Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review

Applications of deep learning in trauma radiology: A narrative review

Diagnostic imaging is essential in modern trauma care for initial evaluation and identifying injuries requiring intervention. Deep learning (DL) has become mainstream in medical image analysis and has shown promising efficacy for classification, segmentation, and lesion detection. This narrative review provides the fundamental concepts for developing DL algorithms in trauma imaging and presents an overview of current progress in each modality. DL has been applied to detect free fluid on Focused Assessment with Sonography for Trauma (FAST), traumatic findings on chest and pelvic X-rays, and computed tomography (CT) scans, identify intracranial hemorrhage on head CT, detect vertebral fractures, and identify injuries to organs like the spleen, liver, and lungs on abdominal and chest CT. Future directions involve expanding dataset size and diversity through federated learning, enhancing model explainability and transparency to build clinician trust, and integrating multimodal data to provide more meaningful insights into traumatic injuries. Though some commercial artificial intelligence products are Food and Drug Administration-approved for clinical use in the trauma field, adoption remains limited, highlighting the need for multi-disciplinary teams to engineer practical, real-world solutions. Overall, DL shows immense potential to improve the efficiency and accuracy of trauma imaging, but thoughtful development and validation are critical to ensure these technologies positively impact patient care.

Plain Chest Film Versus Computed Tomography of the Chest as the Initial Imaging Modality for Blunt Thoracic Injury

BACKGROUND

While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma.

METHODS

The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location.

RESULTS

Propensity score matching yielded 17 716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups (P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178).

DISCUSSION

CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments.

Survival Rate in Emergency Thoracotomy for Penetrating Trauma: A Retrospective Cross-Sectional Study

Background Emergency thoracotomy (ET) is a critical intervention for traumatic thoracic injuries, often required in patients with penetrating trauma. The survival outcomes and the factors that influence survival in these patients remain an area of interest for trauma care providers. Objective The objective of the study is to assess the survival rate and factors influencing the survival of patients undergoing emergency thoracotomy due to penetrating thoracic trauma. Methods This retrospective cross-sectional study was conducted in the thoracic surgery, accident, and emergency department of Lady Reading Hospital, Peshawar, Pakistan. A total of 85 patients who underwent emergency thoracotomy following penetrating trauma between July 2019 and June 2024 were included. Data were extracted from the health information management system (HIMS) and analyzed using SPSS. The study reviewed demographic details, severity of injury, operative details, and postoperative outcomes. Statistical analyses included univariate analysis using chi-square and Fisher's exact tests for categorical data and independent t-tests for continuous variables. Results The study included 85 patients with a mean age of 25.72±7.84 years. The majority of patients were male (81/85, 95.29%), while females accounted for a smaller proportion (4/85, 4.71%), and gunshot trauma accounted for the most frequent cause of penetrating injury (50/85, 58.8%). The time to thoracotomy was within 60 minutes of admission, with a mean time of 48±16.5 minutes. A total of 61/85 (71.5%) patients had isolated thoracic injuries, and 24/85 (28.2%) had associated injuries, with 24/85 (28.2%) patients requiring concomitant laparotomy. The overall mortality rate was 9/85 (10.5%), with 7/9 (77.7%) of deaths occurring intraoperatively. Mortality was significantly higher in patients with combined thoracotomy and laparotomy procedures. Prolonged hospital stays and higher transfusion requirements were observed in gunshot wound victims (50/85, 58.8%). Conclusions Emergency thoracotomy for penetrating thoracic trauma has a significant mortality rate in patients with combined thoracic and abdominal injuries. Factors such as the mechanism of injury, associated injuries, and the need for additional procedures (e.g., laparotomy) influence survival outcomes. Early intervention and proper management of associated injuries are crucial for improving survival rates in these patients.

Impact of Imaging on Surgical Management of Penetrating Chest Trauma: Experience From a High-Volume Trauma Center in a Resource-Constrained Environment

Background Penetrating chest trauma is a significant cause of morbidity and mortality, with the need for accurate and timely diagnosis being crucial in determining appropriate management. This study aims to evaluate the role of computed tomography (CT) imaging in the assessment and surgical management of patients with penetrating chest trauma at a high-volume trauma center in a developing country. Objective To assess the contribution of CT imaging in the evaluation and surgical management of patients presenting with penetrating chest trauma at a resource-limited trauma center in Pakistan. Methods A cross-sectional observational study was conducted in the Thoracic Surgery and Radiology Departments of Lady Reading Hospital, Peshawar, from January 2024 to June 2024. A convenient sampling technique was used to include 139 patients with penetrating chest trauma. Demographic details, trauma complications, fractures, and management strategies were recorded. Thick-slice, non-contrast, chest CT scans were performed and reviewed by a consultant radiologist. Data analysis was carried out using SPSS version 26 (IBM Corp., Armonk, NY). Results The study included 139 patients with a mean age of 26.7 ± 8.2 years (range: 8-70 years). The majority were male (126, 90.6%), and the most common mode of injury was firearm trauma (83, 59.7%). The most frequently observed complications were pneumothorax (110, 79.1%), hemothorax (112, 80.6%), and lung injury (88, 63.3%). Fractures were noted in 54 (38.8%) patients, with rib fractures being the most common (31, 22.3%). The most common management approach was tube thoracostomy (116, 83.5%), followed by conservative management (10, 7.2%) and open thoracotomy (6, 4.3%). Conclusion CT imaging is an invaluable tool in the assessment of penetrating chest trauma, aiding in the identification of hidden injuries and influencing surgical management decisions. Although thin-slice contrast-enhanced CT is the standard protocol in our resource-constrained setting, non-contrast axial CT scans offer critical diagnostic information and guide timely management. Its use significantly improves patient outcomes, especially in a resource-limited setting.

Diagnostic evaluation of blunt chest trauma by imaging-based application of artificial intelligence

Artificial intelligence (AI) is becoming increasingly integral in clinical practice, such as during imaging tasks associated with the diagnosis and evaluation of blunt chest trauma (BCT). Due to significant advances in imaging-based deep learning, recent studies have demonstrated the efficacy of AI in the diagnosis of BCT, with a focus on rib fractures, pulmonary contusion, hemopneumothorax and others, demonstrating significant clinical progress. However, the complicated nature of BCT presents challenges in providing a comprehensive diagnosis and prognostic evaluation, and current deep learning research concentrates on specific clinical contexts, limiting its utility in addressing BCT intricacies. Here, we provide a review of the available evidence surrounding the potential utility of AI in BCT, and additionally identify the challenges impeding its development. This review offers insights on how to optimize the role of AI in the diagnostic evaluation of BCT, which can ultimately enhance patient care and outcomes in this critical clinical domain.

Blunt esophageal injury in the setting of multitrauma: A case report

Blunt esophageal injury is an unusual organ injury that has unclear clinical symptoms due to the overlap of thoracoabdominal trauma in the setting of multiple traumas. The treatment options vary depending on the patient's clinical symptoms, the extent of esophageal damage, and the time from the onset of damage to diagnosis. This article presents a case of a young male patient receiving emergency treatment after a traffic accident. Esophageal perforation was diagnosed through chest computed tomography with contrast injection and oral contrast. The article focuses on imaging characteristics and suggestive signs of blunt esophageal injury in the setting of multitrauma.

Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review

BACKGROUND

Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy.

METHODS

We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression.

RESULTS

There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm.

CONCLUSION

Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Diagnostic Accuracy for Acute Rib Fractures: A Cross-sectional Study Utilizing Automatic Rib Unfolding and 3D Volume-Rendered Reformation

RATIONALE AND OBJECTIVES

The aim of this study was to compare the use of computed tomography (CT) with automatic rib unfolding and three-dimensional (3D) volume-rendered imaging in the detection and characterization of rib fractures and flail chest.

MATERIALS AND METHODS

A total of 130 patients with blunt chest trauma underwent whole-body CT, and five independent readers assessed the presence and characterization of rib fractures using traditional CT images, automatic rib unfolding, and 3D volume-rendered images in separate readout sessions at least 2 weeks apart. A gold standard was established by consensus among the readers based on the combined analysis of conventional and reformatted images.

RESULTS

Automatic rib unfolding significantly reduced mean reading time by 47.5%-74.9% (P < 0.0001) while maintaining a comparable diagnostic performance for rib fractures (positive predictive value [PPV] of 82.1%-93.5%, negative predictive value [NPV] of 96.8%-98.2%, and 69.4%-94.2% and 96.9%-99.1% for conventional axial images and 70.4%-85.1% and 95.2%-96.6% for 3D images) and better interobserver agreement (kappa of 0.74-0.87). For flail chest, automatic rib unfolding showed a PPV of 85.7%-100%, NPV of 90.4%-99.0%, and 80.0%-100% and 89.7%-100% for conventional axial images and 76.9%-100% and 89.0%-92.1% for 3D images.

CONCLUSION

Automatic rib unfolding demonstrated equivalent diagnostic performance to conventional images in detecting acute rib fractures and flail chest, with good interobserver agreement and time-saving benefits.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

From diagnosis to therapy: the acute traumatic hemothorax - an orientation for young surgeons

Introduction

This review aims to provide an overview of diagnosing and managing traumatic haemothorax for young surgeons.

Content

Of 27,333 polytrauma patients in Germany in 2021, 35 % were admitted with thoracic trauma. In polytrauma patients, chest injuries are an independent negative predictor of 30-day mortality. These patients should be treated in an evidence-based and standardized manner to reduce mortality and morbidity. There are several methods of immediate diagnosis that should be used depending on hemodynamic stability. In addition to physical examination and chest X-ray, more specific techniques such as the eFAST protocol and Computed tomography (CT) of the chest  are available. Once the source of bleeding has been identified, acute treatment is given depending on hemodynamic stability. Thoracic drainage remains the gold standard in the initial management of hemothorax. If surgery is required because of an active source of bleeding, a hemothorax that has not been completely relieved, or associated injuries, either a minimally invasive or open approach can be used. The main focus is to stabilize the patient and avoid early and late complications.

Summary and Outlook

Rapid and prompt diagnosis and management of traumatic hemothorax is essential for patient outcome and should be taught to all young surgeons who are in direct contact with these patients.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis

BACKGROUND

Approximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment. This study analyzed and reported the treatment strategy of a single center for BTAI in the last 10 years and the early and middle clinical results.

METHODS

This retrospective study included patients diagnosed with BTAI at Xijing Hospital from 2013 to 2022. All inpatients with BTAI aged ≥ 18 years were included in this study. The clinical data, imaging findings, and follow-up results were retrospectively collected and analyzed. The Kaplan-Meier curve and multivariate logistic regression were used to compare survivors and nonsurvivors.

RESULTS

A total of 72 patients (57% men) were diagnosed with BTAI, with a mean age of 54.2 ± 9.1 years. The injury severity score was 24.3 ± 18, with Grade I BTAI1 (1.4%), Grade II 17 (23.6%), Grade III 52 (72.2%), and Grade IV 2 (2.8%) aortic injuries. Traffic accidents were the main cause of BTAI in 32 patients (44.4%). Most patients had trauma, 37 had rib fractures (51.4%), Sixty patients (83.3%) underwent thoracic endovascular aortic repair (TEVAR) surgery, eight (11.1%) underwent conservative treatment, and only four (5.6%) underwent open surgery. The overall hospitalization mortality was 12.5%. In multivariate logistic regression, elevated creatinine levels (P = 0.041) and high Glasgow coma scale (GCS) score (P = 0.004) were the predictors of hospital mortality. The median follow-up period was 57 (28-87) months. During the follow-up period, all-cause mortality was 5.6% and no aortic-related deaths were reported. Three patients (4.2%) needed secondary surgery and two of them underwent endovascular repair.

CONCLUSION

Although TEVAR surgery may be associated with intra- or postoperative dissection rupture or serious complications in the treatment of Grade III BTAI, the incidence rate was only 8.9%. Nevertheless, TEVAR surgery remains a safe and feasible approach for the treatment of Grade II or III BTAI, and surgical treatment should be considered first,. A high GCS score and elevated creatinine levels in the emergency department were closely associated with hospital mortality. Younger patients need long-term follow-up after TEVAR.