Penetrating Thoracic Injury

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Key points

  • Penetrating thoracic trauma encompasses a wide variety of injuries.

  • The role of imaging in evaluating these patients will be determined by hemodynamic stability, mechanism of injury, and location of injury.

  • Although most injuries will be to the lungs and pleura and may only be evaluated with serial radiographs, multi-detector computed tomography is being used with increasing frequency in hemodynamically stable patients.

  • With an understanding of injury mechanics and trajectory, the radiologist can

Mechanism

Penetrating trauma can be divided into ballistic and nonballistic injuries. The mechanism of injury from nonballistic injuries (ie, stab and puncture wounds) is more intuitive than the mechanism for injury from ballistic trauma. Nonballistic penetrating injuries are caused by tissue disruption and laceration along their trajectory; determining that trajectory on imaging can help identify the injuries it has caused.

Ballistic trauma is a more complex topic; but in the least, a basic understanding

Imaging

Penetrating thoracic trauma encompasses a heterogeneous group of injuries with differing presentations. Most penetrating injuries involve only the chest wall and lung parenchyma14, 15 and may initially be imaged with chest radiography (CXR). Entry and exit wounds should be demarcated by radiopaque markers (a paper clip can be used) to help approximate the injury trajectory and its proximity to the mediastinum. Penetrating nonmediastinal thoracic trauma is historically treated conservatively

Penetrating mediastinal injury

Most patients with thoracic trauma can be treated conservatively; the exception is the subset of patients with penetrating trauma to the mediastinum.17 Transmediastinal penetrating injury is defined as penetrating injury that traverses any part of the mediastinum and by its nature can involve any of the sensitive structures it contains, such as the heart, great vessels, trachea and bronchi, and the esophagus.

These patients have high operative and mortality rates.2, 14, 17, 20, 21, 22, 23, 27

Pulmonary Contusion

Pulmonary contusions are frequently encountered after penetrating chest injuries. Histologically contusions are a result of disruption of the alveolar-capillary membrane and small blood vessels leading to the subsequent filling of the alveoli and interstitium with hemorrhage or fluid.32 Contusions appear as fluffy air-space, nonsegmental opacities that do not respect the pleural boundaries. Typically they occur close to the chest wall in the periphery of the lung demonstrating a 2- to 3-mm area

Pneumothorax

Another common sequela of penetrating trauma is the formation of a pneumothorax. Pneumothoraces can form directly from the penetrating trauma itself or from a leak in the airway. On both CXR and CT, a pneumothorax appears as an air-filled pleural space, devoid of lung markings, surrounding the thin visceral pleura of the lung (Fig. 19). On an erect or semierect CXR, a pneumothorax will most commonly be seen along the apicolateral aspect of the hemithorax.35 They can be overlooked on the initial

Chest wall

The initial CXR may not accurately demonstrate the extent of trauma to the chest wall. The bones of the thorax are frequently injured with penetrating injuries. Rib fractures can injure intercostal vessels, bleed themselves, or tear the chest wall musculature.40 Fractures of the first 3 ribs may be associated with neurovascular and tracheobronchial injuries. Fractures of the lower 3 ribs are associated with diaphragmatic and abdominal organ injuries (particularly liver, spleen, and kidneys).

Diaphragmatic injuries

Diaphragmatic injuries (DI) are often subtle on imaging. The missed diagnosis of a DI can lead to herniation and subsequent strangulation of the herniated viscus even years after the initial injury. In cases of penetrating thoracoabdominal trauma, one must maintain a heightened awareness to the possibility of a DI. Penetrating injuries to the diaphragm usually result in a short defect, 1 to 2 cm in length, and without evisceration.12, 41, 42 One should look closely for small fat-containing

Summary

Penetrating thoracic trauma encompasses a wide variety of injuries. The role of imaging in evaluating these patients will be determined by hemodynamic stability, mechanism of injury, and location of injury. Although most injuries will be to the lungs and pleura and may only be evaluated with serial radiographs, MDCT is being used with increasing frequency in hemodynamically stable patients. With an understanding of injury mechanics and trajectory, the radiologist can play a vital role in

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