SCHWARTZ HOUR: TRAUMA IMAGING (4) Shift in the midline

August 24, 2021 (5) Brain Contusions

(6) Edema
TESTS • Obliterations of gyri
• Ordered after a good history and PE • “naghahalo na ang solid and liquid”

Screening Diagnostic CERVICAL TRAUMA

Asymptomatic subjects Symptomatic subjects Indications:
Primarily to Rule Out Primarily to confirm an (a) Strong force applied to neck (directly or indirectly)
“negative” patients impression (b) Neurologic deficit
(without the disease or (c) Pain (you can do maneuvers to check if the patient
entity) feels pain upon movement of the neck)
High Specificity High Sensitivity
(reliable when the result is Cervical Collar
Negative) • The purpose is not for immobilization BUT to
announce that he might have problems on the neck
Note: and there’s a need to protect it.
• Do not interpret a diagnostic test that is improperly
done What is the most important CXR view?
• Order the diagnostic test that is most appropriate • Cross-Table Lateral View
and cost-effective o Patient in a supine position
• Follow-up the results of your tests ASAP o Shows that the patient has collar

HEAD TRAUMA
• Most important: Injury to the brain NOT the skull

Indications:
(a) Strong force applied to the head (e.g fall from the 8th
floor)
o Includes penetrating injury
(b) Sensorium (GCS ≤14)
(c) History of LOC
(d) Any neurologic symptom present
o Lateralizing signs

What test is the most appropriate? CT SCAN

If no CT Scan, Skull AP-L but, it is a poor second choice.

Depressed Skull Fracture

• Significant if the upper table exceeds the lower table
• May result to infection

Lamina
• Contains the spinal canal where the spinal cord
passes thru
• Injured → injury to spinal cord → risk of infection
→ Meningitis

Note: Any form of fracture in the vertebral body makes it

UNSTABLE.

What to Interpret?
(a) Check if the procedure is done correctly
• All cervical vertebrae are seen and the
In imaging, what to look? upper border of T1 is seen
(1) Fractures • Normal lordosis (slightly angulated/bent)
(2) Foreign Bodies o If is straight, refer as cervical
(3) Bleeding contusion
• Subdural: Concave (venous bleed) • A normal Xray would show good
• Epidural: Convex (arterial bleed) alignment with normal lordosis.
• Subarachnoid Note: Cervical contusion is a general term indicating that
there is existing cervical problem.
Note:
Epidural bleed is more dangerous because it is an (b) Presence of prevertebral space/ soft tissue at the
arterial bleed. It is usually located at the temporal area anterior portion of C2 with a thickness not >4 mm
where the big cerebral arteries. • If thickened: thickened prevertebral space
(contusion)
Kring 1|2
Other Views Grade Fracture not breaking Chipped fracture that
1. Cervical AP: AP alignment 1 the “ring” does not break the
2. “Open mouth” view: for the condition of the ring
odontoid process of C2
• Fractured during whiplash injury Transverse fracture
(commonly during rear-end car accidents) that does not break
making it unstable the ring
Grade Fracture breaking the Break at symphysis
CHEST TRAUMA 2 “ring” at one point pubic
Chest Xray Grade Fracture of a segment Break at sacroiliac +
• PA upright (most important) 3 at the “ring” pubic symphysis →
o The whole lung fields should be seen breaking the ring into
• Lateral a mobile segment
o If you want a 3D view
o To determine where the foreign body Breaks at Superior
(depth and location) lodged and Inferior pubic
rami + pubic
How to interpret? symphysis
(a) Bones Grade Any fracture Involves the femoral
• Sentinel Bones: where presence of fracture 4 involving the joint
should prompt suspicion of injury to other acetabulum
organs
o Rib 1: pulmonary contusion Notes:
o Scapula: injury to soft structures • Grade 2 fracture is very RARE because pelvic ring is
(pulmonary or myocardial so strong. The usually missed fracture is at the
contusions) sacroiliac
(b) Middle Structures • Grade 3 causes more severe pain and is at risk for
• Diameter of Mediastinum (angle at where bleeding → shock
clavicles meet, should not be more than 4 cms) • For Grade 4, the nutrient of the femoral head comes
o Chest Upright from the acetabular vessels (acetabulum) in the
o If taken supine, widened nutrient foramen, when there is fracture →
• Cardiac Diameter ischemia
o Not more than half of the largest • Always rule out injury to bladder and urethra
diameter of the pleural cavity o Urethrogram
(c) Diaphragm o Cystogram
• Right dome is normally higher than the left
because of the liver (should not be more than 4
vertebral bodies)
(d) Pneumothorax and Hemothorax
(e) Extras: Foreign Bodies

What is the best view for pneumoperitoneum? Chest X-ray

Upright

PELVIC TRAUMA
Indications:
(a) History of strong force directly at the pelvis or
indirectly thru the acetabulum
(b) Pain (do maneuvers to check)

Most appropriate? Pelvic AP Supine

How to Grade?

Kring 2|2