trauma - interpretation

Normal
odontoid peg
view

Imaging in major trauma - interpretation

Imaging in major trauma - interpretation

Normal
odontoid peg
view

Imaging in major trauma - interpretation

How do we examine an odontoid peg XR?
AABCs
{
{
{
{
{

A
A
B
C
S

Adequacy
- Alignment
- Bones
- Cartilage
Soft tissues

Imaging in major trauma - interpretation

A
- Adequacy
Normal
AP
cervical spine
Adequate peg
view

Imaging in major trauma - interpretation

A - Alignment

Imaging in major trauma - interpretation

B - Bones

Imaging in major trauma - interpretation

C Cartilage

Imaging in major trauma

Pathology

Imaging in major trauma

Imaging in major trauma - pathology

Type I

Odontoid peg
#s

Type II

Type III

Imaging in major trauma - pathology

Odontoid peg
#

Imaging in major trauma - pathology

Odontoid peg
#

Imaging in major trauma - pathology

Occipito atlantal
dislocation

Imaging in major trauma - pathology

Jefferson
(burst) #

Imaging in major trauma - pathology

Jefferson
(burst) #

Imaging in major trauma - pathology

Jefferson
(burst) #

Imaging in major trauma - pathology

Atlanto-axial
dislocation

Imaging in major trauma - pathology

C2 pedicle #

Imaging in major trauma - pathology

Hangmans
#

Imaging in major trauma - pathology

Teardrop #
C4

Imaging in major trauma - pathology

C5 crush #

Imaging in major trauma - pathology

Unilateral
facet joint
dislocation
C5/6

Imaging in major trauma - pathology

Bilateral
facet joint
dislocation
C5/6

Imaging in major trauma - pathology

# dislocation
C5/6

Imaging in major trauma

{

important new imaging techniques

Imaging in major trauma extra stuff

Imaging in major trauma

{

Any questions?

THE END