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Multidetector CT for Penetrating

Torso Trauma: State of the Art1
REVIEWS AND COMMENTARY 

David Dreizin, MD
The use of computed tomography (CT) for hemodynami-
Felipe Munera, MD
cally stable victims of penetrating torso trauma continues
to increase but remains less singular to the work-up than
in blunt trauma. Research in this area has focused on the
incremental benefits of CT within the context of evolving
diagnostic algorithms and in conjunction with techniques
Online SA-CME such as laparoscopy, endoscopy, and angiographic inter-
See www.rsna.org/education/search/ry vention. This review centers on the current state of multi-
detector CT as a triage tool for penetrating torso trauma
and the primacy of trajectory evaluation in diagnosis,
Learning Objectives: while emphasizing diagnostic challenges that have lingered
After reading the article and taking the test, the reader will despite tremendous technological advances since CT was
be able to:
first used in this setting 3 decades ago. As treatment strat-
n Identify when a recommendation of nonoperative
management may be appropriate based on the egies have also changed considerably over the years in
available evidence regarding the diagnostic parallel with advances in CT, current management impli-
performance of multidetector CT for penetrating torso cations of organ-specific injuries depicted at multidetector
trauma
CT are also discussed.
n Explain why, with improved resuscitation techniques
and adjunct procedures such as angioembolization,
multidetector CT can potentially be used more © RSNA, 2015
liberally for determining the feasibility of nonoperative
management and for preoperative planning
n Describe the role that multidetector CT plays in
diagnostic algorithms for tangential, transmediastinal,
thoracoabdominal, and transpelvic penetrating wounds
Accreditation and Designation Statement
The RSNA is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing
medical education for physicians. The RSNA designates this
journal-based SA-CME activity for a maximum of 1.0 AMA
PRA Category 1 Credit™. Physicians should claim only the
credit commensurate with the extent of their participation in
the activity.
Disclosure Statement
The ACCME requires that the RSNA, as an accredited
provider of CME, obtain signed disclosure statements from
the authors, editors, and reviewers for this activity. For this
journal-based CME activity, author disclosures are listed at
the end of this article.

1
  From the Department of Diagnostic Radiology and
Nuclear Medicine, University of Maryland Medical Center, R
Adams Cowley Shock Trauma Center, 22 S Greene St,
Baltimore, MD 21201 (D.D.); and Department of Diagnostic
Radiology, University of Miami Leonard Miller School of
Medicine, Jackson Memorial Hospital & Ryder Trauma
Center, Miami Fla (F.M.). Received October 20, 2014;
revision requested December 10; revision received March
8, 2015; accepted April 1; final version accepted April 14;
final review June 28. Address correspondence to D.D.
(e-mail: daviddreizin@gmail.com).

q
 RSNA, 2015

338 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015

STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
A
pproximately 80  000 nonfatal
firearm-related injuries and
30  000 firearm-related deaths
occur in the United States each year.
An additional 130 000 nonfirearm as-
sault–related penetrating injuries were
reported in 2012 (1). These numbers
are similar in magnitude to yearly U.S.
traffic fatalities (2) and comparable to
incidence and mortality data for some
of the leading causes of cancer (3).
Computed tomography (CT) continues
to play an increasing role in diagnos-
tic algorithms for hemodynamically
stable, nonperitonitic patients with
penetrating torso trauma and is used
to triage patients for surgery or ex-
pectant management (4). A familiarity
Essentials
nn A substantial number of stable
patients with CT findings of trans-
mediastinal and transpelvic
wounds can be managed without
exploratory surgery; CT has been
shown to result in cost savings
related to simplification of the
diagnostic algorithm for both of
these injuries.
nn Trajectory evaluation provides a
focused time-saving approach to
the search and can add diagnostic
value for a range of organ-specific
injuries including wounds to the
heart, aerodigestive tract, dia-
phragm, small bowel and stom-
ach, pancreas, and rectum.
nn CT has a sensitivity, specificity,
and accuracy of 94%, 95%, and
95%, respectively, for predicting
the need for laparotomy in pene-
trating abdominal injuries.
nn Laparoscopy continues to be used
aggressively for left thoracoab-
dominal penetrating trauma
because of the risk of missed dia-
phragmatic and gastric injury at
CT.
nn Because of potential uncertainty in
the diagnosis of intra- or retroper-
itoneal hollow visceral injuries,
follow-up scans for ambiguous
cases, 4–12 hours after the initial
scan, have been suggested.
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 339
with protocol considerations, organ-
specific diagnostic performance, utility
of trajectory evaluation, and the role
of adjunct semi-invasive diagnostic
techniques is necessary to ensure ap-
propriate utilization of multidetector
CT in the setting of penetrating torso
trauma.
The Evolving Role of Triple-Contrast CT
Prior to the introduction of selective
nonoperative management (SNOM)
in the 1960s for stable nonperitonitic
patients with anterior stab wounds
on the basis of physical examination,
routine laparotomy for penetrating ab-
dominopelvic wounds resulted in non-
therapeutic laparotomy rates as high
as 30%–47% (5–12). Since then, in-
creasingly technology-driven manage-
ment practices have led to significant
decreases in hospitalization time and
costs in nonsurgical cases, while min-
imizing morbidity from missed injury
(9,13–15).
The role of “triple-contrast CT,”
which involves the use of rectal, oral,
and intravenous contrast material, is
still evolving (8), and reliance on CT
varies considerably between trauma
centers. In the mid-1980s, skeptics of
the early adoption of triple-contrast CT
cited the potential for increased mor-
tality from delays in diagnosing bowel
injury, significant costs, and questions
about the accuracy of CT and its effec-
tiveness as a triage tool (16–21). During
the era of first-generation scanners, av-
erage time to final interpretation ranged
from 3 to 6 hours (16,17). Rate-limiting
steps included oral contrast agent ad-
ministration requiring up to 90 minutes
of preparation time and slow data ac-
quisition speeds, with scan times rang-
ing from 30 to 45 minutes (22).
Nevertheless, encouraging data
for CT in patients with blunt trauma
(23–25) led to a first wave of 1–2-year
prospective studies evaluating the clin-
ical utility and diagnostic accuracy of
triple-contrast CT for stab wounds to
the back (22,26,27). The back is pro-
tected by the thick paraspinal muscles,
and stab wounds in this area have a
low likelihood of major organ injury.
The potential benefits of safe and early
discharge, taken with the low rate of
retroperitoneal penetration, made
this a favorable initial population to
study (27–29). On the whole, triple-
contrast CT had excellent sensitivity
ranging from 89% to 100% (27,30) for
excluding surgically important injury,
with resulting nontherapeutic laparot-
omy rates as low as 3% (17,27,31). CT
was also shown to be cost effective, by
facilitating definitive triage and early
discharge (22). In clinical practice,
increased confidence in the technique
quickly resulted in shorter periods of
observation (22,27,32).
The next wave of investigation fo-
cused on the utility of triple-contrast
CT for penetrating wounds to the an-
terior abdomen. The relatively limited
image quality of single-section CT re-
quired reliance on secondary signs
of bowel injury with limited specific-
ity and accuracy (26,27). Because of
this, studies initially focused primarily
on the use of triple-contrast CT for
exclusion of peritoneal violation. Fa-
vorable accuracies for the detection
of peritoneal penetration were docu-
mented prospectively in the late 1980s
and early 1990s (13,20,26,27), leading
to the clinical practice of discharging
patients without further observation in
the absence of CT stigmata of perito-
neal penetration.
The advent of spiral and then mul-
tidetector CT technology in the early
2000s stimulated a reassessment of
triple-contrast CT for both stab and
gunshot wounds to the abdomen
(4,31,33,34), with marked improve-
ments in diagnostic performance
(4,17,31,34). A meta-analysis in 2009
showed pooled estimates of 94%
Published online
10.1148/radiol.2015142282  Content codes:
Radiology 2015; 277:338–355
Abbreviations:
IVC = inferior vena cava
MIP = maximum intensity projection
MPR = multiplanar reconstruction
RPH = retroperitoneal hematoma
SNOM = selective nonoperative management
Conflicts of interest are listed at the end of this article.
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
sensitivity, 95% specificity, and 95%
accuracy for CT in predicting the need
for laparotomy in penetrating abdomi-
nal injuries (5).
Trauma surgeons began to explore
expectant management for right up-
per quadrant transabdominal gunshot
wounds with liver injury as early as
1986 (4,8,35,36), and with the increas-
ing use of adjunct angioembolization,
this has been extended to transabdom-
inal and transpelvic gunshot wounds
(23,33,35,37,38). In general, stan-
dards of care for thoracic penetrating
trauma are more uniform than in the
abdomen (39). Nevertheless, multide-
tector CT and CT angiography have led
to the simplification of complex diag-
nostic algorithms in patients with pre-
cordial, parasternal, and even trans-
mediastinal wounds (40).
Adjunct Diagnostic Techniques
The gas and fluid introduced by diag-
nostic peritoneal lavage can confound
CT findings and result in false-positive
findings when performed prior to
scanning. Diagnostic peritoneal lavage
also has little added value after a neg-
ative CT study (17,41,42). FAST (“fo-
cused assessment with sonography in
trauma”) is a nonspecific tool for infer-
ring surgically important injury by the
presence of abdominopelvic free fluid.
FAST has little added value in hemo-
dynamically stable patients who are
candidates for CT. Its primary utility is
in hemodynamically unstable patients
prior to emergent surgery (7,13). Lo-
cal wound exploration and laparoscopy
remain important elements of diagnos-
tic algorithms in conjunction with mul-
tidetector CT (7,13,31,41,42).
Local Wound Exploration
Local wound exploration is used for
stab wound evaluation, but rarely for
gunshot injury (9,43). Local wound
exploration is limited in patients who
are obese or muscular and is unre-
liable in back and flank injuries, as
well as for long or obliquely oriented
wounds (7). Stab wounds above the
costal margins are not explored be-
cause of the risk of pneumothorax
340 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015
(32,44). When a tangential stab
wound is not obviously superficial, CT
has superior accuracy for excluding
peritoneal penetration (31,34). Sta-
ble patients with wounds determined
to be superficial at local wound ex-
ploration are not routinely scanned
at some trauma centers (13). Such
institution-specific factors can have a
significant impact on the positive pre-
dictive value of multidetector CT.
Laparoscopy
Laparoscopy has the benefit of visual
observation of potentially intermit-
tently bleeding structures over the
entire period of surgery, for visual-
izing bile or enteric content staining
(45), and for removing foreign objects
such as clothing that may not be rec-
ognized at CT (41). Laparoscopy con-
tinues to be used aggressively for left
thoracoabdominal penetrating trauma
(46,47) because of the risk of missed
diaphragmatic and gastric injury;
however, recent data suggest that
laparoscopy can be obviated in se-
lect patients with left-sided penetrat-
ing thoracoabdominal wounds (48).
Drawbacks of laparoscopy include the
time and resources involved and the
need for general anesthesia (49). Ex-
amining the full length of the bowel
is difficult with laparoscopy, requires
specialized training, and can lead to
missed injury (7,50). Diaphragmatic
injuries can be missed, particularly
when right-sided, and insufflation
can potentially exacerbate or cause
tension pneumothorax in this setting
(41). Laparoscopy has limited value
for simultaneously examining extra-
peritoneal pelvic or retroperitoneal
injuries (4,9,38). For these reasons,
laparoscopy is more commonly used
for problem-solving after multidetec-
tor CT than as a stand-alone diagnos-
tic tool. The combined use of CT and
laparoscopy has been shown to result
in substantial cost reductions, by de-
creasing the number of nontherapeu-
tic exploratory laparotomies for iso-
lated omental or solid organ injuries
in hemodynamically stable patients
with penetrating abdominal or thora-
coabdominal wounds (41).
Triple-Contrast Multidetector CT
Protocol
Evolving Indications and
Contraindications
The threshold for what is considered
physiology not compatible with CT
scanning remains subjective and has
been a moving target over the years
as prehospital times and resuscitation
techniques improve (51). Indications
and contraindications for triple contrast
multidetector CT are summarized in
Table 1. Criteria for scanning patients
with penetrating trauma are more
stringent than those for blunt trauma,
with hemodynamic instability or overt
peritonitis traditionally considered ab-
solute contraindications (9). Neverthe-
less, experience with conservative man-
agement of patients initially presenting
with shock has been documented since
the 1980s (6). Occasionally “transient
responders” to volume resuscitation
may be mistaken as hemodynamically
stable. Peritonitis is a subjective clinical
sign, leading to nontherapeutic laparot-
omy in up to 29% of patients (7,22,23).
The presence of pneumoperitoneum
was once thought to require emergent
laparotomy (6); however, this finding
can arise from a number of nonsurgical
causes (Table 1). A number of clinical
findings previously considered absolute
contraindications for CT scanning are
now considered only relative contrain-
dications (Table 1). These include mac-
roscopic hematuria, hematochezia, and
hematemesis.
Oral and Rectal Contrast Agent
Administration
Triple-contrast CT involves adminis-
tering oral, rectal, and intravenous
contrast material (Fig 1). Oral con-
trast agent administration is the rate-
limiting step, and rectal contrast agent
administration should not lead to addi-
tional delays in most circumstances. In
blunt trauma, oral contrast material is
no longer used at initial CT examina-
tion at many institutions to decrease
time to interpretation. In penetrating
trauma, oral contrast agent administra-
tion times have been reduced to 20–30
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera

Table 1
Triple-Contrast Multidetector CT for Penetrating Torso Trauma: Indications and Contraindications
Indications and Contraindications

Uses/Indications in Hemodynamically Stable Patients

  Tangential or superficial wounds: Exclusion of peritoneal or pleural penetration (8,13,20,31)
  Thoracoabdominal wounds/anterior abdominal wounds: For gastric, small bowel, or colonic injury, high-grade solid organ injury, pancreaticobiliary injury, major
    vascular injury, and diaphragmatic injury (4,5,31,33,34,51,119)
  Transpelvic gunshot wounds: For rectal or bladder injury, and intra- versus extraperitoneal involvement; evaluate for major vascular injury; performed for surgical
    planning or to evaluate potential candidates for nonoperative management (37,71,72,107,108)
  Back and flank wounds: For retroperitoneal injury potentially involving colon, kidneys, ureters or major vessels (26,27,32)
  Precordial, parasternal, periclavicular and transmediastinal wounds: For cardiac injuries, closed aortic or great vessel injuries, and aerodigestive tract
   injuries (40,73,74,89)
  Other: For wounds not amenable to local wound exploration (ie, gunshot wounds, obese or muscular patients, back and flank injuries, wounds above costal margin,
   long obliquely oriented wounds) (7,9,32,34,43); For severe distracting pain, neurologic injury, or intoxication, which may confound physical examination; For
patients with neurologic or extremity injuries which require surgical intervention and cannot be closely monitored (35)
Contraindications
  Absolute: Hemodynamic instability not responsive or transiently responsive to fluid resuscitation (sometimes defined as systolic blood pressure , 90 mmHg after
    2 liters of intravenous fluid). CT would delay life-saving care. Emergent laparotomy or thoracotomy is needed (5,9)
  Relative
  Pneumoperitoneum on radiograph: Air may result from perforated hollow viscera but can also be introduced into the abdominal cavity through wound track or from
    pneumothorax migrating through a diaphragmatic defect (6)
  Peritonitis: Subjective sign. May be masked or mimicked by severe pain. Classically from hollow visceral perforation but can sometimes result from solid organ
   injuries (4,7,23)
  Hematuria: May indicate surgical renal injury or ureteral injury. However, many renal injuries that can be managed nonoperatively may still present with hematuria.
    CT is often used for grading penetrating renal injuries (60,97)
  Hematochezia: Usually indicative of hollow visceral injury requiring laparotomy; however, hematochezia may result from extraperitoneal rectal injury, which can
    be treated laparoscopically in select cases. Preoperative CT can often be used to distinguish between extra- and intraperitoneal rectal injury (12,108)
  Hematemesis: If the patient is hemodynamically stable, CT may occasionally be used to determine injuries before surgical intervention (31)

minutes at some centers, particularly if Figure 1

the main purpose is to opacify retroper-
itoneal structures (ie, descending and Figure 1:  Image in an 18-year-old patient with
ascending colon, and 2nd–4th portions multiple gunshot wounds to the abdomen who pre-
of the duodenum) in back and flank sented hemodynamically stable with abdominal
injuries (27). Oral contrast material is pain. Thick-slab maximum intensity projection (MIP)
from triple-contrast multidetector CT shows a large
sometimes obviated to avoid diagnos-
volume contrast agent leak. Multiple small bowel
tic delays, and there is some evidence
enterotomies, gastric perforations, and cecal, trans-
that excellent diagnostic performance
verse, and sigmoid colon injuries were repaired at
can be achieved with intravenous con- exploratory laparotomy.
trast material only (52), although this is
controversial. The possibility of missed
bowel injury must be weighed with the
increased time to diagnosis.

Image Acquisition
For torso wounds involving the chest,
thoracoabdominal region, or multiple
body regions, arterial phase images are
usually acquired from the thoracic inlet
to the greater trochanters to screen for
vascular injuries. If it is highly likely that chest portion of the examination can of oblique trajectories crossing body
a single wound involves only the lower be limited to below the internipple line regions. CT protocols vary from insti-
abdomen or pelvis (approximately one- (31). For gunshot wounds, care should tution to institution in terms of fixed
fourth of patients [4]), scanning of the be taken to consider the possibility scanning delays versus bolus triggering;

Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 341

STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera

Table 2
Example Triple-Contrast 64-Section Multidetector CT Protocol
Protocol

Contrast Agent Administration

  800 mL water-soluble oral contrast agent (Gastroview; Mallinckrodt, Hazelwood, Mo) divided into two 400 mL doses; first dose is administered over the course of
   30 minutes prior to scanning, second dose is given immediately before scan
  1000 mL water-soluble rectal contrast agent (1:25 dilution), administered while the patient is on the CT table
  If injury to the urinary bladder is suspected at triple-contrast CT, dedicated CT cystography can be performed with 300 mL water-soluble contrast agent
  (1:10 dilution)
  100–120 mL intravenous contrast agent (ioversol 350 mg/mL; Mallinckrodt) injected at 4 mL/sec via central venous catheter or 18–20-gauge antecubital vein
  intravenously
Scanning Parameters
  Arterial phase images acquired using a fixed delay of 25–30 seconds from the thoracic inlet to lesser trochanters. Scanning can be performed from nipple line
  down if high likelihood of isolated thoracoabdominal or abdominopelvic injury. A 60–70-second delay is used for portal venous phase images of the upper
abdomen. Five-minute delayed phase images can be acquired after review of arterial and portal venous phase images to distinguish pseuodaneurysm from active
hemorrhage and to identify collecting system injuries or urine leak from renal or lacerations or ureteral transections. Delayed images also offer another later time
point for perforated bowel to result in detectable leak (71)
  Tube current modulation used in all cases with 250 mAs and 120 kVp
  1.5-mm reconstructed images with 50% overlap sent to picture archiving and communication system. 0.6-mm collimated source images available for
   three-dimensional postprocessing and trajectory analysis using thin client software (TeraRecon; Foster City, Calif) at the radiologist’s workstation

Figure 2 Portal venous phase images are usu-

ally acquired through the upper abdo-
men to screen for solid organ injuries
during peak parenchymal enhancement.
Protocols can be tailored for acquisition
of lower-dose delayed phase images on
an as needed basis in the presence of
transabdominal or transpelvic trajec-
tories (53). Patients with tangential or
superficial trajectories can usually be
spared the additional ionizing radiation
(54). A dedicated CT cystogram can be
obtained if bladder injury is suspected
based on presence of hematuria or pel-
vic trajectory (Fig 2).
Newer generation scanners have im-
proved detectors and better image qual-
ity at lower radiation dose and use tube
Figure 2:  Images in 26-year-old patient with pelvic gunshot wound. (a) CT cystogram obtained immedi- current modulation. Faster scan times
ately prior to CT of abdomen and pelvis with rectal and intravenous contrast agent administration. On this result in decreased diaphragmatic mo-
axial image, intraperitoneal contrast agent leak (straight arrows) is seen, emanating from a perforation in the tion artifact and more consistent vascu-
left aspect of the bladder dome (curved arrow). (b) Curved planar reformatted image in same patient shows a lar opacification after a contrast material
curved bullet track through the pelvis (green line; A 5 anterior entry wound, B 5 posterior exit wound) and bolus. The acquisition of near-isotropic
passing immediately contiguous and tangential to the rectum (), and traversing the bladder (arrow). A datasets of the entire torso within
mixed intra- and extraperitoneal anterior rectal perforation was identified at the inferiormost aspect of the the same phase of enhancement has
rectovesical pouch at exploratory laparotomy. The bladder was repaired. Access for repair of the rectal perfo- been possible since the introduction of
ration was extremely difficult due to the narrow male pelvic anatomy, and an end colostomy was created with 64-section scanners in 2004 (55). Near-
a Hartman pouch. Both injuries healed, the colostomy was subsequently taken down, and the colon was isotropic datasets are essential for high-
reanastomosed. quality coronal and sagittal reformats,
which allow rapid evaluation of the
collimation; image overlap; use of iter- phase images. A representative triple- retroperitoneal vascular column along
ative reconstruction; and acquisition contrast multidetector CT protocol is its long axis, viewing the diaphragm
of arterial, portal venous, and delayed shown in Table 2. in profile, or examining injuries to the

342 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015

STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
spinal column. They are also necessary
for diagnostically acceptable trajec-
tory evaluation in nonstandard planes
(48,54,56–58).
Gunshot Wounds versus Stab Wounds
Gunshot wounds of the abdomen cause
internal wounds in over 80%–90% of
patients, and in 75%, more than one
organ is injured (59). Nevertheless, as
many as 42% of gunshot wounds in sta-
ble patients may qualify for SNOM pro-
tocols (60). Far fewer abdominal stab
wounds (anterior abdomen, back, and
flank) require laparotomy, as only 50%–
75% of stab wounds enter the perito-
neal cavity, and of those 50%–75% will
have an injury requiring surgical repair
(7,43). Overall, less than one-third of
knife wounds and approximately one-
half to two-thirds of gunshot wounds
in stable patients will require surgical
repair (34,61).
Solid organ injuries are much more
likely to be low grade from stab wounds
and are also more likely to involve
other solid organs and diaphragm with-
out involving the bowel (11). A substan-
tial proportion of CT studies in stable
patients with gunshot wounds may be
expected to show tangential wounds
(8); however, an increasing number of
trans-torso gunshot wounds are being
scanned for surgical planning or as po-
tential SNOM candidates (35).
Ballistics: Facts and Myths
Permanent Cavity and Concussion Zone
(“Temporary Cavity”)
The permanent cavity refers to the
zone of direct laceration and contusion
composing the wound track, which typ-
ically measures between 0.5 and 2 cm
(62–64). The term temporary cavity re-
fers to the effect of bullets on ballistic
gelatin in experimental studies but is
sometimes used synonymously with the
concussion zone caused by shockwaves
as the bullet passes through tissue.
Damage increases with tissue density
and is inversely related to tissue elastic-
ity (53,54). Dense tissue such as renal
parenchyma, liver, and spleen exhibit
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 343
greater degrees of tissue destruction
and fragmentation (39,54,63,65). Con-
tusion around the bullet path in the
highly elastic lung is the most com-
monly visible demonstration of concus-
sion effects at CT (54).
Shockwave has been described as
traveling up to 6–30 cm away from
the permanent cavity (62), but there
is scant evidence in the literature that
such a clinically significant remote in-
jury may result (64). Histopathologic
examination of the hilar renal arteries
in nephrectomy specimens following
renal gunshot wounds results in only
minor intimal injuries, despite the
proximity (64,65), and parenchymal
injury from wound paths adjacent to
the kidney appears to only be clinically
significant when the path is less than
1 cm from the renal margin (65). In-
stances of ballistic trauma causing sur-
gically important injury to the hollow
viscera without peritoneal penetration
are extremely rare (62,63,66,67). On
the other hand, intraperitoneal bullet
tracks that come within close proxim-
ity of the colon may result in surgically
important injury (Fig 3). Placing too
great an emphasis on the possibility of
remote shockwave-related injury can
lead to avoidable false-positive exami-
nations (64).
High- versus Low-Velocity Rounds
Gunshot trauma has often been classi-
fied based on whether the weapon used
has a high muzzle velocity (military or
hunting weapons; greater than 600 m/
sec) or low to medium muzzle velocity
(handguns; less than 600 m/sec); how-
ever, wounding potential is largely de-
termined by the amount of energy dis-
sipated in the target, which depends to
a great extent on projectile caliber and
design (39). For this reason, wounds
from low-velocity handguns may be
more destructive than those from high-
velocity assault weapons, and gener-
alizations about the effects of weapon
velocity or between “high-powered”
military-grade versus civilian weapons
on wounding potential should be avoid-
ed. The pervasive misunderstanding of
these issues has been referred to as
“the idolatry of velocity” (64,68). The
Figure 3
Figure 3:  Image in 35-year-old patient who sus-
tained a gunshot wound to the left lateral back. He
had minimal tenderness over the left flank and was
hemodynamically stable. The track (blue cross
cursor line; green line 5 perpendicular cross-cursor
line) penetrates the peritoneum, and the off-axial CT
trajectogram suggests that the splenic flexure may
have been perforated; however, there was no rectal
contrast agent leak. At laparotomy, a 3–4-cm seg-
ment of splenic flexure was denuded. Resection of
this segment was performed with reanastomosis.
The injury was attributed in part to shockwave injury,
given the immediate proximity of the intraperitoneal
track at surgery. Had this injury been entirely extra-
peritoneal, colonic injury from blast effect would
have been extremely unlikely.
fully jacketed rounds used in warfare
are small in caliber, light for portability,
and are designed to pass through light
armor without fragmenting, and as
such, transfer less kinetic energy while
passing through the target, despite high
muzzle velocities (64). On the other
hand, soft or hollow point bullets such
as those used in low-velocity handguns
carried by police and air marshals, are
intentionally designed to have greater
stopping power, while decreasing the
likelihood of injury to bystanders or the
hull of an aircraft (39,64). Ammunition
used in handguns is often designed to
widen on impact, which can quadru-
ple the cross-sectional area of the per-
manent cavity, and is more frangible
(39,64), resulting in secondary missiles
that ensure complete transfer of kinetic
energy to the target.
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera

Figure 4 Figure 5

Figure 5:  Image in an 18-year-old man with

knife wound to the left flank, who presented as
hemodynamically stable and underwent CT. Thick-
Figure 4:  Images in a 19-year-old man who sustained a transmediastinal gunshot wound, with entry and section off-axial MIP image best demonstrates the
exit wounds at the right and left shoulder, respectively. (a) Off-axial MIP CT angiogram shows a nonlinear superficial track (white arrow), splenic laceration
path, delineated proximally by the green cross-cursor arrow, with ricochet off of the anterior vertebral body at (black arrow), and a peripancreatic hematoma
this level. The bullet path crosses through the region containing the esophagus. (b) Rotation around a (circle). At exploratory laparotomy, the patient un-
straightened curved planar reformatted image about a green centerline that follows the injury track does not derwent splenorrhaphy and left diaphragmatic
reveal intimal injury, pseudoaneurysm, or dissection involving the aorta (arrow) or great vessels (not shown) injury repair. After careful examination of the pan-
along the track. Major vascular injury was excluded with a high degree of confidence at this examination. As creas and lesser sac, a superficial pancreatic injury
shown in a, trajectory raised the possibility of esophageal injury. Subsequently, the patient developed labile was suspected based on significant staining of the
blood pressure, which stabilized after successful rapid transfusion. This allowed time for direct inspection of peripancreatic hematoma with pancreatic fluid,
the airway with bronchoscopy, which revealed no injury. An esophageal wound was then identified at endos- and a surgical drain was placed.
copy. The esophagus was repaired by means of a right thoracotomy.

most pancreatic injuries are the result Figure 6

Wound Trajectories
Pattern recognition forms the basis of
an efficient CT search strategy in blunt
trauma, where combinations of injuries
cluster based on mechanism, and in-
juries are more common at fixed points
of attachment. In penetrating trauma,
associated injuries are determined
solely by injury trajectories. More com-
monly encountered injuries at CT are
more survivable and are unlikely to
involve critical structures, even when
wound tracks are in close proximity.
For instance, a patient with a trans-
mediastinal gunshot wound able to be
imaged with CT is likely to have an in-
jury that has avoided the heart, central
pulmonary arteries, and aorta (Fig 4).
Another concept that plays a
greater role in assessing blunt trauma
than penetrating trauma is that of “well
protected” organs. For example, the
pancreas is typically injured only in
the most severe deceleration injuries
due to its posterior location. Since tra-
jectories are relatively indiscriminate,
of penetrating trauma (Fig 5). Other
injuries more common in penetrating
than blunt trauma include rectal in-
juries, small diaphragmatic defects, and
injuries to the inferior vena cava (IVC)
(69–71). There are a few instances in
which shielding of organs comes into
play to a limited extent in penetrating
wounds. For example, the thick mus-
cular and fascial structures of the back
and the bony armor of the pelvis can
have a protective effect on the kidneys
and vital pelvic structures, respectively.
The flank is more penetrable but flank Figure 6:  Triple-contrast multidetector CT off-axial
fat provides distance between wound double oblique trajectogram in a 29-year-old man
tracks and hollow viscera (22) (Fig 6). with a right flank gunshot wound. The wound path,
depicted by the green cross-cursor line, crossed the
Wound Path Analysis, or CT retroperitoneal flank fat but was not in proximity to
Trajectography the colon. The patient was discharged uneventfully
after a brief period of observation.
The utility of evaluating injury trajec-
tory at CT has been recognized since
the mid-1980s. Interest in this evalu- simplify sophisticated diagnostic algo-
ation arose from a desire to decrease rithms in mediastinal and pelvic trauma
morbidity related to nontherapeutic (37,40,72–75). Trajectory analysis can
abdominal surgery, to target use of add diagnostic value while providing a
laparoscopy (9,27,28,33,38,61), and to focused time-saving approach to the

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STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
search for injured organs and struc-
tures (76,77).
Wound tracks, particularly those
with oblique orientation, were difficult
to assess before the advent of multide-
tector CT (20) but are much more often
visualized with modern day scanners.
In the surgical literature, the utility of
“CT trajectograms” has mostly been
examined using axial images. Accuracy
has improved with the use of thin sec-
tions and multiplanar reconstructions
(MPRs) (38,56). Additional benefit
can be gained by evaluating trajectory
in nonstandard planes by manipulating
near-isotropic datasets using postpro-
cessing software (48,57,76–79). The
technique, which has been referred
to as trajectory analysis or CT trajec-
tography (or “CTT”) (48,57), involves
placing a cross-cursor on the point
of entry, and swiveling the cut planes
obliquely in orthogonal planes to obtain
a “double oblique” orientation in which
the wound track is visualized in profile.
Independent groups have described its
use in both civilian and wartime pene-
trating torso trauma, and using a Car-
tesian coordinate system, it has been
shown to have excellent interobserver
agreement (56,76–79).
Imaging Findings and Pitfalls
The wound track is depicted by lac-
eration and tissue destruction, foci of
gas, hematoma, bone fragments, and
“lead dust” or small bullet fragments
(22,30,56). A conically shaped “snow-
storm pattern” that widens with in-
creasing distance from the entry site
can result when frangible bullets break
apart into multiple ballistic elements.
Entrance wounds are usually smaller
than exit wounds (56). Bony beveling
is used to describe the phenomenon
wherein fractured bone takes the shape
of a cone or crater at the surface oppo-
site the entry wound. Taken together,
these findings can help determine the
direction of injury (34,56).
Trajectories should not be extrapo-
lated strictly based on surface wounds,
or they will be prone to the same lim-
itations as physical examination (9).
True curvature may result from bullet
yaw (see Fig 2b), and ricochet off of
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 345
bony structures (5) (see Fig 4a). More-
over, false curves or discontinuity can
be seen due to arm elevation and var-
iations in respiratory phases from the
moment of injury to the time of scan-
ning (48,56,57) (Fig 7). The wound
path can extend very close to a poten-
tially injured organ, within the small ra-
dius where shockwave may be a source
of injury, thereby resulting in diagnostic
uncertainty. Streak artifact from bullet
fragments or an impaling object can
obscure adjacent soft tissue structures
(31,56). Bullet fragments may rarely
migrate as a result of vascular embo-
lization or through the gastrointestinal
tract (29,76,80). Retained projectiles
from prior penetrating trauma are an-
other pitfall (9).
Diaphragm motion can limit evalu-
ation of potential transdiaphragmatic
trajectories (9,48,57). Accurate de-
lineation of trajectory in patients with
multiple entry wounds can be difficult
but can add some specificity when sec-
ondary signs are diffuse (14,48,57).
Although knife wounds are com-
monly amenable to SNOM and clini-
cians place a high reliance on CT for
this purpose (35), knife wound tracks
can be very subtle (20,30,48), and a
continuous indurated track may not be
visible. In other words, stab wounds are
less likely to cause surgically important
injury but are harder to see when they
do. This paradox results in both a lower
true-positive rate and higher false-neg-
ative rate for stab wounds compared
with gunshot wounds (5,34). Small
discontinuous foci of gas may be useful
to identify a knife track, and these are
more easily appreciated on thin-section
images. Knife wounds are difficult to
follow through paraspinal muscles, and
migration of soft-tissue emphysema
along the body wall can potentially ob-
scure the superficial portion of a track.
CT Features of Penetrating Injuries by
Body Region
Surface Landmarks
Trauma surgeons have long used sur-
face landmarks to distinguish pene-
trating wounds by body region. This
Figure 7
Figure 7:  Image in a 21-year-old man who had
intraperitoneal free air and free fluid after a stab
wound to the right thoracoabdominal region. The
off-axial CT trajectogram shows a track (green
cross-cursor line) appearing to extend from the point
of entry just medial to the anterior axillary line, to the
superficially lacerated kidney, through the colon.
There was no colonic contrast agent leak. Induration
and discontinuous gas are seen within the body wall
along the wound track (arrows). At laparotomy, the
patient had no hollow visceral injury. The colon may
have become interposed between the body wall and
kidney during arm raising for the scan.
information is used to predict the most
likely organs to be injured. Radiolo-
gists should be familiar with the body
regions and the anatomic landmarks
that delimit them to facilitate commu-
nication. The torso is synonymous with
the trunk and includes the chest, ab-
domen, flank, back, and pelvis (4,31).
The thoracoabdomen and precordium
or “cardiac box” are separately defined
high-risk areas. Demarcations for each
body region are described in Table 3
and shown in Figure 8.
Chest
Injuries to the chest wall, pleura, and
lung.—In the past decade, there has
been a marked increase in utilization of
chest CT to screen patients with pene-
trating chest trauma (40,73); 88%–97%
of penetrating chest injuries involve the
chest wall, pleura, or lung (30), and
pneumo- and hemothoraces make up
the vast majority of injuries (30). Ten-
sion pneumothorax may develop in up
to one-third of patients (30). The phys-
iologic state of an initially stable patient
with a large hemothorax can be ten-
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera

Table 3
Body Regions in Penetrating Trauma
Body Region

Chest
  The chest extends from the clavicles to the sixth intercostal space anteriorly and between the superior and inferior angles of the scapula posteriorly (11)
Thoracoabdominal Region
  The thoracoabdominal region extends from the nipple lines and sixth intercostal space superiorly, anterior axillary lines laterally, and costal margins inferiorly (4)
Precordium: Cardiac Box and Cardiac Diamond
  The “cardiac box” describes a rectangular area bounded by the midclavicular lines laterally, clavicles superiorly, and intersection of the midclavicular lines with the
  costal margins inferiorly; The area denotes precordium at risk for cardiac, aortic, or central pulmonary vessel injuries from stab wounds (120); Gunshot wounds are
more likely to penetrate this area from remote sites, and the concept of the cardiac box is less relevant for these injuries (120)
  The cardiac diamond is a less commonly used surface region bounded by the sternal notch, nipples, and umbilicus (84); This emphasizes that the heart can be
  reached from anywhere in this region depending on angle and highlights potential difficulties determining appropriate surgical sequencing (88); Repair of
abdominal regions should follow repair of the heart
Back and Flanks
  The back includes the area of the body between the tips of the scapulae superiorly, posterior axillary lines laterally and the iliac crests inferiorly (121); The flank is the
   area between anterior and posterior axillary lines from the sixth intercostal space cephalad to the superior iliac crest caudad (44)
Anterior Abdomen
  The anterior abdomen is demarcated by the costal margins superiorly, anterior axillary lines laterally, and anterior superior iliac spines inferiorly (4,32)
Pelvis
The pelvic landmarks include the iliac crests superiorly to the inguinal ligaments anteriorly and the gluteal folds posteriorly (4)

Figure 8 

Figure 8:  Body regions in penetrating trauma: A, posterior view, B, lateral view, C, frontal view, D cardiac box, E, cardiac diamond. See Table 2 for text descriptions.
Anatomic areas are colored as follows: back (orange); flanks (red); pelvis (green); anterior abdomen (purple); thoracoabdomen (yellow); chest (light blue).

uous, as each hemithorax can accom-
modate more than half of a patient’s
total blood volume (81).
Patients will often already have tho-
racostomy tubes placed by the time CT
is performed. Chest tubes may not be
effective for draining hemothorax if not
positioned dependently. Large hemo-
thoraces (over 1 L) may warrant a tho-
racotomy, since there is a greater like-
lihood of an associated major vascular
injury and complications from retained
hemothorax (82). Minor peripheral
lung injury tracks can be oversewn but
stapled pulmonary tractotomy may be
required if there is a large amount of
tissue destruction (83,84). Eighty-five
percent of pulmonary injuries requir-
ing surgery can potentially be man-
aged with this technique (39). Large
hemothoraces may result from active

346 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015

STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
Figure 9
Figure 9:  Off-sagittal double oblique trajectogram
in a 21-year-old man with right precordial stab
wound. Wound track extended toward the right
ventricle (depicted by pink cross-cursor line) and
there was associated hemopericardium (arrows) and
right hemothorax (not shown). There was no CT
evidence of tamponade physiology. The patient
became unstable shortly after CT and underwent
sternotomy and right ventricular repair.
bleeding from the internal thoracic or
intercostal arteries (83). In these pa-
tients, coil embolization may be war-
ranted rather than thoracotomy.
Transmediastinal, precordial, and
periclavicular injuries.—Transmediasti-
nal gunshot wounds are associated with
severe hemodynamic instability related
to thoracic vascular injury in approxi-
mately 50% of patients and have a high
surgical mortality rate (74,75). This
also means that those patients who are
stable enough to undergo CT often have
no major injury, and only 7%–33% of
stable patients with transmediastinal
gunshot wounds will require surgical
intervention (75). In the past, patients
with transmediastinal wounds rou-
tinely underwent extensive multimodal-
ity work-ups including panendoscopy,
esophagram, and echocardiography.
Significant cost-savings can be gained
when CT is used to characterize wound
trajectory (73). Wound trajectory in
proximity to the esophagus or trachea
is the primary indication for perform-
ing endoscopy, bronchoscopy, and
esophagram, and these modalities can
be obviated if the wound trajectory
clearly avoids the aerodigestive tract
(38,75). CT has a sensitivity of nearly
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 347
Figure 10
Figure 10:  Images in a 22-year-old man with precordial stab wound. (a) Off-axial double oblique CT tra-
jectogram shows blue cross-cursor line along right paramediastinal wound path, extending to the right hilum
(arrow). A large right hemothorax is seen (). (b) Thick slab arterial phase MIP image in the same patient
shows hilar contrast agent blush (circle), large hemothorax (), and subjacent compressed lung (). The
patient became hypotensive shortly after the CT scan and underwent clamshell thoracotomy. Central hilar
pulmonary venous injury was identified, necessitating a complete pneumonectomy. The patient was placed
on veno-venous extracorporeal membrane oxygenation (ECMO) due to expected poor pulmonary reserve and
right-sided heart failure and was subsequently successfully weaned from the device and decannulated.
100% and specificity of 97.5% for in- or arteries is initially diagnosed with
juries of the thoracic aerodigestive tract CT on rare occasions, usually from stab
(85,86). Scans are considered inconclu- wounds (30), and may require lobec-
sive if there is mediastinal hematoma, tomy or pneumonectomy depending
pneumomediastinum, and cervical soft- on the centrality of the injury (Fig 10)
tissue emphysema, and may strongly (82–84).
suggest injury if the track crosses or Even though clinically occult pseu-
is proximal to vital structures (73) (Fig doaneurysms represent only a small
4). Pneumomediastinum can result subset of great vessel and subclavian
from airway or esophageal injury but artery injuries, a high index of suspicion
can also result from nonsurgical causes of injuries to these vessels or branches
such as the Macklin effect, which refers should be maintained in periclavicular
to migration of air to the mediastinum wounds (40,90) (Fig 11). Concurrent
along the bronchovascular sheaths after filling of engorged veins suggests ar-
alveolar rupture (87). teriovenous fistula. Small lesions are
The majority of injuries to the great sometimes treated expectantly and
vessels in stable patients will be closed stent placement or angioembolization
injuries (ie, pseudoaneurysm, intimal is also used (39,40,90).
injury, or dissection) (73), which can
be excluded with excellent accuracy by Thoracoabdominal Region
using arterial phase CT (88) (Fig 4). The thoracoabdominal region is the
Occult injuries of the right atrium or site of wound entry in approximately
ventricle can occur, primarily from stab 40% of patients with penetrating torso
wounds within the cardiac box, and are trauma (34). Points of entry are typi-
suggested by injury trajectory and he- cally intercostal or involve the epigas-
mopericardium, which can be small ow- trium (20). Multiple injuries to the tho-
ing to the low pressure within the right racoabdominal region above and below
side of the heart (40,83,89) (Fig 9). the diaphragm can make trajectory dif-
Active bleeding from pulmonary veins ficult to trace. Laparoscopy remains a
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
Figure 11
Figure 11:  Image in a 33-year-old man with left
clavicular/periclavicular gunshot track, with a peri-
clavicular expanding hematoma at clinical exami-
nation. CT angiogram shows irregular beaded
appearance of the superior intercostal artery, a
branch of the costocervical trunk, with abrupt cut-off
(arrow). Embolization of the costocervical trunk was
subsequently performed with polyvinyl alcohol parti-
cles and coils.
useful problem-solving tool in left-sided
thoracoabdominal wounds when dia-
phragmatic or gastric injuries cannot
be excluded with a high degree of con-
fidence at CT.
Penetrating diaphragmatic injuries
are usually small, on the order of 1–2
cm, and are typically asymptomatic at
admission, but rents can propagate,
resulting in subsequent hollow viscus
herniation and strangulation (9,44).
Penetrating diaphragmatic injuries have
been found with an incidence of 7% af-
ter abdominal stab wounds (44,91) and
up to 59% of thoracoabdominal gun-
shot wounds (39). Numerous reports
described limited reliability of single-
section CT for diaphragmatic injuries
(4,17,20,31–33,44), but significant
improvement in diagnosis has been
achieved with multidetector CT, MPRs,
and evaluation of trajectory in nonstan-
dard planes (48,57,92–94). In recent
studies, sensitivities have ranged from
73% to 100%, and overall accuracies
from 70% to 89% (48,57,93).
Herniation-related signs tradition-
ally used in the diagnosis of blunt dia-
phragmatic rupture are highly specific
348 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015
Figure 12
Figure 12:  Axial CT image in a 43-year-old man
with left thoracoabdominal stab wound shows a
chest wall hematoma () and hemopneumothorax
(arrow). A discrete wound track was not apparent.
No diaphragmatic injury was visualized in multiple
planes. There was no evidence of injury below the
diaphragm. Laparoscopy was subsequently per-
formed, and no diaphragmatic, gastric, or colonic
injury was identified.
but notably insensitive in penetrating
trauma. The “contiguous injury” sign,
defined as evidence of injury—either
focal or diffuse—along both sides of the
diaphragm, is sensitive for diaphrag-
matic injury and a useful surrogate
when wound trajectory is not readily
apparent (93). When contiguous in-
jury is negative (ie, signs of injury are
present on only one side of the dia-
phragm), the likelihood of penetrating
diaphragmatic injury is low. Particularly
when signs of injury are limited to the
chest, patients might be spared further
evaluation with laparoscopy (Fig 12).
Anterior Abdomen, Back, and Flank
Peritoneal penetration.—Air bubbles
can be introduced from the penetrating
wound. Therefore, unlike in blunt
trauma, the utility of pneumoperito-
neum as a sign of hollow visceral injury
is poor. Pneumoperitoneum is a surpris-
ingly uncommon finding in peritoneal
violation, seen in only approximately
35% of patients with multidetector CT,
and is specific for intraperitoneal injury
but not for visceral injury when present
(31). The most common CT finding of
Figure 13
Figure 13:  Off-sagittal CT trajectogram in a
25-year-old man who presented with thoracoab-
dominal gunshot wound in stable condition with
reportedly mild abdominal pain. The gunshot track
(pink cross-cursor line) traverses the left hemidia-
phragm, spleen, stomach, and liver. Although there
was no oral contrast agent extravasation from the
stomach at triple-contrast CT, the combination of
marked thickening of the greater curvature of the
stomach (arrow) and transgastric trajectory (arrow-
heads) was specific for gastric injury. The patient
underwent splenectomy and repair of the left dia-
phragm and gastric wall.
intraperitoneal injury is free fluid, seen
in 85% of patients (31). In its absence
the likelihood of peritoneal violation is
very low (31). The accuracy of CT for
diagnosing or excluding peritoneal vio-
lation approaches 98% (31).
Hollow visceral injuries.—Small
bowel and gastric injuries: The organ-
specific diagnostic accuracy of multide-
tector CT for small bowel and gastric
injuries remains limited (4,45,46). A
trajectory extending up to or through
an injured stomach or small bowel has
been identified as a sensitive sign, seen
in 77% of patients with penetrating ab-
dominal wounds, and can be used to
diagnose injury with a relatively high
degree of confidence when present in
conjunction with indirect signs such as
wall thickening (Fig 13), mesenteric
hematoma, or polygonal collections of
interloop fluid (30,31,33,34). In the
absence of a visible trajectory, these
secondary signs lack specificity. Con-
versely, direct signs are highly specific
but rarely encountered. These include
contrast material leak, seen in only
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
Figure 14
Figure 14:  Arterial phase axial CT image in a
51-year-old patient with abdominal gunshot wound
who subsequently underwent exploratory lapa-
rotomy with right colectomy and ileocolic anasto-
mosis. Image shows incomplete passage of rectal
contrast agent, which did not enter the right colon.
A “dirty mass” and “dirty stranding” (circle) are
seen extending from the hepatic flexure, in keeping
with colonic perforation. Subhepatic hemoperito-
neum is also seen (), resulting from a right lobe
liver laceration.
19% of full-thickness injuries, and
transmural defects, which are rarely
appreciated (31,71,95).
Injuries to the colon: Missed in-
juries of the colon may require multi-
staged repair with colostomy rather
than primary repair, which is otherwise
usually possible with early diagnosis.
Retroperitoneal colonic wounds are
very rare in stab wounds, occurring in
less than 1% of these patients (27), and
are more common in gunshot trauma.
CT findings of colonic injuries include
“dirty masses” and “dirty stranding”
corresponding with fecal collections
(96) (Fig 14). Fecal peritonitis may be
localized or diffuse (96); however, cor-
responding peritoneal enhancement is
often not visualized during the early
period after injury. Inadequate colonic
distension with rectal contrast material
or incomplete passage of contrast ma-
terial through the colon can be a limita-
tion. With optimal rectal opacification
and distension, contrast material leak
is definitive and may be focal (Fig 15)
or diffuse (Fig 1). Because of potential
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 349
Figure 15
Figure 15:  CT image in a 49-year-old man with
transabdominal gunshot wound track (green cross-
cursor line). The injury trajectory crosses the colon,
and focal colonic contrast agent extravasation is in
evidence (circle). The patient underwent exploratory
laparotomy. Colonic repair as well as several jejunal
repairs and resections were required for multiple
enterotomies.
uncertainty in the diagnosis of intra- or
retroperitoneal hollow visceral injuries,
follow-up CT scans for ambiguous cases
have been suggested, from 4 to 12 hours
after the initial scan (18,31,34,95).
Solid organ injuries.—Most patients
with penetrating injuries involving solid
organs are unstable or have other indi-
cations for emergent laparotomy (51).
However, improved resuscitation, more
liberal definitions of hemodynamic sta-
bility, and increased use of angioem-
bolization in patients with significant
transfusion requirements have been
a major driving force in the evolution
of SNOM for penetrating solid organ
injuries (60,97). While American As-
sociation for the Surgery of Trauma in-
jury grades are determined surgically,
estimates of injury grade at CT are
important prognostically (51,98), with
increased grades correlating with the
likelihood of SNOM failure.
Hepatic injuries: Gunshot wounds
to the right upper quadrant and liver
are the most common transabdomi-
nal injury with isolated solid organ in-
volvement, and successful nonoperative
management using angioembolization
as an adjunct has been extensively docu-
mented (4,9,28,31,35,99–102) (Fig 16).
Up to half of grade IV injuries to the
liver (25%–75% liver parenchymal in-
Figure 16
Figure 16:  CT tractogram in a 23-year-old man
with right upper quadrant gunshot wound who was
hemodynamically stable and underwent CT on ad-
mission. Image shows perforating (ie, through and
through) transabdominal bullet track (depicted by
blue cross-cursor line) involving the medial upper
pole of the right kidney and the liver. Injury trajectory
was remote from hollow viscera, although a right
hemidiaphragmatic injury was suspected. There was
no evidence of active bleeding from either the kid-
ney or liver at arterial, portal venous, or delayed
phase imaging, and there was no evidence of urine
leak to suggest involvement of the collecting system.
The patient was managed expectantly with angio-
embolization, at which time two hepatic arterial to
portal venous fistulas were identified (not appre-
ciable at CT) and embolized with gelfoam. The bullet
trajectory is in immediate proximity to the retrohe-
patic IVC; however, an injury to this vessel would be
very unlikely with hemodynamic stability.
volvement, or 1–3 Couinaud segments
injured) may be managed expectantly
(51), with greater degrees of paren-
chymal destruction amenable to SNOM
than in injuries to other solid organs.
SNOM for grade III liver injuries (less
than 25% parenchymal destruction)
have an intrinsic complication rate of
less than 1% (99).
Liver injuries may be associated
with right-sided diaphragmatic injuries;
however, these are not uniformly re-
paired (9) because of the shielding
effect of the liver from visceral her-
niation. Uncommonly, biliary-pleural
fistulas may result and can become su-
perinfected. Retrohepatic caval injuries
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
Figure 17
Figure 17:  Arterial phase coronal CT image in a
43-year-old patient with left flank stab wound, re-
sulting in hematuria, shows active hemorrhage
(arrow) and large associated retroperitoneal hema-
toma (). Based on injury trajectory, no colonic
injury, diaphragmatic injury, or peritoneal violation
were suspected. The patient was treated with super-
selective microcoil embolization of the bleeding
renal arterial branch.
and hepatic venous injuries associated
with penetrating liver injuries have a
very high mortality rate (70,99) and are
unlikely to be encountered at CT.
Renal injuries: SNOM may be safe in
as many as 40% of stable patients with
gunshot wounds involving the kidneys
and 50% of stab wounds (8,11,103).
Conservative management is associ-
ated with a renal preservation rate of
75%–100% (60,103). Nephron-sparing
management with angioembolization
of arteriovenous fistulas, pseudoaneu-
rysms, and active bleeding from paren-
chymal branches is guided primarily
by means of CT (60,97) (Fig 17).
High SNOM success rates have been
achieved with grade IV injuries, which
extend to the collecting system or are
associated with closed vascular in-
juries of the main renal artery or vein
(11,103). Nephrectomy is increasingly
reserved for patients with massive vas-
cular injury resulting in large devital-
ized nonenhancing fragments and renal
artery avulsion or thrombosis (grade V
injuries) (11,53,97,104).
350 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015
Figure 18
Figure 18:  Images in a 31-year-old patient with stab wound to the right upper quadrant. (a) An entry wound
and some emphysema were visualized in the musculofascial soft tissues, but no discrete track could be
traced. Nonspecific free fluid is visualized in the vicinity of the gallbladder (curved arrow). The fluid was simple
density, with mean attenuation less than 5 HU, suggesting hollow visceral perforation. On the arterial phase
coronal image, reactive enhancement of the liver can be seen in segment 4b (white arrow) and segment 6
(black arrow). (b) Faint peritoneal enhancement is visualized on this portal venous phase axial image (arrow).
The patient subsequently developed signs of peritonitis and underwent exploratory laparotomy. The gallbladder
appeared ischemic and there was surrounding bile leak at surgery. A cholecystectomy was performed.
By definition, high-grade renal were considered candidates for SNOM
trauma (American Association for the (51); however, overall, 63% of patients
Surgery of Trauma grade IV and V) is with penetrating splenic injuries were
associated with urinary extravasation managed without exploration (51).
(53). Urinomas occur in up to 7% of Splenic active extravasation is seen in
patients with renal penetrating trauma. approximately 43% of patients with
These are often appreciated as subcap- penetrating splenic trauma (31) and is
sular or perinephric low-attenuation associated with a high transfusion re-
collections (53). Intraperitoneal urine quirement. This necessitates a liberal
leaks can also occur with penetrating interpretation of hemodynamic stability
trauma owing to disruption of fascial to proceed with multidetector CT (98).
planes (53). Delayed phase images may Associated hollow visceral and dia-
show subtle or gross urine leak de- phragmatic injuries are common, with
pending on injury severity. Urinomas rates of 38% and 60%, respectively
are generally amenable to conservative (51). A high index of suspicion must be
management with nephrostomy tube or maintained based on injury trajectory.
percutaneous drainage. Trajectories that extend more centrally
Splenic injuries: Recent exploration are more likely to result in hollow vis-
of SNOM in penetrating splenic trauma ceral, pancreatic tail (Fig 5), or major
has been driven in part by the potential vascular injury, precluding SNOM (98).
risk of overwhelming sepsis in asplenic Pancreaticobiliary injuries.—Pan-
patients (51). The majority of patients creatic and biliary injuries may occur
with penetrating splenic trauma un- in stable nonperitonitic patients (32)
dergo emergent laparotomy (51). In and are sometimes encountered at
a recent series, only 25% of patients CT. These are an important source of
with grade III injuries (lacerations morbidity and mortality in penetrating
greater than 3 cm in depth) or grade trauma. Localized collections of bile or
IV injuries (lacerations involving more pancreatic fluid may reside in the lesser
than 25% of the splenic parenchyma) sac or subhepatic space (45) (Fig 18).
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
As with bowel injuries, secondary signs
of pancreatic injury are nonspecific,
and evaluation is especially limited in
patients with little peripancreatic or
retroperitoneal fat (22). Visualization
of pancreatic injuries has improved
with thin-section CT scanning (99).
Peak pancreatic parenchymal enhance-
ment occurs earlier than other solid
organs, and lacerations may be best
appreciated in the late arterial/early
portal venous phase (105).
Pancreatic injuries are much more
likely to result from gunshot than stab
wounds (99), and as such, bullet tra-
jectories leading up to or traversing the
pancreas are the most useful CT find-
ings (26,32). Because of the dire conse-
quences of missed pancreatic injuries,
trajectories in the general proximity of
the pancreas require exploration even
when other major surgical injuries are
absent (22). Penetrating injuries to
the distal pancreas are more likely to
be encountered at CT as they are less
likely to involve the mesenteric vessels
and portal vein (106) (Fig 5).
Pelvis
Because of the proximity of many vi-
tal structures in the pelvis, bone and
secondary ballistic fragments can cause
injuries to multiple organs and vessels
(72). Still, as with stable transmedi-
astinal gunshot wounds, a surprising
number—from 26% to 52% of stable
patients—have no major injury and can
be managed nonoperatively (37,107).
Transpelvic gunshot wounds are of-
ten exclusively extraperitoneal and diffi-
cult to explore surgically (38). Patients
with transpelvic trajectories that do not
involve the rectum, bladder, or pros-
tate can usually be spared exploration
(9,72). The alternative to routine CT
scanning in transpelvic gunshot wounds
is a complex and time-consuming algo-
rithm that includes proctosigmoidosco-
py, conventional cystography, and serial
clinical examinations (107,108). CT can
play a major role in decreasing hospi-
talization time and reducing cost (38).
Rectal injuries.—Rectal injuries re-
sult primarily from gunshot wounds
(71,95,109). Proctosigmoidoscopy is es-
pecially limited in an unprepped bowel,
Radiology: Volume 277: Number 2—November 2015  n  radiology.rsna.org 351
and rectal injuries can be missed in up
to 50% of patients (71,110). The pro-
cedure can also potentially exacerbate
existing injuries (71). Wound trajec-
tory at CT may be at least as accurate
as proctosigmoidoscopy in diagnosing
penetrating rectal trauma (71,111) and
can be used to identify a significant pro-
portion of rectal injuries that would be
missed at surgery (72).
Rectal injuries
are most commonly extraperitoneal,
followed by combined intra- and extra-
peritoneal wounds (109). Trajectories
guide management decisions based on
anatomic distinction (112); because of
the confined space and nearby urogeni-
tal and neurovascular structures, repair
of extraperitoneal injuries is technically
difficult (109) and is usually not per-
formed. Extraperitoneal injuries typ-
ically heal successfully with diverting
sigmoid colostomy alone, which can be
performed as a laparoscopic procedure
(112,113). On the other hand, exclu-
sively intraperitoneal wounds are usu-
ally repaired primarily and commonly
do not necessitate fecal diversion (112).
Several landmarks can be used in
assessing the extra- or intraperitoneal
course of bullet trajectories. The anorec-
tal junction is demarcated by the levator
ani muscles (71) and the rectosigmoid
junction corresponds with the level of
the sacral promontory (71). Between
these two points, the rectum can be di-
vided into thirds (Fig 19). Posteriorly,
the peritoneal reflection occurs at the
top third, while anteriorly at the recto-
uterine or rectovesical pouch, the reflec-
tion occurs at the bottom third (71).
Bladder and ureters.—Ureteral in-
juries can be associated with hematuria
but can also be asymptomatic (108) and
are sometimes missed at surgical explo-
ration (37). Injury trajectories should
be carefully evaluated for ureteral
proximity, and delayed phase images
should be obtained when these injuries
are suspected. Injuries to the bladder
are common in transpelvic gunshot
wounds, occurring in approximately
one-third of patients (37,72,109). Con-
current rectal and bladder injuries may
necessitate omentoplasty to prevent the
development of rectovesical fistulae.
Extraperitoneal bladder injuries, which
Figure 19
Figure 19:  Image in a 32-year-old patient with
left to right transpelvic gunshot wound, resulting in
extraperitoneal rectal perforation. Curved planar
reformatted trajectogram is used to delineate a
curved gunshot track, and the thick MPR function is
used with bone windows to show the contrast
agent–filled rectum together with the sacral prom-
ontory, and terminal bullet fragment in the right
anterior acetabular wall. The rectum is divided into
thirds, from the levator ani to the sacral promontory.
The lower third, involved in this case, is entirely
extraperitoneal, and this was treated with diverting
colostomy. Bone deformity of the anterior inferior
iliac spine on the right is from old injury.
leak into the space of Retzius, will tam-
ponade and are usually self-limiting.
These are often treated nonoperatively
with suprapubic drainage (9), whereas
intraperitoneal injuries require repair
to prevent urinary peritonitis (see Fig
2). The distinction is usually made at
CT cystography, and trajectories play a
more limited role.
Evaluation of Retroperitoneal
Hematomas and Vascular Injuries
Hematomas can be seen in up to 14%
of patients with abdominal penetrat-
ing trauma undergoing CT, and these
are mostly retro- or extraperitoneal
(31,34). Retroperitoneal hematomas
(RPHs) used to mandate surgical ex-
ploration, even in stable patients, but
this has changed with the advent of
CT angiography (104,114). RPHs of-
ten result from small retroperitoneal
branch or tributary hemorrhage; para-
spinal, body wall, diaphragmatic, or
STATE OF THE ART: Multidetector CT for Penetrating Torso Trauma Dreizin and Munera
Figure 20
Figure 20:  CT image in a 20-year-old patient who
sustained a transpelvic gunshot wound (track delin-
eated by blue cross-cursor line). A terminal bullet
fragment is seen in the rectus abdominis muscle.
The right iliac artery (arrow) appears intact but a
large adjacent hematoma is demonstrated (). The
hematoma was not opened, avoiding the potential
for release of tamponade.
musculofascial bleeding; solid organ
laceration; and pelvic or vertebral col-
umn fracture, which do not require sur-
gery (18,27,30,31,115). RPHs may also
result from nonvascular surgically im-
portant injuries to the duodenum and
colon. Major injuries to the mesenteric
arteries and aorta have a high mortal-
ity and as a result are unlikely to be
seen at CT (36,106,116). However, con-
tained pseudoaneurysms or tampon-
aded IVC injuries may be encountered
(108,114). Although vasospasm, inter-
mittent bleeding, and volume depletion
in transient responders can occasion-
ally confound accurate characterization
of RPH (31), arterial phase scanning is
diagnostic for pseudoaneurysms and
active bleeding in the majority of pa-
tients (53). Accurate staging with arte-
rial phase CT can prevent unnecessary
surgical release of tamponade and cat-
astrophic hemorrhage in contained he-
matomas that would be better left un-
disturbed and could be managed with
surveillance or angiographic techniques
(34,104,114,117) (Fig 20).
Future Avenues of Investigation
The incidence of nontherapeutic lap-
arotomy in candidates for SNOM has
352 radiology.rsna.org  n  Radiology: Volume 277: Number 2—November 2015
decreased considerably with the use of
CT (35). Further improvements in diag-
nostic performance of multidetector CT
will likely lead to incremental decreases
of both nontherapeutic laparotomy and
the need for adjunct semi-invasive diag-
nostic procedures. The small numbers
of any given injury type in 1–2-year
prospective studies have posed dif-
ficulties in evaluating organ-specific
performance of multidetector CT for
injuries including diaphragm and hol-
low viscera. Despite the limitations of
blinded retrospective studies, these of-
fer more concentrated populations with
specific injuries and are useful for eval-
uating diagnostic benefits gained from
new-generation scanners, thin-section
images, MPRs, wound path analysis in
nonstandard planes, as well as the rel-
ative value of optimal bowel distension
and opacification with enteric or rectal
contrast material. These can serve as an
important stop-gap until large multicen-
ter prospective studies are carried out.
Hybrid surgical suites with sliding
gantry CT scanners are increasingly
used at major tertiary referral centers
in oncologic and other nonemergent
applications. In the future, this tech-
nology may facilitate scanning in pen-
etrating trauma patients with tenuous
hemodynamic status or obvious perito-
neal signs who would otherwise not be
transferrable to CT (118).
Disclosures of Conflicts of Interest: D.D. dis-
closed no relevant relationships. F.M. disclosed
no relevant relationships.
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