Imaging in major trauma

Dr Paul Middleton
Medical Adviser
Chair, Clinical Advisory Committee
Ambulance Service of NSW
Imaging in major trauma
Dr Paul Middleton
Senior Lecturer in
Emergency Medicine
Prince of Wales Hospital / UNSW
Imaging in major trauma
Dr Paul Middleton
Retrieval Specialist
CareFlight
Primary survey - ATLS

/EMST

A Airway with cervical spine control

B Breathing and ventilation
C Circulation and haemorrhage control
D Disability
E Exposure, environment and
everything else
Radiology comes at E trauma series
Radiology also comes in the Secondary
survey
Imaging in major trauma - perspective
Imaging in major trauma - perspective
Trauma series of X-rays
Chest X ray
Pelvis X ray
Lateral cervical spine X ray
Additional views
AP cervical spine X ray
Open mouth odontoid peg X ray
Oblique views of cervical spine
CT
FAST
Imaging in major trauma - perspective
Trauma series of X-rays
Chest X ray
Pelvis X ray
Lateral cervical spine X ray
Additional views
AP cervical spine X ray
Open mouth odontoid peg X ray

Oblique views of cervical spine

Oblique views of cervical spine
Oblique views of cervical spine

CT
CT
CT

FAST
FAST
FAST
Imaging in major trauma - perspective
Spinal immobilisation is a priority in multiple
trauma, spinal clearance is not.
The spine should be assessed and cleared
when appropriate, given the injury and
physiological state.
Imaging the spine does not take precedence
over life-saving diagnostic and therapeutic
procedures.
Chest X ray
Imaging in major trauma
How do we examine a CXR?
Imaging in major trauma - interpretation
How do we examine an XR?
AABCs
Imaging in major trauma - interpretation
A Adequacy
A - Alignment
B - Bones
C - Cartilage
S Soft tissues
Imaging in major trauma - interpretation
Normal CXR
How do we examine a CXR?
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
How do we examine a CXR?
Some
B*****d
Pinched
My
Toy
Dinosaur
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Soft tissues
B*****d
Pinched
My
Toy
Dinosaur
Imaging in major trauma - interpretation
Soft tissues
Bones
Pinched
My
Toy
Dinosaur
Imaging in major trauma - interpretation
Soft tissues
Bones
Pleura / Parenchyma
My
Toy
Dinosaur
Imaging in major trauma - interpretation
Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Toy
Dinosaur
Imaging in major trauma - interpretation
Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Trachea
Dinosaur
Soft tissues
Bones
Pleura / Parenchyma
Mediastinum
Trachea
Diaphragms
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Normal
CXR
Soft
tissues
Imaging in major trauma - interpretation
Normal CXR
Bones
Imaging in major trauma - interpretation
Normal CXR
Pleura
Imaging in major trauma - interpretation
Normal CXR
Parenchyma
Imaging in major trauma - interpretation
Normal CXR
Mediastinum
Imaging in major trauma - interpretation
Normal CXR
Trachea
Imaging in major trauma - interpretation
Normal CXR
Diaphragms
Imaging in major trauma
Pathology
Imaging in major trauma - pathology
Subcutaneous
emphysema
Imaging in major trauma - pathology
Multiple rib
#s
Imaging in major trauma - pathology
Flail chest
Imaging in major trauma - pathology
Simple
pneumothorax
Imaging in major trauma - pathology
Simple
pneumothorax
- detail
Imaging in major trauma - pathology
Simple
pneumothorax
- detail
L tension
pneumothorax
Imaging in major trauma - pathology
Imaging in major trauma - pathology
Erect
haemothorax
Imaging in major trauma - pathology
Supine
haemothorax
Imaging in major trauma - pathology
Massive
haemothorax
Imaging in major trauma - pathology
Pulmonary
contusion
Imaging in major trauma - pathology
Widened
mediastinum
Imaging in major trauma - pathology
Oesophageal
rupture
Pelvis X ray
Imaging in major trauma
How do we examine a PXR?
Imaging in major trauma - interpretation
How do we examine a PXR?
AABCs
A Adequacy
A - Alignment
B - Bones
C - Cartilage
S Soft tissues
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Normal AP
pelvis
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Normal AP
pelvis
Imaging in major trauma - interpretation
Normal AP
pelvis
Imaging in major trauma - interpretation
Normal AP
pelvis
Imaging in major trauma - interpretation
Normal AP
pelvis
Imaging in major trauma - interpretation
Dont forget!
Imaging in major trauma - interpretation
Dont forget!
Imaging in major trauma - interpretation
Dont forget!
Imaging in major trauma
Pathology
Imaging in major trauma - pathology
Open book
pelvic #
Imaging in major trauma
Open book
pelvic #
Imaging in major trauma
Malgaigne
pelvic #
Imaging in major trauma - pathology
Lateral
compression
pelvic #
Imaging in major trauma - pathology
Lateral
compression
pelvic # -
CTR
Imaging in major trauma - pathology
Lateral
compression
pelvic # -
CTR
Imaging in major trauma
Central
dislocation
of hip
Imaging in major trauma
Vertical
shear #
Imaging in major trauma
Anterior +
posterior hip
dislocations
Imaging in major trauma
Shear# +
central
dislocation
Imaging in major trauma
Sacral #
Imaging in major trauma
Widened SI
joint
Cervical spine X ray
Imaging in major trauma - interpretation
Cervical spine why is it a problem?
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Pathology
Serious head and neck injuries 35mph
2001 Daytona 500 fatal accident - change in
velocity ~ 43 mph
Resultant load in neck (tension + shear
loading) exceeds injury threshold.
Also leads to base of the skull (basilar)
fractures - most common cause of death in
racing drivers (and lots of other drivers!)
Imaging in major trauma
Pathology
Severe flexion, extension, and rotational
forces
Atlanto-occipital disarticulations occur in
high-energy impacts and collisions
Associated with
aortic laceration in 25%
basilar skull fracture in 21%
WHY DOES THIS ALL HAPPEN?
Imaging in major trauma
Anatomy
7 vertebral bodies connect head to torso
C1 (atlas) & C2 (axis) - special shape
Supports the head
Permits head turning
Permits upward and downward tilting
Lower 5 vertebrae similar in appearance &
function
Permit flexion / extension / rotation, lateral
bending
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
Imaging in major trauma
FORCES ACTING ON CERVICAL SPINE
Tension
loading
Imaging in major trauma
FORCES ACTING ON CERVICAL SPINE
Tension
loading
Compressive
loading
Imaging in major trauma
FORCES ACTING ON CERVICAL SPINE
Tension
loading
Compressive
loading
Shear
forces
Imaging in major trauma
FORCES ACTING ON CERVICAL SPINE
Tension
loading
Shear
forces
Torsional
forces
Compressive
loading
Imaging in major trauma
How do we examine a lateral cervical
spine XR?
Imaging in major trauma - interpretation
How do we examine a lateral cervical
spine XR?
AABCs
A Adequacy
A - Alignment
B - Bones
C - Cartilage
S Soft tissues
Imaging in major trauma - interpretation
A - Adequacy
Inadequate
lateral cervical
spine view
Imaging in major trauma - interpretation
A - Adequacy
Adequate
(just!) lateral
cervical spine
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
A - Alignment
Imaging in major trauma - interpretation
B - Bones
B - Bones
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
B - Bones
C - Cartilage
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Additional views
Imaging in major trauma - interpretation
How do we examine an AP cervical spine
XR?
Imaging in major trauma - interpretation
Normal AP
cervical spine
Imaging in major trauma - interpretation
How do we examine an AP cervical spine
XR?
AABCs
A Adequacy
A - Alignment
B - Bones
C - Cartilage
S Soft tissues
Imaging in major trauma - interpretation
Normal AP
cervical spine
Imaging in major trauma - interpretation
A - Adequacy
Adequate AP
cervical spine
Imaging in major trauma - interpretation
A - Alignment
Imaging in major trauma - interpretation
B - Bones
Imaging in major trauma - interpretation
B Bones
Space
Invader Sign
Imaging in major trauma - interpretation
C Cartilage
How do we examine an odontoid peg XR?
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Normal
odontoid peg
view
Imaging in major trauma - interpretation
Imaging in major trauma - interpretation
Normal
odontoid peg
view
How do we examine an odontoid peg XR?
AABCs
A Adequacy
A - Alignment
B - Bones
C - Cartilage
S Soft tissues
Imaging in major trauma - interpretation
Normal AP
cervical spine
Imaging in major trauma - interpretation
A - Adequacy
Adequate peg
view
Imaging in major trauma - interpretation
A - Alignment
Imaging in major trauma - interpretation
B - Bones
Imaging in major trauma - interpretation
C Cartilage
Imaging in major trauma
Pathology
Imaging in major trauma
Imaging in major trauma - pathology
Odontoid peg
#s
Type I
Type II
Type III
Odontoid peg
#
Imaging in major trauma - pathology
Imaging in major trauma - pathology
Odontoid peg
#
Imaging in major trauma - pathology
Occipito -
atlantal
dislocation
Imaging in major trauma - pathology
Jefferson
(burst) #
Jefferson
(burst) #
Imaging in major trauma - pathology
Imaging in major trauma - pathology
Jefferson
(burst) #
Imaging in major trauma - pathology
Atlanto-axial
dislocation
Imaging in major trauma - pathology
C2 pedicle #
Imaging in major trauma - pathology
Hangmans
#
Teardrop #
C4
Imaging in major trauma - pathology
Imaging in major trauma - pathology
C5 crush #
Unilateral
facet joint
dislocation
C5/6
Imaging in major trauma - pathology
Bilateral
facet joint
dislocation
C5/6
Imaging in major trauma - pathology
# dislocation
C5/6
Imaging in major trauma - pathology
Imaging in major trauma
important new imaging techniques
Imaging in major trauma extra stuff
Imaging in major trauma
Any questions?
THE END