Bone Bruise versus Fracture on MRI and the Relevance to Return to Play

We review the spectrum of acute osseous injuries in athletes, ranging from osseous contusion (bone bruise) injuries to nondisplaced cortical fractures. The basic biomechanical concepts, underlying histopathologic changes, and characteristic magnetic resonance imaging (MRI) features of acute osseous injuries are presented. Bone bruise injuries of varying severity are highlighted to showcase the breadth of imaging findings on MRI and methods for characterizing such lesions. We emphasize the importance of accurately assessing patterns of injury on MRI to communicate more effectively with team medical staff and recognize the implications on return to play. This article offers the foundational tools for approaching bone bruise injuries in elite athletes to add value to the diagnosis and treatment of this unique patient population.

Karate kick-induced myocardial contusion

Myocardial contusion should be suspected in a selected patient group with blunt thoracic trauma, who have elevated troponin, ECG changes and/or haemodynamical instability. Echocardiography is useful for direct visualisation of possible complications. In stable conditions, MRI allows for good visualisation of the heart and can confirm a suspected myocardial contusion as well as demonstrate the extent of myocardial damage. Based on the present literature, the authors developed a diagram for the diagnostic approach of a patient with suspected myocardial contusion.

Sustained pain and macrophage infiltration in a mouse muscle contusion model

INTRODUCTION/AIMS

Prior studies have emphasized the role of inflammation in the response to injury and muscle regeneration, but little emphasis has been placed on characterizing the relationship between innate inflammation, pain, and functional impairment. The aim of our study was to determine the contribution of innate immunity to prolonged pain following muscle contusion.

METHODS

We developed a closed-impact mouse model of muscle contusion and a macrophage-targeted near-infrared fluorescent nanoemulsion. Closed-impact contusions were delivered to the lower left limb. Pain sensitivity, gait dysfunction, and inflammation were assessed in the days and weeks post-contusion. Macrophage accumulation was imaged in vivo by injecting i.v. near-infrared nanoemulsion.

RESULTS

Despite hindpaw hypersensitivity persisting for several weeks, disruptions to gait and grip strength typically resolved within 10 days of injury. Using non-invasive imaging and immunohistochemistry, we show that macrophage density peaks in and around the affected muscle 3 day post-injury and quickly subsides. However, macrophage density in the ipsilateral sciatic nerve and dorsal root ganglia (DRG) increases more gradually and persists for at least 14 days.

DISCUSSION

In this study, we demonstrate pain sensitivity is influenced by the degree of lower muscle contusion, without significant changes to gait and grip strength. This may be due to modulation of pain signaling by macrophage proliferation in the sciatic nerve, upstream from the site of injury. Our work suggests chronic pain developing from muscle contusion is driven by macrophage-derived neuroinflammation in the peripheral nervous system.

Pulmonary contusion: automated deep learning-based quantitative visualization

PURPOSE

Rapid automated CT volumetry of pulmonary contusion may predict progression to Acute Respiratory Distress Syndrome (ARDS) and help guide early clinical management in at-risk trauma patients. This study aims to train and validate state-of-the-art deep learning models to quantify pulmonary contusion as a percentage of total lung volume (Lung Contusion Index, or auto-LCI) and assess the relationship between auto-LCI and relevant clinical outcomes.

METHODS

302 adult patients (age ≥ 18) with pulmonary contusion were retrospectively identified from reports between 2016 and 2021. nnU-Net was trained on manual contusion and whole-lung segmentations. Point-of-care candidate variables for multivariate regression included oxygen saturation, heart rate, and systolic blood pressure on admission. Logistic regression was used to assess ARDS risk, and Cox proportional hazards models were used to determine differences in ICU length of stay and mechanical ventilation time.

RESULTS

Mean Volume Similarity Index and mean Dice scores were 0.82 and 0.67. Interclass correlation coefficient and Pearson r between ground-truth and predicted volumes were 0.90 and 0.91. 38 (14%) patients developed ARDS. In bivariate analysis, auto-LCI was associated with ARDS (p < 0.001), ICU admission (p < 0.001), and need for mechanical ventilation (p < 0.001). In multivariate analyses, auto-LCI was associated with ARDS (p = 0.04), longer length of stay in the ICU (p = 0.02) and longer time on mechanical ventilation (p = 0.04). AUC of multivariate regression to predict ARDS using auto-LCI and clinical variables was 0.70 while AUC using auto-LCI alone was 0.68.

CONCLUSION

Increasing auto-LCI values corresponded with increased risk of ARDS, longer ICU admissions, and longer periods of mechanical ventilation.

The Predicted Position of the Knee Near the Time of ACL Rupture Is Similar Between 2 Commonly Observed Patterns of Bone Bruising on MRI

BACKGROUND

Bone bruises observed on magnetic resonance imaging (MRI) can provide insight into the mechanisms of noncontact anterior cruciate ligament (ACL) injury. However, it remains unclear whether the position of the knee near the time of injury differs between patients evaluated with different patterns of bone bruising, particularly with regard to valgus angles.

HYPOTHESIS

The position of the knee near the time of injury is similar between patients evaluated with 2 commonly occurring patterns of bone bruising.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Clinical T2- and T1-weighted MRI scans obtained within 6 weeks of noncontact ACL rupture were reviewed. Patients had either 3 (n = 20) or 4 (n = 30) bone bruises. Patients in the 4-bone bruise group had bruising of the medial and lateral compartments of the femur and tibia, whereas patients in the 3-bone bruise group did not have a bruise on the medial femoral condyle. The outer contours of the bones and associated bruises were segmented from the MRI scans and used to create 3-dimensional surface models. For each patient, the position of the knee near the time of injury was predicted by moving the tibial model relative to the femoral model to maximize the overlap of the tibiofemoral bone bruises. Logistic regressions (adjusted for sex, age, and presence of medial collateral ligament injury) were used to assess relationships between predicted injury position (quantified in terms of knee flexion angle, valgus angle, internal rotation angle, and anterior tibial translation) and bone bruise group.

RESULTS

The predicted injury position for patients in both groups involved a flexion angle <20°, anterior translation >20 mm, valgus angle <10°, and internal rotation angle <10°. The injury position for the 3-bone bruise group involved less flexion (odds ratio [OR], 0.914; 95% CI, 0.846-0.987; P = .02) and internal rotation (OR, 0.832; 95% CI, 0.739-0.937; P = .002) as compared with patients with 4 bone bruises.

CONCLUSION

The predicted position of injury for patients displaying both 3 and 4 bone bruises involved substantial anterior tibial translation (>20 mm), with the knee in a straight position in both the sagittal (<20°) and the coronal (<10°) planes.

CLINICAL RELEVANCE

Landing on a straight knee with subsequent anterior tibial translation is a potential mechanism of noncontact ACL injury.

Quantitative assessment of changes in skeletal muscle injury by computer-aided analysis based on two-dimensional ultrasonography combined with contrast-enhanced ultrasonography and estimated by a modified semi-quantitative scoring system: An experimental study in a contusion model

The aim of this study was to investigate the potential application of computer-aided analysis in the quantitative assessment of changes in skeletal muscle injury in the rabbit contusion model. Forty healthy rabbits were randomly divided into control (n = 5) and contusion (n = 35) groups. Rabbits in the contusion group were used to construct a muscle contusion model induced by a hammer hitting the right gastrocnemius, while the muscles of rabbits in the control group were non-injured. Two-dimensional ultrasound (2D US) and contrast-enhanced ultrasonography (CEUS) were performed on the rabbits that had received skeletal muscle contusion injury at 1 h, and 1, 3, 7, 14, 21 and 28 days after injury. Afterwards, a multiscale blob feature (MBF) method was used to extract the textural features from the 2D US, and the muscle injuries were quantitatively evaluated. The eight textural parameters of skeletal muscle analysed by MBF at 1 h, and 1, 3 and 7 days post-injury were found to be significantly higher in the contusion group than in the control group (p < .05). On Day 14, the textural parameters (e.g., greyscale mean [Mean], greyscale standard deviation [SDev], number of blobs, average size of blobs, homogeneity of distribution, periodicity of distribution [POD] and irregularity) were also evidently higher in the contusion group than in the control group (p < .05). On Day 28, Mean, SDev and POD in the contusion group were markedly higher (p < .05). After that, the microcirculation in the injured areas increased from Day 7 to Day 21 after injury, but decreased on Day 28 after injury. Thus the quantitative assessment of changes in skeletal muscle injury (SMI) using computer-aided analysis allowed us to describe the geometric features of injured muscle fibres and the microperfusion changes estimated by the modified semi-quantitative scoring system. This provides a scientific basis for the development of a novel approach for the evaluation of SMI and rehabilitation process.

Imaging findings of pulmonary contusions on multidetector CT: A retrospective study comparing adults and children

To describe imaging findings of pulmonary contusions (PC) in adults and children using multidetector computed tomography (CT) scanners. We conducted a retrospective single center study. All chest multidetector computed tomography (MDCT) scans of victims of blunt trauma admitted to the emergency unit of a reference trauma center of Brazil between January 2015 and December 2016 were reviewed in search of opacities compatible with PC. The CT images were analyzed in conjunction with medical records, that provided demographic and clinical data. The obtained data were analyzed in the overall population and comparing children and adults. Significant P value was defined as <.05. 52.7% of patients presented bilateral opacities. Middle third, posterior and peripheral portions of the lungs were more frequently affected, in the craniocaudal, anteroposterior and axial axes, respectively. A vast majority of patients (80.6%) presented multiple opacities, whereas a minority showed subpleural sparing (26.9%) and fissure crossing (22.6%), with similar frequencies in children and adults. Children, although, more frequently presented consolidation and more diffuse lesions in the anteroposterior axis compared to adults, with statistically significant differences. PC usually are multiple and predominate in middle, posterior and peripheral portions of the lungs. Subpleural sparing and fissure crossing seems to be infrequent and have similar frequencies between children and adults. Although, there are differences between these age groups, as younger people tend to have more consolidation and diffuse opacities in the anteroposterior axis than older ones.

[Traumatic Lung Injury]

Thoracic injuries are significant causes of morbidity and mortality in trauma patients. Traumatic pulmonary contusion and/or laceration are often observed in patients with chest trauma, explosion injuries or a shock wave associated with penetrating trauma. A pulmonary contusion is an injury to the lung parenchyma without actual structural damage. As a result of damage to alveoli and capillaries, it results in leakage of blood and other interstitial fluids across the alveolar-capillary membrane into lung tissue and alveolar space. Since oxygenated air can not enter into fluid-filled alveoli, hypoventilation and decreased perfusion by reflux vasoconstriction result in hypoxemia and hypercapnia. Pulmonary laceration is a lung injury with disruption of the architecture of the lung, while pulmonary contusion does not. There is almost always concurrent pulmonary contusion, and pneumothorax, hemothorax, or hemopneumothorax. In addition, pulmonary laceration can be a cause of forming a cyst or hematoma, which usually disappears over a period of weeks or months. However, pneumatocele can occur in some cases when lacerations are enlarged with air-filled cavity. It is important for thoracic surgeons to understand pathophysiology of traumatic lung injury, and to know the diagnosis and treatment.

Bruise Location in Supracondylar Humerus Fractures Predicts Specific Neurovascular Injuries

PURPOSE

The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured.

METHODS

Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured.

RESULTS

Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury-of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P<0.05) or anterior (17/45, 37.8%, P>0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P<0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P<0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone.

CONCLUSION

Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs.

LEVEL OF EVIDENCE

Level IV, case series.

Fracture-Associated Bruising and Soft Tissue Swelling in Young Children With Skull Fractures: How Sensitive Are They to Fracture Presence?

OBJECTIVES

The aim of this study was to determine how reliable scalp bruising and soft tissue swelling/cephalohematomas (STS) are for underlying young child skull fractures.

METHODS

This was a retrospective clinical and imaging review from 2011 to 2012 of children younger than 4 years with skull fractures from 2 tertiary care hospitals. Imaging was reread by 3 pediatric radiologists. Descriptive statistics were utilized. The retrospective review had institutional review board approval.

RESULTS

We identified 218 subjects for review: 210 unintentional and 8 abusive. One hundred forty-three had available 3-dimensional computed tomography reconstructions: 136 unintentional and 7 abused. Two-thirds were younger than 1 year. Twelve subjects had visible scalp bruising, but 73% had clinically and 93% radiologically apparent fracture-associated STS. There was no difference in clinical STS with simple (79%) versus complex (68%) fractures. Nor was there difference in subjects with fractures from minor (77%) versus major (70%) trauma. Unintentionally injured infants did not differ from abused for detectable STS (74% vs 50%). Parietal and frontal bones most frequently sustained fractures and most consistently had associated STS.

CONCLUSIONS

Clinically apparent STS is present in approximately three-fourths of children with skull fractures. It may not be important to consistently identify skull fractures in unintentionally injured children. Point-of-care ultrasound may be adequate. For abuse concerns, it is important to identify skull fractures as evidence of cranial impacts and intracranial hemorrhages. The most sensitive, widely available imaging technique, cranial computed tomography scan with 3-dimensional skull reconstruction, should be utilized. Scalp bruising is present in a minority of young children with skull fractures. Its absence does not exclude cranial impact injury.

A Case Report Utilizing Ultrasound for the Identification of Traumatic Pulmonary Contusion

Pulmonary contusions are a common injury in both military and civilian trauma patients. In austere and resource-limited settings common to deployment, military physicians may be limited on their ability diagnose or differentiate this entity from other traumatic injuries. We describe the use of ultrasound for the identification of pulmonary contusion in a patient with a gunshot wound while performing an extended Focused Assessment with Sonography (eFAST). The utility of ultrasound in polytraumatic patients stretches far beyond the initial FAST exam and can drastically inform clinical decision making and treatment.

Isolated gallbladder injury from blunt abdominal trauma: A rare co-incidence

Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.

Sex Difference in Contusion of the Medial Femoral Condyle Rim-Association with MRI Occult Meniscal Tears in the ACL Deficient Knee

BACKGROUND

Meniscal tears, specifically lateral meniscal tears, have a larger than expected un-derdiagnosis rate in the presence of an ACL tear. The purpose of our study was to search for an MRI bone contusion pattern associated with MRI occult meniscal tears in patients with an ACL tear, specifically a contusion of the rim of the medial femoral condyle (RMFC). Our hypothesis was that there would be a significant association between RMFC contusions and MRI occult meniscal tears in patients with an ACL tear. We also searched for a difference between sexes with respect to the presence of the RMFC contusion in the setting of an occult meniscal tear. We also categorized the type, size, and location of these occult meniscal tears in the setting of an ACL tear.

METHODS

This was a retrospective study that examined characteristics of occult meniscal tears and their association with a RMFC bone contusion. IRB approval was obtained. The date range of the study was June 2009 through December 2015. 6392 consecutive knee MRI reports in patients with an ACL deficient knee were reviewed. The study group included 22 patients with MRI occult meniscal tears, the control group included 110 patients. Relevant statistical values were calculated.

RESULTS

The most common type of occult meniscal tears were small radial and small longitudinal tears of the lateral meniscus. Occult meniscal tears were associated with an RMFC contusion in the study group (p=0.0457), particularly in males (p = 0.0003). In males with a torn ACL, the sensitivity of an RMFC contusion for an occult meniscal tear was 80%.

CONCLUSION

In males with an ACL tear, there was a significant association between a contusion of the RMFC and an occult meniscal tear (commonly small radial or small peripheral partial-thickness longitudinal tears). RMFC contusions were reliably identified by radiologists in this study.Level of Evidence: II.

Application of automated bronchial 3D-CT measurement in pulmonary contusion complicated with acute respiratory distress syndrome

BACKGROUNDQuantitative measurement of bronchial morphological changes in pulmonary contusion with acute respiratory distress syndrome (ARDS) has important clinical implications.OBJECTIVETo investigate the morphological changes in bronchus before and after treatment in patients with pulmonary contusion combined with ARDS using an automated bronchial three-dimensional computed tomography (3D-CT) measurement method.METHODSThe study involves a dataset of CT images of 62 patients diagnosed with pulmonary contusion combined with ARDS. The volume of pulmonary contusion lesions was calculated as a percentage of the total lung volume using the automated 3D-CT method. The bronchial luminal cross-sectional area, wall cross-sectional area, the maximum and average wall thickness, the maximum and average luminal densities, intraluminal and extraluminal diameters, and circumferences of generations 2-4 bronchi before and after treatment were measured. Furthermore, the corresponding differences were analyzed statistically.RESULTSThe luminal cross-sectional area, wall cross-sectional area, intraluminal and extraluminal diameters, and circumferences of generations 2-4 bronchi were all significantly lower before treatment than after treatment (P < 0.05). However, the maximum and average wall thicknesses were both significantly higher before treatment than after treatment (P < 0.05). No significant difference was found in the maximum and average luminal densities before and after treatment (P > 0.05). The percentage of the pulmonary contusion lesion volume to the total lung volume correlated positively with the thoracic trauma severity score (r = 0.74, P < 0.01).CONCLUSIONSQuantitative bronchial CT image analysis enables to detect and assess bronchial morphological changes in patients diagnosed with pulmonary contusion combined with ARDS.

Non-invasive Assessment of Changes in Muscle Injury by Ultrasound Shear Wave Elastography: An Experimental Study in Contusion Model

The present study investigated the potential of ultrasound shear wave elastography (SWE) in assessment of muscle stiffness in muscle injury. SWE was performed on the injured muscle in 30 New Zealand rabbits that were randomly assigned to three groups: the contusion group, which was not treated with an efficient therapeutic strategy after muscle injury; the treatment group, which was treated with a therapeutic scheme after muscle injury; and the healthy group, which was not injured and served as a control. Both the mean Young's modulus (E_mean) and the maximum Young's modulus (E_max) were obtained pre-injury and 0.5, 1, 3, 5, 7, 14 and 28 d post-injury. At these time points, a rabbit in each group was randomly selected for biopsy for histopathological observation as well as comparison with Young's modulus. Eventually, all muscle tissues were collected for histologic analysis of collagen fiber formation. The contusion group had the highest Young's modulus, followed by the treatment group and then the healthy group (p < 0.05). In both the contusion and treatment groups, E_mean and E_max gradually increased within 1-3 d after injury, followed by a gradual decrease. Compared with the healthy group, histopathologic analysis of the contusion and treatment groups revealed the myofibril destruction process, inflammatory reaction and myofibril regeneration. The amount of collagen fibers in the contusion group was maximal compared with the treated and healthy groups (p = 0.001 and p < 0.001, respectively). There were more collagen fibers in the treatment group than in the healthy group (p = 0.003). The abundance of collagen fibers was positively correlated with the value of Young's modulus (E_mean: r = 0.706, p < 0.001; E_max: r = 0.761, p < 0.001). Thus, SWE can be used to detect pathologic changes in injured muscle and to monitor therapeutic effects.

Pneumatoceles in pediatric blunt trauma: Common and benign

INTRODUCTION

Traumatic pneumatoceles are reported to be rare in children and to have an uncertain clinical significance. We report a single institution series of traumatic pneumatoceles to better define their frequency and clinical significance.

METHODS

After obtaining approval from the IRB, data were extracted from the trauma registry of a level 1 pediatric trauma center on children diagnosed with a pulmonary contusion (International Classification of Diseases-9th edition diagnosis codes: 861.21 to 861.31) who presented between June, 2006 and September, 2016. Patient demographics, mechanism of injury, injury severity score, diagnosis and procedure codes, length of hospital stay, outcome, imaging techniques and findings with attention to the identification of a pneumatocele, were examined.

RESULTS

Of the 10,229 trauma admission, 204 children were identified as having a pulmonary contusion, 25 of whom (12.3%) were diagnosed with a pneumatocele. Their mean age was 13years (3-17). Seventy-six percent (19) were male. The most common mechanism of injury was a motor vehicle collision (10), followed by falls (6), and sports (5). Sixteen children (64%) suffered a long bone fracture, 12 (48%) an abdominal solid organ injury and 3 (12%) a traumatic brain injury. The mean Injury Severity Score was 17 (9-34). Twenty-three patients presented as transfers. There were no fatalities. The pneumatocele was identified on chest computerized tomography (CT) alone in 15 (60%), on chest CT and chest radiograph (CXR) in 3 (12%), the upper portions of an abdominal CT in 6 (24%) and on CXR alone in 1 (4%). Seven patients were found to have a solitary pneumatocele and 18 patients had 2 or more. The largest pneumatocele was 3.7cm in diameter. Ten children (40%) were admitted to the intensive care unit, 3 of whom required intubation. One patient (4%) had a respiratory complication: pneumonia. Three patients underwent chest tube placement for: pneumothorax, hemothorax and hemopneumothorax. No child underwent intervention specific to the pneumatocele. Seventeen (68%) patients were seen in follow-up in Trauma Clinic and the remainder by another practitioner ranging from 1week to 6months after injury. One child (4%) underwent a follow-up chest CT to rule out a congenital pulmonary malformation 6months after injury and this demonstrated complete resolution of the pneumatocele.

CONCLUSION

The incidence of traumatic pneumatoceles among children with a pulmonary contusion was 12.3% in this series, but is probably higher given that only 24% were visible on radiographs and a small minority of children with pulmonary contusions underwent chest CT. Pneumatoceles are common in children with pulmonary contusions, but are usually small. The majority do not appear to be clinically significant nor require follow-up imaging.

LEVEL OF EVIDENCE

IV.

Spinal cord injury without radiographic abnormality (SCIWORA) in adults: A report of two cases

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role.

Lesson of the month 2: Contusion confusion

This lesson of the month highlights that certain radiology terminology may be used to report bleeding on head computerised tomography (CT) reports. On-call junior doctors should not be expected to interpret CT head images, so often their decisions will be based on the written report. The wording used can change the clinical decision and therefore the treatment given by a junior doctor. Clinical teams and junior doctors should be educated on terminology in relation to bleeding on CT head reports.

Contusional Cerebellar Hemorrhage Related to Placement in the Protrusion Position After Atlantoaxial Fusion

BACKGROUND

Various complications after C1 lateral mass and C2 pedicle screw fusion surgery (C1LM-C2PSFS) have been reported. However, to our knowledge, this is the first report of contusional cerebellar hemorrhage caused by placement in the protrusion (chin-out) position after C1LM-2PSFS.

CASE DESCRIPTION

An 81-year-old woman complaining of gait disturbance and clumsiness of both hands was diagnosed with cervical myelopathy with atlantoaxial subluxation. After we performed C1LM-C2PSFS, her neurologic deficits gradually improved, and there was no radiologic evidence of construct failure. One month after surgery, she had severe headache and vomiting immediately after taking some medications while in the protrusion position. Head computerized tomography scan showed left cerebellar hemorrhage, and titanium rods penetrated the occipital bone on both sides. Flexion/extension radiography showed no loosening of any screws or rods. However, protrusion radiography showed that the tip of the left titanium rod intruded into the intracranial region. We considered that the penetration of the occipital bone by the left titanium rod caused the contusional left cerebellar hemorrhage. We immediately performed revision surgery to replace the titanium rods on each side with shorter rods, and no cerebrospinal fluid leakage was observed. The headache disappeared after the revision surgery.

CONCLUSIONS

We report a case of contusional cerebellar hemorrhage caused by the intrusion of a rod into the occipital bone when the patient was placed in the protrusion position. The rod length on the cranial side must be as short as possible, with careful consideration of placing the head in the protrusion position after C1LM-2PSFS surgery.

[Pulmonary contusion]

Pulmonary contusion is a common finding after blunt chest trauma. It occurs in 23-35% of all cases. Alveolar capillaries are injured due to the trauma, which results in accumulation of blood and other fluids within lung tissue. The fluids interfere with gas exchange, leading to hypoxemia. The consequences of pulmonary contusion include ventilation/perfusion mismatching, increased AV shunts and loss of compliance of lung parenchyma. These physiological consequences are manifested within hours from injury and usually resolve in 7 days. Computed tomography (CT) is a sensitive and main diagnostic tool. Clinical symptoms include hypoxemia and hypercapnia, manifested predominantly during 72 hours from injury. Patients are treated primarily conservatively; surgery may be needed due to haemothorax associated with lung contusion or progression of AV shunts due to localized pulmonary contusion.Key words: pulmonary contusion blunt chest trauma computed tomography.

Spinal Bone Bruise: Can Computed Tomography (CT) Enable Accurate Diagnosis?

RATIONALE AND OBJECTIVES

The study aimed to evaluate the usefulness of dual-energy computed tomography (DECT) before and after calcium subtraction in the diagnosis of spinal bone bruise.

MATERIALS AND METHODS

Among the patients who visited our emergency department between January 2013 and July 2014 who underwent both spinal DECT and magnetic resonance imaging, 38 patients (men:women = 25:13; mean age: 55.6 years, range: 28-82) were included. The patients were divided into two groups, those with and without acute spinal compression fracture, based on magnetic resonance imaging findings. In the fracture group (n = 22), the ratio of Hounsfield unit (HU) values was calculated between the fracture level and the next normal inferior vertebra in the DECT before and after calcium subtraction. In the non-fracture group (n = 16), the ratios of HU values were calculated between two normal adjacent vertebrae. The mean HU ratios were compared between the two groups.

RESULTS

The mean HU ratio was higher in the fracture group (calcium subtraction: before: 1.57 and 1.59; after: 1.74 and 1.76) than the non-fracture group (before: 1.07 and 1.08; after: 1.07 and 1.07) (P < 0.001). The mean HU ratio between before and after calcium subtraction images was different only in the fracture group (P < 0.05). There was no significant difference in the area under the curve, sensitivity, specificity, positive and negative predictive values, and accuracy (before: 0.846, 87.5%, 81.2%, 87.5%, 81.2%, 85%; after: 0.865, 91.7%, 81.2%, 88%, 86.7%, 87.5% in high energy) between the images before and after calcium subtraction.

CONCLUSION

The HU ratio between the fractured and next normal vertebra was diagnostic for spinal bone bruise on DECT images both before and after calcium subtraction.

Hemiplegia Following Mild Head Injury in a Child with Sturge-Weber Syndrome - A Diagnostic Dilemma

Sturge-Weber syndrome (SWS) is a neurocutaneous disorder with skin, eye, and brain involvement. Hemiplegia in children with SWS after a mild head injury is known to occur in up to one-fifth of cases. A3-year male child presented with a sudden onset hemiplegia following a mild head injury. He was known to have seizure disorder and was being treated with sodium valproate. CTscan of the brain showed contusion. He was admitted for neurological observations and the patient made complete recovery with conservative treatment. MRI scan of the brain done 5 days later which showed venous malformation of choroid plexus on the left side. These changes were considered to be consistent with a preexisting cerebral lesion which coincidentally got detected at neuroimaging done after the mild head injury. There is need for good seizure control as it is likely to be associated with better neurological outcome. The case emphasizes the need for clinical correlation with findings at neuroimaging in children with SWS presenting with head injuries.

Plantar talar head contusions and osteochondral fractures: associated findings on ankle MRI and proposed mechanism of injury

OBJECTIVE

To evaluate the significance of plantar talar head injury (PTHI) in predicting osseous and soft tissue injuries on ankle MRI.

MATERIALS AND METHODS

The IRB approved this HIPAA-compliant retrospective study. The study group consisted of 41 ankle MRIs with PTHI that occurred at our institution over a 5 ½ year period. Eighty MRIs with bone injuries in other locations matched for age, time interval since injury, and gender formed a control group. Injuries to the following structures were recorded: medial malleolus, lateral malleolus/distal fibula, posterior malleolus, talus, calcaneus, navicular, cuboid, lateral, medial and syndesmotic ligaments, spring ligament complex, and extensor digitorum brevis (EDB) muscle. Twenty separate logistic regressions determined which injuries PTHI predicted, using the Holm procedure to control for family-wise alpha at 0.05.

RESULTS

PTHI strongly predicted the occurrence of injuries involving the anterior process of the calcaneus [24 % of cases, odds ratio (OR) 12.66], plantar components of the spring ligament (27 %, OR 9.43), calcaneal origin of the EDB and attachment of the dorsolateral calcaneocuboid ligament (22 %, OR 7.22), cuboid (51 %, OR 6.58), EDB (27 %, OR 5.49), anteromedial talus (66 %, OR 4.78), and posteromedial talus (49 %, OR 4.48). PTHI strongly predicted lack of occurrence of syndesmotic ligament injury (OR 19.6). The PTHI group had a high incidence of lateral ligamentous injury (78 %), but not significantly different from the control group (53 %).

CONCLUSIONS

PTHI is strongly associated with injury involving the transverse tarsal joint complex. We hypothesize it results from talo-cuboid and/or talo-calcaneal impaction from a supination injury of the foot and ankle.

Use of dual-energy CT and virtual non-calcium techniques to evaluate post-traumatic bone bruises in knees in the subacute setting

OBJECTIVE

The purpose of this study was to determine the ability of dual-energy computed tomography (DECT) and virtual non-calcium (VNCa) imaging to detect magnetic resonance imaging (MRI)-demonstrated bone bruises several weeks after unilateral knee injury.

MATERIALS AND METHODS

Patients with unilateral knee injury and MRI-confirmed bone bruises who had undergone a DECT scan of both knees were retrospectively identified. Two radiologists evaluated VNCa images for bruises in four regions per knee without knowing the MRI results. The mean CT numbers were calculated for the lesion-positive and lesion-negative regions of the injured knee, and the contralateral knee.

RESULTS

Fourteen patients with a total of 36 regions positive for bone bruises on MRI were identified. The median delay between injury and DECT was 37 days (range, 11-99 days). The mean CT numbers in VNCa images for lesion-positive and lesion-negative regions were -7.6 ± 24.9 HU and -58.2 ± 19.5 HU, respectively. There were no significant differences in mean CT number between the lesion-negative regions in the injured knee and the contralateral knee. No resolution of bruising was seen before week 5, and bone bruising was still identifiable in one out of the two patients scanned at 10 weeks following injury.

CONCLUSIONS

DECT and VNCa images can identify bone bruising for at least 10 weeks after injury.

Estimated incidence of cardiac contusion using transthoracic echocardiography in patients suffering from severe blunt trauma to the chest

BACKGROUND

Cardiac contusion (CC) is a known complication of blunt trauma to the chest. There have been debates about its true incidence and there are different reports which claim that it occurs in less than 10% to more than 70% of patients. The goal of this study is to estimate the incidence of CC in patients with severe blunt chest trauma (SBCT) using transthoracic echocardiography (TTE).

METHODS

After defining inclusion and exclusion criteria, all cases with clinical evidences of SBCT from February 2010 until October 2011 were included in this study. Patients were assessed using electrocardiography (ECG) and transthoracic echocardiography (TTE). Transient echocardiographic changes, including wall motion abnormalities, valvular or papillary muscle dysfunction, pericardial effusion or tamponade, free wall rupture and interatrial/interventricular septum defects, were considered to be abnormal and trauma-related.

RESULTS

A total of 210 patients were assessed for CC. Fifty-two trauma-related echocardiographic changes in 47 patients were observed, in which 34 cases had simultaneous transient ECG changes. The estimated incidence of CC in these subjects was calculated to be 23.38% and 16.19%, respectively. There was a statistically significant relationship between the presence of both echocardiographic changes and ECG abnormalities, and those subjects without ECG changes (P = 0.03). As we evaluated stable patients without any cardiac-related clinical manifestations and TTE was chosen as our diagnostic modality, we claim that the true incidence must be higher.

CONCLUSIONS

We believe that a comparison of our findings with those presented in the literature shows that the actual incidence of CC in blunt chest trauma is underestimated.

[Contrast-enhanced ultrasonography for detecting testicular perfusion in acute testis contusion in rabbits]

OBJECTIVE

To evaluate contrast-enhanced ultrasonography (CEUS) in detecting testicular perfusion in acute testis contusion.

METHODS

We established the model of testis contusion in 11 healthy male New Zealand rabbits by randomly hitting one side of the scrotum under general anesthesia. We examined the bilateral scrotums of all the animals before, immediately after and at 2, 4 and 6 hours after modeling by color Doppler flow imaging (CDFI) and CEUS, and analyzed the time-intensity curve (TIC), arriving time (AT), time to peak intensity (TTP), peak intensity (PI), half time of descending peak intensity (HT) and area under the curve (AUC) in the healthy and injured testis, respectively.

RESULTS

CEUS exhibited a higher sensitivity in detecting tissue perfusion than CDFI. The mode of contrast agent perfusion in testicular contusion was fast in and slow out. There were no evident differences between the contused and the healthy testis in AT, TTP and PI before modeling. The contused testis showed significantly earlier AT and TTP, higher PI and larger AUC (P < 0.05) than the healthy one at different time points after modeling, but no statistically significant difference was found in HT (P > 0.05).

CONCLUSION

Accurate parameters of testicular perfusion in acute testis contusion can be quantitatively obtained by CEUS, which are of important value for the diagnosis of testis contusion.

Investigation of pulmonary contusion extent and its correlation to crash, occupant, and injury characteristics in motor vehicle crashes

BACKGROUND

Pulmonary contusion (PC) is a leading injury in blunt chest trauma and is most commonly caused by motor vehicle crashes (MVC). To improve understanding of the relationship between insult and outcome, this study relates PC severity to crash, occupant, and injury parameters in MVCs.

METHODS

Twenty-nine subjects with PC were selected from the Crash Injury Research and Engineering Network (CIREN) database, which contains detailed crash and medical information on MVC occupants. Computed tomography scans of these subjects were segmented using a semi-automated protocol to quantify the volumetric percentage of injured tissue in each lung. Techniques were used to quantify the geometry and location of PC, as well as the location of rib fractures. Injury extent including percent PC volume and the number of rib fractures was analyzed and its relation to crash and occupant characteristics was explored.

RESULTS

Frontal and near-side crashes composed 72% of the dataset and the near-side door was the component most often associated with PC causation. The number of rib fractures increased with age and fracture patterns varied with crash type. In near-side crashes, occupant weight and BMI were positively correlated with percent PC volume and the number of rib fractures, and the impact severity was positively correlated with percent PC volume in the lung nearest the impact.

CONCLUSIONS

This study quantified PC morphology in 29 MVC occupants and examined the relationship between injury severity and crash and occupant parameters to better characterize the mechanism of injury. The results of this study may contribute to the prevention, mitigation, and treatment of PC.

Imaging of muscle injury in the elite athlete

Injuries to muscle in the elite athlete are common and may be responsible for prolonged periods of loss of competitive activity. The implications for the athlete and his/her coach and team may be catastrophic if the injury occurs at a critical time in the athlete's diary. Imaging now plays a crucial role in diagnosis, prognostication and management of athletes with muscle injuries. This article discusses the methods available to clinicians and radiologists that are used to assess skeletal muscle injury. The spectrum of muscle injuries sustained in the elite athlete population is both discussed and illustrated.

Masquerading pneumonia--pulmonary contusion

Pneumonia is diagnosed and treated with symptoms of fever, cough, expectoration and chest X ray showing evidence of consolidation. When a pattern of opacification does not fit into segmental or lobar pattern, reevaluation is essential. We report a case of 18 yr old boy with symptoms of respiratory infection, and X ray diagnosis suggestive of infective consolidation which turned out to be a case of pulmonary contusion.

A novel CT volume index score correlates with outcomes in polytrauma patients with pulmonary contusion

BACKGROUND

Exact quantification of pulmonary contusion by computed tomography (CT) may help trauma surgeons identify high-risk populations. We hypothesized that the size of pulmonary contusions, measured accurately, will predict outcomes. Our specific aims were to (1) precisely quantify pulmonary contusion size using pixel analysis, (2) correlate contusion size with outcomes, and (3) determine the threshold contusion size portending complications.

METHODS

Thoracic CTs of 106 consecutive polytrauma patients with pulmonary contusion were evaluated at a university-based urban trauma center. A novel CT volume index (CTVI) score was calculated based on the ratio of affected lung to total lung [slices of lung on CT × affected pixel region/lung pixel region × 0.45 (left side) + slices of lung on CT × affected pixel region/lung pixel region × 0.55 (right side)]. Multivariate analysis correlated CTVI and patient predictors' impact on outcomes.

RESULTS

Of 106 polytrauma patients (mean ISS = 28 ± 1.2, AIS chest = 3.5 ± 0.1), 39 developed complications (acute respiratory distress syndrome [ARDS], pneumonia, and/or death). Mean CTVI was significantly higher in the group with complications (0.28 ± 0.03 versus 17 ± 0.02, P = 0.01). By multivariate analysis, CTVI predicted longer ICU LOS (R(2) = 0.84, P < 0.01). A receiver operating curve (ROC) analysis identified a CTVI threshold score of 0.2 (AUC 0.67, P < 0.01) for developing pneumonia, ARDS or death. Patients with CTVI scores of 0.2 or more had longer hospitalization, longer ICU LOS, more ventilator days, and developed pneumonia (P < 0.01).

CONCLUSIONS

Higher CTVI scores predicted prolonged ICU LOS across all sizes of pulmonary contusion. Pulmonary contusion volumes greater than 20% of total lung volume specifically identifies patients at risk for developing complications.

Ability of a chest X-ray and an abdominal computed tomography scan to identify traumatic thoracic injury

OBJECTIVE

Our objective was to show that a chest X-ray (CXR) and an abdominal computed tomography (CT) scan are sufficient to identify most clinically significant thoracic injuries in trauma patients, rendering the thoracic CT scan useful in only a subset of patients.

METHODS

A retrospective study identified thoracic injuries in 374 trauma patients evaluated with a CXR, a thoracic CT scan, and an abdominal CT scan. Injuries seen on the initial CXR versus those seen on a CT scan only (occult) were identified and assessed for clinical relevance.

RESULTS

An abdominal CT scan identified 65% (15/23) of occult pneumothoraces, 100% (25/25) of occult hemothoraces, 64% (18/28) of occult pulmonary contusions, and 58% (18/31) of occult rib fractures. No occult pneumothoraces seen on the thoracic CT scan alone required tube thoracostomy.

CONCLUSIONS

Our pilot study suggests that a CXR and an abdominal CT scan will identify most occult intrathoracic injuries. Reserving a thoracic CT scan for patients with an abnormal CXR or high-risk mechanism could safely reduce cost and radiation exposure while still diagnosing significant thoracic injuries.

The clinical significance of occult thoracic injury in blunt trauma patients

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed "occult injury". The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: (1) no injury (normal CXR, normal TCT, n=1337); (2) occult injury (normal CXR, abnormal TCT, n=205); and (3) overt injury (abnormal CXR, abnormal TCT, n=227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.

[Herniation of the middle lobe of the right lung due to a coarsely dislocated sternum fracture]

In cases of multiple trauma in patients with an injury severity score (ISS) > or =16 chest injuries, abbreviated injury scale (AIS) > or =3, are also sustained in 57.2% of all patients. Life-threatening complications may occur with lung contusions and rib fractures also in combination with hemothorax/pneumothorax being the most common diagnoses. In addition the lungs can also be functionally impaired by ruptures of the great thoracic vessels or in isolated cases by herniation of lung tissue following tears in the wall of the thorax. A case of multiple trauma in a 44-year-old male (ISS 29) with blunt thoracic trauma resulting in herniation of the middle lobe of the right lung into the subcutaneous tissue due to a coarsely dislocated fracture of the sternum is reported. This still ventilated lung tissue was surgically resituated 4 weeks after the event and the sternum fracture was simultaneously stabilized by plate osteosynthesis. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential. Therefore, standard diagnostic procedures combined with multislice computed tomography during the first examination and reassessment should be included to avoid missed injuries.

[Acute traumatic abdominal wall hernia after blunt abdominal trauma]

Traumatic abdominal wall hernias are rare injuries despite the high incidence of blunt abdominal traumas. The mechanism of this injury includes a sudden increase in intra-abdominal pressure and extensive shear forces applied to the abdominal wall. The typical location is found at anatomic weak areas in the lower abdomen. Often, significant intra-abdominal injuries or injuries of the pelvis and chest are associated. We describe a case of an abdominal contusion trauma leading to a traumatic abdominal wall hernia beside the rectal sheath. In this case, parts of the small bowel penetrated through the ruptured muscle of the abdominal wall up to the subcutis. After appropriate diagnosis, the defect was repaired using a sheet of synthetic mesh to stabilize the abdominal wall. Based on this case, the management of blunt abdominal wall hernias and the literature are discussed.

Radiology corner. Answer to last month's radiology case (#26) and image: Lung laceration with loculated blood, active bleeding, contusion and hemothorax

The following case demonstrates the importance of emergent imaging in victims of gunshot wound to the chest. The AP chest in our case highlights findings that correlate well with support of follow up CT Angiogram of the chest. This case also exemplifies description of complex planes now available with modern CT imaging capabilities described here as para-axial, para-coronal and para-sagittal reconstructions.

Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma

BACKGROUND

Blunt thoracic trauma is a major concern in critically ill patients. Repeated lung diagnostic evaluations are needed in order to follow up the clinical situation and the results of the therapeutic strategies. The aim of this prospective clinical study was to evaluate the possible role of lung ultrasound (LU) compared with bedside radiography (CXR) and computed tomography (CT) used as the gold standard in the evaluation of trauma patients admitted to the intensive care unit with acute respiratory failure.

METHOD

A total of 15 thoracic trauma patients were studied at intensive care unit (ICU) arrival (T1) and 48 h later (T2) with CT, CXR and LU. We evaluated the presence of pleural effusion (PE) and lung contusion (LC). For this purpose the lung parenchyma was divided into 12 regions so that we could compare 180 lung regions at T1 and T2, respectively.

RESULTS

Sensitivity of ultrasound was 0.94 for PE and 0.86 for LC while specificity 0.99 and 0.97, respectively. The likelihood ratio was 94 (rho(+)) and 0.06 (rho(-)) for PE and 28.6 (rho(+)) and 0.14 (rho(-)) for LC.

CONCLUSIONS

Ultrasound provides a reliable noninvasive, bedside method for the assessment of chest trauma patients with acute respiratory failure in the ICU.

Ventilation-perfusion relationships following experimental pulmonary contusion

Ventilation-perfusion changes after right-sided pulmonary contusion (PC) in swine were investigated by means of the multiple inert gas elimination technique (MIGET). Anesthetized swine (injury, n = 8; control, n = 6) sustained a right-chest PC by a captive-bolt apparatus. This was followed by a 12-ml/kg hemorrhage, resuscitation, and reinfusion of shed blood. MIGET and thoracic computed tomography (CT) were performed before and 6 h after injury. Three-dimensional CT scan reconstruction enabled determination of the combined fractional volume of poorly aerated and non-aerated lung tissue (VOL), and the mean gray-scale density (MGSD). Six hours after PC in injured animals, Pa(O(2)) decreased from 234.9 +/- 5.1 to 113.9 +/- 13.0 mmHg. Shunt (Q(S)) increased (2.7 +/- 0.4 to 12.3 +/- 2.2%) at the expense of blood flow to normal ventilation/perfusion compartments (97.1 +/- 0.4 to 87.4 +/- 2.2%). Dead space ventilation (V(D)/V(T)) increased (58.7 +/- 1.7% to 67.2 +/- 1.2%). MGSD increased (-696.7 +/- 6.1 to -565.0 +/- 24.3 Hounsfield units), as did VOL (4.3 +/- 0.5 to 33.5 +/- 3.2%). Multivariate linear regression of MGSD, VOL, V(D)/V(T), and Q(S) vs. Pa(O(2)) retained VOL and Q(S) (r(2) = .835) as independent covariates of Pa(O(2)). An increase in Q(S) characterizes lung failure 6 h after pulmonary contusion; Q(S) and VOL correlate independently with Pa(O(2)).

[Pulmonary pseudocysts. A rare entity after thoracic injury]

Post-traumatic pulmonary pseudocyst is a rare manifestation of blunt thoracic injury. Young adults and adolescents are predominantly affected. Here we report the successful outcome of post-traumatic pseudocysts secondary to severe lung contusion with severe intrathoracic haemorrhage in both lower lobes and the upper right lobe by aggressive coagulation management, kinetic therapy/postural drainage and control of secondary infection.

The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

INTRODUCTION

Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest.

METHODS

A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury.

RESULTS

The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p<0.001), reduced air-entry (OR=4.48, 95% CI=1.33, 15.02, p=0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p=0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae.

CONCLUSION

In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.

[Early postcontusion eyeball circulation as evidenced by color Doppler mapping]

Early postcontusion hemodynamic disorders were studied, by analyzing the results of color Doppler mapping. The study included patients aged 10 to 45 years with moderate and severe postcontusion retinal changes and a visual acuity of 0.8 to 0.01. Color Doppler mapping was used to visualize blood flow in the ophthalmic artery, central retinal artery, and posterior short ciliary arteries. Preliminary studies revealed circulatory changes in the ophthalmic arterial system in the early postcontusion period. In severe macular and optic nerve lesions, a significant reduction in blood flow was detectable in all the vessels under study, but there was its more pronounced reduction in the central retinal artery and posterior short ciliary arteries, which directly corrected with the found retinal changes since these arteries are the only source of retinal circulation.

[Thorax injuries]

Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.

Chest Ultrasonography in Lung Contusion

STUDY OBJECTIVE

Despite the high prevalence of chest trauma and its high morbidity, lung contusion (LC) often remains undiagnosed in the emergency department (ED). The present study investigates the possible clinical applicability of chest ultrasonography for the diagnosis of LC in the ED in comparison to radiography and CT.

MATERIALS AND METHODS

One hundred twenty-one patients admitted to the ED for blunt chest trauma were investigated using ultrasonography by stage III longitudinal scanning of the anterolateral chest wall to detect LC. Data were retrospectively collected in an initial series of 109 patients (group 1) and prospectively in the next 12 patients (group 2). All patients who presented with pneumothorax were excluded. After the ultrasound study, all patients were submitted to chest radiography (CXR) and CT. The sonographic patterns indicative of LC included the following: (1) the alveolointerstitial syndrome (AIS) [defined by increase in B-line artifacts]; and (2) peripheral parenchymal lesion (PPL) [defined by the presence of C-lines: hypoechoic subpleural focal images with or without pleural line gap].

RESULTS

The diagnosis of LC was established by CT scan in 37 patients. If AIS is considered, the sensitivity of ultrasound study was 94.6%, specificity was 96.1%, positive and negative predictive values were 94.6% and 96.1%, respectively, and accuracy was 95.4%. If PPL is alternatively considered, sensitivity and negative predictive values drop to 18.9% and 63.0%, respectively, but both specificity and positive predictive values increased to 100%, with an accuracy of 65.9%. Radiography had sensitivity of 27% and specificity of 100%.

CONCLUSIONS

Chest ultrasonography can accurately detect LC in blunt trauma victims, in comparison to CT scan.