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Imaging and Management of Thoracic Trauma

Alex Newbury, Jon D. Dorfman, Hao S. Lo

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DOI: https://doi.org/10.1053/j.sult.2018.03.00610.2214/ajr.176.5.176127310.1097/TA.0b013e31827019
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Imaging and Management of Thoracic Trauma

Alex Newbury, MS; Jon D. Dorfman, MD; Hao S. Lo, MD

Department of Radiology (A.N., H.S.L.), Department of Surgery (J.D.D.) University of

Massachusetts Medical School. UMass Memorial Medical Center. Worcester, MA

Correspondence: Hao S. Lo, MD, Department of Radiology. University of Massachusetts

Medical School, UMass Memorial Medical Center. 55 Lake Ave North Worcester MA 01655.
E-mail: Hao.Lo@umassmemorial.org

Authors Contributions: H.S.L. conceived the study. All authors drafted the manuscript and
contributed to its revision.

Abstract

Thoracic injury results from penetrating and blunt trauma and is a major contributor to overall

trauma morbidity and mortality in the United States. Modern imaging algorithms utilize

ultrasound, CXR, and CT with intravenous contrast to accurately diagnose and effectively treat

patients with acute thoracic trauma. This review focuses on the etiologies, signs and symptoms,

imaging, and management of several life-threatening thoracic injuries including tracheobronchial

rupture, pulmonary parenchymal injury, hemothorax, pneumothorax, diaphragmatic rupture, and

axial skeleton injury.

Keywords: Blunt thoracic trauma, penetrating thoracic trauma, diaphragmatic rupture, chest wall

injury, pneumothorax, pulmonary parenchymal injury, tracheobronchial rupture

Introduction

Thoracic injury is common and contributes to significant trauma-related morbidity and

mortality in the United States, with incidence trailing only head and extremity injuries. It leads to

a fatality rate as high as 10% (1). The thorax includes components of the chest wall and

associated organs, mainly pleura, diaphragm, lungs, esophagus, great vessels, heart,

tracheobronchial tree and axial skeleton. We exclude cardiac and great vessel injury from this

review, as it requires a separate exhaustive discussion.

Falls account for a majority of the blunt trauma seen in U.S. emergency rooms, followed

by motor vehicle collisions (MVC) and assaults (1). Increased age, higher injury severity scores

(ISS), and multiple rib fractures are associated with progressively worse morbidity and mortality

(2). Penetrating trauma is generally caused by stabbings and gunshot wounds, comprising 4-15%

of total trauma center admissions (3). Although penetrating mechanisms are less common than

blunt mechanisms, they result in a higher mortality rate. These injuries vary geographically with

urban centers reporting higher rates of interpersonal violence and higher incidence of severe

penetrating trauma (4). This review describes the common injuries seen in blunt and penetrating

thoracic trauma, with attention to etiology, common signs and symptoms, relevant imaging

findings and patient management.

Imaging Algorithm

At most Level 1 trauma centers, imaging evaluation of thoracic trauma is incorporated

within a comprehensive diagnostic algorithm, comprised of clinical, laboratory and radiologic

components as advocated by the Advanced Trauma Life Support (ATLS) course curriculum. At

our institution, a single, portable, semi-erect anteroposterior view chest radiograph (CXR) serves
as the initial screening exam. Displaced fractures, significant pulmonary or mediastinal

abnormalities and hemopneumothorax can be detected on portable CXR. Point-of-care

evaluation with extended Focused Assessment with Sonography for Trauma (FAST) is used to

assess for pericardial effusion, hemothorax and pneumothorax. Finally, contrast-enhanced

multidetector computed tomography (MDCT) with multiplanar reconstructions serves as the

mainstay imaging modality for diagnosing suspected thoracic injury. Additional three-

dimensional volume-rendered reconstructions are often useful for improved visualization of

chest wall pathology, such as comminuted fractures or spatially complex dislocations. For

reference, our institution employs a 64 multi-detector, 128 channel CT scanner (SOMATOM

Definition Edge; Siemens Healthcare, Erlangen, Germany).

Pulmonary Parenchymal Injury

Lung parenchymal injury is a common sequela of thoracic trauma. Pulmonary contusion

arises from hemorrhage into the local alveolar space (5). It is typically caused by the rapid

deceleration of the lung as it impacts against the fixed, noncompliant chest wall. Pulmonary

laceration (i.e., traumatic pneumatocele) arises from a focal tear of parenchyma. Penetrating

injuries involving bullet fragments or other high velocity debris can also cause physical

destruction of parenchymal tissue, resulting in contusions or lacerations. Parenchymal injury can

cause a wide spectrum of clinical presentations, including wheezing/coughing, tachypnea,

hypoxemia and hemoptysis. While up to 50% of cases present without symptoms, pulmonary

contusions typically worsen over 24-48 hours and may become symptomatic and clinically

significant (6, 7).

 On CXR, pulmonary contusions appear as patchy, ill-defined airspace opacities or

homogenous consolidation, not restricted by lobar boundaries (8). Lacerations appear as oval or

round, thin walled air-filled or circumscribed soft tissue density opacities. CXR has poor

sensitivity, as about one-third of contusions are not apparent on the initial CXR. MDCT is

superior to CXR and can differentiate contusion, hematoma and laceration. On CT images,

contusions typically appear as airspace ground glass opacity in a nonsegmental distribution,

either at the direct site of impact or on the contralateral side via a coup-countercoup mechanism

(9) (Figure 1). Lacerations appear as one or more oval or loculated air collections. Intralesional

air-fluid level or soft tissue density reflects the presence of blood products (i.e.,

hemopneumatocele) (Figure 2). A classification system for pulmonary lacerations has been

promoted, based on etiology and imaging features (Table 1). There has been debate regarding the

effect of these findings on clinical management decisions (10, 11). It has been noted that

contusions apparent on CT, but not CXR, are typically associated with better patient outcomes

(12).

Pulmonary parenchymal injury evolves over time and typically worsens in the first 48

hours. Supportive care with supplemental oxygen, and even intubation, may be required. If

intubation is necessary, acute respiratory distress syndrome protocols should be followed

including increased positive end expiratory pressure and low tidal volume ventilation. Prone

positioning, chemical paralysis and sometimes inhaled nitric oxide can be considered. Judicious

volume resuscitation and minimization of intravenous fluids is also practiced.

Pneumothorax, Hemothorax

Pneumothorax is a common result of thoracic trauma. In blunt etiologies, it is believed

that rib fractures puncture the lung parenchyma and allow air to fill the pleural potential space.

They are classified as either “open” or “closed” based on the presence or absence of a

communication to the external environment (13). Open chest wall injuries are infrequent. The

critical diagnosis of tension pneumothorax arises when intrapleural pressure is greater than

atmospheric pressure via a one-way valve mechanism, leading to shifting of the mediastinum

away from the pneumothorax and hypotension. Clinical symptoms include hypotension, air

hunger, respiratory distress, tracheal deviation and jugular venous distention (14). Hemothorax

reflects blood filling the pleural space. Patients typically present with sudden onset, sharp,

unilateral chest pain, and dyspnea from associated rib fractures. They can have diminished or

absent breath sounds and/or hyperressonance to percussion on the affected side, although these

signs are difficult to detect in a noisy trauma bay. Massive hemothorax refers to greater than one

liter of pleural blood, in the clinical setting of shock and/or hypoperfusion (6).

Initial supine CXR typically shows a displaced lateral border of lung separated from the

chest wall, with associated absence of normal bronchovasculature. The pleural space appears

radiolucent compared to the adjacent lung parenchyma (15). Supine radiographs may show the

“double diaphragm” sign, described as air outlining the anterior portions of the affected

hemidiaphragm and the anterior costophrenic sulcus (16). Also described is an abnormal deep

and asymmetric costophrenic angle on the affected side, the so-called “deep sulcus” sign (17).

On CT images, abnormal air density with the pleural space defines a simple pneumothorax.

Tension pneumothorax is suggested by contralateral mediastinal shift, flattened inverted

ipsilateral hemidiaphragm and hyperexpanded ipsilateral hemithorax (Figure 3). In current

practice, the initial diagnosis of pneumothorax or hemothorax oftentimes occurs on FAST, which

has demonstrated better sensitivity than supine CXR. Supine CXR is to unable to detect the

common gravity antidependent anterior pneumothorax (18).

Due to the increased utilization of MDCT, occult pneumothorax (i.e., not detected by

CXR) is an increasingly common finding (19). It is more common in patients on positive

pressure ventilation, clinically significant in only 5-10 percent of cases (20). Currently,

asymptomatic occult pneumothoraces in blunt trauma patients are managed with observation

alone. Chest tube placement is reserved for patients who develop symptoms or significantly

increased lesion size (21).

In the case of a hemothorax, CXR is often inadequate. A volume of approximately

300mL of blood is needed for a positive finding on CXR. Furthermore, hemothorax appears

radiologically similar to a simple pleural effusion. On CT images, pleural fluid density of 35-70

Hounsfield units indicates the presence of blood products (22). FAST has also shown to be

highly sensitive and specific for detecting hemothorax (23).

Tracheobronchial Injury

Tracheobronchial injury (TBI) is rare, seen in less than 1% of total blunt thoracic trauma

cases (24). Classically, it is the result of high-energy impact, such as high-speed motor vehicle

collision or fall from a significant height. Clinical presentation depends on the segment of airway

affected and the extent of the injury. Dyspnea and respiratory distress are the most common

presentations, with cough, stridor, diminished breath sounds on exam (25,26). Significant

hemoptysis can be seen if there is concomitant pulmonary vasculature injury communicating

with the airway. Bronchial tree injury is more common than tracheal injury. It can result from

parenchymal lacerations extending to the adjacent bronchial cartilage (9). TBI can introduce air

into the surrounding soft tissue spaces of the chest, abdomen, and neck in upwards of 85% of

patients, resulting in subcutaneous emphysema (27). Persistent pneumothorax despite chest tube

placement or large continuous air leak from the chest tube water seal chamber should raise the

suspicion of this injury (28).

CXR can reveal subcutaneous emphysema as radiolucent striations outlining muscle

fibers and abnormal elevations of fascial planes. On CT images, there may be a focal

discontinuity of the tracheal or bronchial wall. Associated imaging findings include

subcutaneous emphysema pneumothorax, pneumomediastinum, and interstitial air within the

wall of the trachea or bronchi (Figure 4). If damage to the trachea occurs, the hyoid bone

elevates above C3, as the larynx rises. A completely torn bronchus collapses toward the chest

wall, away from the mediastinum. This “fallen lung” sign can be seen on both CT and CXR and

is considered a specific finding for TBI. The lung moves toward the posterior chest wall and

diaphragm in a supine patient (29). While CT can identify upwards of 90% of TBI, confirmatory

diagnosis is usually achieved in the operating room and/or via bronchoscopy (25, 26).

Diaphragm Injury

Diaphragmatic injury results from tear or rupture of the diaphragm musculature.

Penetrating causes, such as gunshot wounds and stabbings account for about 65% of all

diaphragmatic injuries (30, 31). Diaphragmatic rupture secondary to blunt trauma accounts for

33% of all cases and is usually due to motor vehicle accidents (31). The mechanism involves

transferring forces from a high-energy impact to the fixed diaphragm, via sudden increase in the

intraabdominal and/or intrathoracic pressure. The resulting tear most commonly affects the
posterolateral surface, near the site of embryonic fusion (9). Due to the protective effect of the

liver, left hemidiaphragmic rupture is twice as prevalent as right (30, 31, 32). Left diaphragm

injury leads to herniation and potential strangulation of abdominal contents, such as bowel,

omentum, spleen, and stomach (33). Penetrating injuries tend to be more focal, and more

difficult to detect, than blunt injuries. Herniation of abdominal contents may not occur initially.

Sometimes symptoms present years later, as the focal tear gradually enlarges (34, 35).

Nonemergent diagnostic laparoscopy may be warranted to exclude small focal diaphragmatic

injuries.

Affected patients may present with respiratory distress, diminished breath sounds and/or

intrathoracic bowel sounds on exam (36). Other symptoms include nausea, vomiting, or referred

shoulder pain from phrenic nerve irritation. Shock occurs if intrathoracic pressures overcome the

ability for the heart to maintain stable cardiac output.

Radiographic and CT images can demonstrate intrathoracic hollow viscera herniation,

loss of diaphragmatic contour, elevation of the affected hemidiaphragm, or visualization of a

nasogastric tube above the normal diaphragmatic boundary (9). Specific CXR findings are absent

in up to of 50% of cases (37). CT scan in hemodynamically stable patients has a sensitivity of

70-100% and specificity of 75-100% for diagnosing blunt diaphragmatic rupture, especially for

left sided injuries (30, 32, 38). CT is more useful in the assessment of the posterior lumbar

elements of the diaphragm such as the crura and the arcuate ligaments. Segmental loss of the

normal diaphragm contour, known as the “discontinuous diaphragm” sign, is the most common

finding, seen in about 96% of cases. Diaphragmatic thickening near the site of rupture is seen in

approximately 70% of cases (39). Additional CT signs include the “dependent viscera” and the

“collar” sign. The dependent viscera sign appearance is created by herniated abdominal organs
lying dependently along the posterior chest wall. The collar sign is the result of an hourglass

shaped constriction of abdominal contents at the site of rupture, seen best with sagittal and

coronal reconstructed images (40) (Figure 5). Lastly, blood on both sides of the diaphragm is

strong secondary evidence supporting the diagnosis of rupture.

Chest Wall Injury

Clinically relevant chest wall injuries include fractures of the ribs, sternum, clavicle and

scapula, as well as sternoclavicular dislocation, scapulothoracic dissociation and chest wall

rupture. Rib fracture is the most common skeletal injury in blunt chest trauma, seen in 50% of

cases (9). Since ribs 1 and 2 are protected by the clavicles, scapulae, and local musculature, their

injury implies high-energy trauma. This injury pattern has been associated with injury to the

aorta, tracheobronchial tree, brachial plexus, and subclavian vasculature (9). Ribs 4-8 are most

important for respiratory cycle function. Fracture of ribs 9-12 are associated with trauma to the

upper abdominal organs (41). Multiple and/or bilateral rib fractures are associated with severe

intrathoracic or abdominal injuries, resulting in higher morbidity and mortality (42). Patients

will typically present with tachypnea, dyspnea, and chest wall pain, classically worse with

inspiration.

CXR has poor sensitivity and may fail to detect fractures in up to of 75% of cases (43).

CT routinely detects twice as many rib fractures per patient (41). CT provides more accurate

visualization of fracture location, while concurrently identifying associated injuries to the thorax

or abdomen (9). Three-dimensional reconstructions are helpful for characterizing severely

displaced fractures and guiding best operative approach (44). The clinical diagnosis of flail chest

can be suggested on imaging when three or more contiguous ribs are fractured in two or more

sites. Flail chest is confirmed by paradoxical movement of the affected segment during the
respiratory cycle (45, 46) (Figure 6). A review of the National Trauma Data Bank suggests flail

chest is present in 1% of all admissions at Level 1 and Level 2 trauma centers (47). The

dangerous sequela of this condition is loss of normal pulmonary mechanics, leading to increasing

atelectasis and eventual respiratory failure.

The indications for surgical rib fixation remain unclear. For intubated, ventilator

dependent patients, there is debate about the cause of the respiratory failure – chest wall injury or

underlying pulmonary contusions (48). In select patient populations, rib fixation has been shown

to reduce ventilator days (49). Whether internal rib fixation improves pain control is even less

certain (50). Additional studies are required to further delineate who will benefit from this

procedure.

Clavicle fractures are typically managed nonoperatively, with a sling and pain control.

Operative repair is reserved for open fracture or tenting of the overlaying skin, increasing risk for

necrosis. Surgical intervention may also be indicated if the clavicle fragments significantly

overlap (14).

Sternal fractures are the result of direct impact to the anterior chest wall or sudden

deceleration, such as in MVC (51). They classically involve both the sternal body and the

manubrium. Sternomanubrial joint disruption is associated with thoracic, cardiac, and spinal

injuries (52, 53). Complicated sternal injury can lead to life-threatening hemopericardium, blunt

cardiac injury, and aortic disruption (54). While typically nonspecific, clinical presentation

includes swelling, bruising, tenderness to palpation, and crepitus. Anteroposterior CXR provides

50% sensitivity for detecting a sternal fracture, while lateral views can be slightly more sensitive

(55). MDCT with coronal and sagittal reconstruction is the diagnostic gold standard. Respiratory

motion artifact can notoriously mimic a nondisplaced fracture. Also, a fracture line is difficult to
detect on axial images only. The presence of an anterior mediastinal hematoma can suggest the

diagnosis (9).

Sternoclavicular joint dislocations are uncommon (55). The more typical and less serious

anterior variety classically results from direct impact to the anterior shoulder or fall onto the

acromion with an adducted arm (56). Posterior dislocation is the result of direct posterior impact

to the medial clavicle. It is more perilous because of potential injury to the esophagus, trachea,

and lungs. Posterior dislocation is significantly more difficult to reduce (57). Physical

examination reveals a shortened affected shoulder, tenderness, edema, and pain with limited

range of motion. Stridor, dysphagia, and paresthesia indicate sequelae of posterior dislocation

and warrant prompt imaging confirmation. Patients suffering either type of dislocation should

undergo neurovascular testing to ensure the integrity of the brachial plexus and upper extremity

vessels (56).

Although CXR can show joint space widening, it is less helpful for diagnosing SC joint

dislocation due to prominent overlying shadows of the ribs, vertebrae, and medial clavicle (57).

CT with intravenous contrast is the ideal modality for visualization of articular surface

dislocation and associated organ injury or vascular complication (i.e., thrombosis, occlusion,

dissection) (9).

On CT images, chest wall rupture is defined by a focal musculoskeletal defect, invariably

associated with rib/sternal fractures, subcutaneous contusion/emphysema, hemopneumothorax

and pulmonary parenchymal injury (58, 59) (Figure 7). Pulmonary herniation is a rare, but

associated, condition that is defined by pleura-covered lung extrusion through the chest wall

defect. Surgical repair is typically required repair the chest wall defect, especially since positive

pressure ventilation may induce or worsen any herniation (58, 59).

 Conclusion

Thoracic injury is an important and relatively common condition in cases of penetrating

and blunt trauma. Numerous potentially life-threatening injuries are reviewed here, including

pulmonary parenchymal injury, hemopneumothorax, diaphragmatic rupture, and

tracheobronchial tear/rupture. Clinical presentation typically involves pain, respiratory

symptoms, focal deformity or systemic sequela. While the physical exam and history provide

helpful information, point of care ultrasound, CXR and CT with contrast (with multiplanar/3D

reconstruction) comprise the modern imaging algorithm for the acutely traumatized patient.

Effective patient management demands accurate initial identification and appropriate follow-up

of significant imaging diagnoses.

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Table 1. Classification of Pulmonary Laceration
Classification Type I Type II Type III Type IV
Mechanism Compression-rupture Compression shear Direct rib Adhesion shear
lacerations penetration
laceration
Area Central lung Posterior lung, near spine Near chest wall Subpleural
Features - Most common - Shear injury of posterior - Fractured rib - Pre-existing
- Air-filled lung lung against spine penetrates pleuropulmonary
suddenly compressed - Sudden compression of pleural wall lesions/adhesions
- Can be large (2-8 lower chest - Multiple sites sheared by chest
cm) - Pneumothorax wall fracture or
collapse inwards
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Parenchymal Lung Injury in Blunt Chest Trauma. Diagnostic and Therapeutic Implications.” The Journal of Computed
Tomography 12, no. 4 (October 1988): 270–81.
Figure 1. Bilateral pulmonary contusions. (A) Axial CT image showing right lower lobe
multifocal, predominantly peripheral, ground glass airspace opacities (black arrows), consistent
with pulmonary contusions. (B) Coronal CT image demonstrating the bilateral nature of the
multiple contusions (black arrows). Note the non-anatomic distribution of the finding, typical of
pulmonary contusion.

Figure 2. Pulmonary laceration. (A) Axial CT image showing a right lower lobe subpleural,
round laceration (thick black arrow). There is an associated small anterior pneumothorax (white
arrow). The left lower lobe contains a similar, but smaller subpleural laceration (thin black
arrow). (B) Sagittal CT image showing the ellipsoid shape of the right lower lobe subpleural
laceration (white arrow). Adjacent ground glass opacity represents associated pulmonary
contusion (black arrow).

Figure 3. Tension pneumothorax. Semi-erect anteroposterior chest radiograph demonstrating a

thin right-sided pleural line (long white arrows), compatible with a moderate sized
pneumothorax. Radiographic signs of tension pneumothorax include flattening of the ipsilateral
hemidiaphram (thick black arrow), leftward shift of the right heart border (short white arrows),
and leftward shift of the anterior pleural border (thin black arrow). Note the overall hyperlucency
of the right hemithorax.

Figure 4. Tracheal rupture. (A) Axial CT image of the lower neck in bone window demonstrating
the presence of an endotracheal tube located outside and posterior to the trachea (long white
arrow). Directly adjacent location of the orogastric tube (short white arrow) is compatible with
intraesophageal location of both tubes. The presence of extensive subcutaneous emphysema
(black arrow) is consistent with underlying tracheal rupture. (B) Axial CT image at the level of
the aortic arch shows expected intratracheal location of the endotracheal tube (white arrow) and
intraesophageal location of the orogastric tube (black arrow). Note the small amount of soft
tissue air tracking along the right tracheal wall (white arrowhead).

Figure 5. Diaphragmatic rupture. (A) Coronal contrast-enhanced CT image in an acutely

traumatized patient showing the intrathoracic stomach (thick arrow), adjacent hematoma (thin
arrow) and herniated intraperitoneal fat (arrowhead). (B) Axial CT image demonstrating the
intrathoracic stomach abutting the left posterior thoracic wall without perceivable intervening
hemidiaphragm musculature (black arrow), known as the “dependent viscera sign.” Additionally,
there is focal waist-like constriction of the herniated stomach indicating the “collar” sign (white
arrows).
Figure 6. Flail chest. (A) Posterior view 3D reconstructed CT image showing multiple
contiguous right-sided segmental rib fractures (white arrows), suggesting unilateral flail chest.
(B) Oblique view 3D reconstructed CT images demonstrating the lateral fractures to better effect.
There was associated paradoxical respiratory motion on physical exam, confirming the clinical
diagnosis of flail chest.

Figure 7. Chest wall rupture. (A) Axial CT image showing a focal defect in the left anterior chest
wall (thick white arrows) with extension of the moderate pneumothorax (thin white arrow) into
the subcutaneous tissues. Note the associated contusion or atelectasis in the dependent left lower
lobe (black arrow). (B) Coronal reconstructed CT image showing the focal left anterior chest
wall defect (thick white arrow), herniated moderate pneumothorax (thin white arrow) and
extensive pneumothorax (black arrow).