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Imaging Manifestations of Chest
Trauma
Brittany T. Lewis, MD
Keith D. Herr, MD
Scott A. Hamlin, MD
Travis Henry, MD
Brent P. Little, MD
David M. Naeger, MD
Tarek N. Hanna, MD
Abbreviations: AAST = American Association
for the Surgery of Trauma, AP = anteroposterior,
ARDS = acute respiratory distress syndrome,
FAST = focused assessment in sonography for
trauma, MVC = motor vehicle collision, OIS =
Organ Injury Scale
RadioGraphics 2021; 41:1321–1334
https://doi.org/10.1148/rg.2021210042
Content Codes:
From the Department of Radiology and Imag-
ing Sciences, Emory University, 550 Peachtree
Rd, Atlanta GA 30308 (B.T.L., K.D.H., S.A.H.,
T.N.H.); Department of Radiology and Bio-
medical Imaging, University of California San
Francisco, San Francisco, Calif (T.H.); Depart-
ment of Radiology, Harvard Medical School,
Boston, Mass (B.P.L.); Department of Radiology,
Denver Health and Hospital Authority, Denver,
Colo (D.M.N.); and Department of Radiology,
University of Colorado, Denver, Colo (D.M.N.).
Received February 28, 2021; revision requested
April 5 and received April 9; accepted April 13.
For this journal-based SA-CME activity, the
authors, editor, and reviewers have disclosed no
relevant relationships. Address correspondence
to T.N.H. (e-mail: tarek.hanna@emory.edu).
©
RSNA, 2021
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
Discuss common mechanisms and bio-
„ estimated overall at 10% (1,3–5). However, in more severe cases, such
mechanics of pulmonary trauma.
Identify and describe common imaging
„
features of pulmonary parenchymal and
pleural injuries.
Recognize important imaging findings
„
of complications associated with pulmo-
nary trauma.
See rsna.org/learning-center-rg.
1321
CHEST IMAGING
Trauma is the leading cause of death among individuals under 40
years of age, and pulmonary trauma is common in high-impact
injuries. Unlike most other organs, the lung is elastic and disten-
sible, with a physiologic capacity to withstand significant changes in
contour and volume. The most common types of lung parenchymal
injury are contusions, lacerations, and hematomas, each having
characteristic imaging appearances. A less common type of lung
injury is herniation. Chest radiography is often the first-line imag-
ing modality performed in the assessment of the acutely injured pa-
tient, although there are inherent limitations in the use of this mo-
dality in trauma. CT images are more accurate for the assessment
of the nature and extent of pulmonary injury than the single-view
anteroposterior chest radiograph that is typically obtained in the
trauma bay. However, the primary limitations of CT concern the
need to transport the patient to the CT scanner and a longer pro-
cessing time. The American Association for the Surgery of Trauma
has established the most widely used grading scale to describe lung
injury, which serves to communicate severity, guide management,
and provide useful prognostic factors in a systematic fashion. The
authors provide an in-depth exploration of the most common types
of pulmonary parenchymal, pleural, and airway injuries. Injury
grading, patient management, and potential complications of pul-
monary injury are also discussed.
©
RSNA, 2021 • radiographics.rsna.org
Introduction
Trauma is the third leading cause of death in all age groups and the
most common cause of death in the first four decades of life (1). In the
United States, 35 million emergency department visits occur annually
as a result of trauma (2). Thoracic trauma occurs in approximately
60% of patients with polytrauma and has a wide range of mortality,
as blunt polytrauma with bilateral pulmonary contusions and a hemo-
pneumothorax, mortality exceeds 50% (4). In patients with tracheo-
bronchial injuries, the prognosis is even more grim, with up to 80%
prehospital mortality (6). The posttraumatic course of trauma patients
is significantly influenced by the presence and extent of pulmonary
injuries, with contusions being independently associated with the de-
velopment of acute respiratory distress syndrome (ARDS) (7,8).
Imaging is crucial in the diagnosis and management of pulmo-
nary trauma. While radiography is useful in initial critical manage-
ment and triage, CT is more accurate in helping to delineate injury
severity and detect additional findings that may change manage-
ment (5,9). In this article, we narrowly focus only on imaging
of both blunt and penetrating injuries to the airways and lungs,
including the tracheobronchial tree, pulmonary parenchyma, and
those contained within the pleural space. Specifically, we review
1322  September-October 2021 radiographics.rsna.org
TEACHING POINTS
„ In blunt trauma or blast injuries (or in ballistic injuries with pro-
tective gear), pulmonary contusion volume is directly related
to the maximum intensity of the intrathoracic pressure wave.
„ The most common types of lung parenchymal injury are con-
tusions, lacerations, and hematomas, each having characteris-
tic imaging appearances. A less common type of lung injury is
herniation, which occurs when a sudden increase in intratho-
racic pressure forces lung tissue through a chest wall defect,
one that is either preexisting or the result of acute trauma.
„ Contusions may not be visible at radiography in the first 6
hours following trauma but peak in conspicuity and extent
within 48–76 hours. Uncomplicated contusions resolve within
1–2 weeks at radiography.
„ The traumatic laceration cavity can fill with air (pneuma-
tocele), blood (hematocele or hematoma), or both air and
blood (hematopneumatocele). The number and appearance
of lacerations range from a solitary cavity (most common) to
numerous small lacerations that produce a Swiss cheese ap-
pearance.
„ Four types of lacerations have been described according to
mechanism of injury, CT findings, location of associated rib
fracture, or surgical findings: compression rupture, compres-
sion shear, rib penetration tear, and adhesion tear.
injury mechanisms, biomechanics, and imag-
ing techniques; describe and illustrate pleural,
parenchymal, and tracheobronchial injuries; and
discuss management implications.
Mechanisms of Injury and
Pathophysiology
Trauma Mechanisms
More than two-thirds of blunt thoracic trauma in
developed countries is caused by motor vehicle
collisions (MVCs), while the remainder result
from falls from height or direct impact to the
chest (5). Penetrating injuries to the chest include
gunshot, stab, and blast injuries and penetration
from other objects (including workplace injuries
and sporting or hunting injuries, such as from
participating in sports in which hunting arrows
are used) (10). Ballistic injuries are a major cause
of morbidity and mortality in the United States
and commonly involve the thorax (10).
Regarding airway injuries, the cervical trachea
is at high risk of injury from penetrating trauma
to the neck, but cervical tracheal injuries can also
result from blunt trauma. Specifically, neck hy-
perextension can result in cervical tracheal tears
(sudden deceleration during high-speed MVCs),
while severe direct impact to the neck can crush
the trachea against the spine (neck versus steering
wheel in high-speed MVCs) (6). Blunt trauma to
the chest can also result in explosive rupture of
the airways due to a rapid rise in pressure against
a reflexively closed glottis (6).
Biomechanics of Pulmonary Injury
Unlike most other organs, the lung is both
elastic and distensible, with a physiologic capac-
ity to withstand marked changes in contour and
volume (11). Pulmonary compliance (which is
inversely proportional to elasticity) is a mea-
sure that captures the extent to which the lungs
expand in response to intrapulmonary pressure
(11). Although counterintuitive, the fragility of
the lung to excessive force is closely related to its
high compliance (12). Owing to its intrinsic tissue
properties, pressure waves propagated within the
lung are smaller in wavelength than those in other
organs or tissues, and lung damage is in part due
to the propagation of pressure waves (12).
In blunt trauma or blast injuries (or in ballistic
injuries with protective gear), pulmonary contu-
sion volume is directly related to the maximum
intensity of the intrathoracic pressure wave
(13,14). The pressure-related forces exerted on
the lung can be divided into two interrelated
peaks: a high-frequency response associated with
small tissue displacement but propagation of a
pressure wave from the primary impact, followed
by a low-frequency response caused by the dis-
tortion of the thoracic wall, which itself changes
intrathoracic pressures (12). Of note, children
are more susceptible than adults to pulmonary
trauma owing to increased compliance of the
chest wall from incomplete ossification of the ribs
and lower muscle mass (15,16).
Pathophysiology of Pulmonary Injury
The three primary traumatic forces involved in
pulmonary injury are deceleration, crush, and
penetration. In blunt trauma, there are three pro-
posed mechanisms for parenchymal injury that
may occur in isolation or in combination:
1. The implosion effect, in which the expan-
sion and movement of air related to a pressure
wave leads to alveolar tearing.
2. The inertia effect, in which the differential
deceleration of alveoli and their supporting struc-
tures results in shearing of the alveolar-capillary
membrane, with subsequent bleeding and accu-
mulation of edema in the alveoli and interstitium.
3. The spalling effect, which is characterized by
destructive biophysical phenomena that occur as
pressure waves encounter gas-liquid interfaces (17).
In addition to these forces, the following
mechanisms have been described to explain the
development of pulmonary lacerations: (a) direct
puncture by a fractured rib, (b) tearing of lung tis-
sue adjacent to a previously formed adhesion and/
or scar, (c) rupture of alveoli due to high intra-
alveolar pressures generated against a closed glot-
tis at the time of trauma, and (d) compression of
alveoli against the ribs or spine (18,19). Primary
RG  •  Volume 41  Number 5 Lewis et al  1323
penetrating injuries (eg, ballistic, knife) as well as
secondary penetration (rib fractures violating the
pleural or parenchymal tissues) can have a similar
imaging appearance, although secondary penetra-
tion injuries are usually more superficial.
Imaging Techniques for Pulmonary
Trauma
In blunt thoracic trauma, the National Emer-
gency X-Radiography Utilization Studies
(NEXUS) chest decision algorithm suggests any
of the following findings warrant subsequent
imaging evaluation: patient age greater than 60
years, rapid deceleration mechanism, chest pain,
intoxication, altered mental status, distracting in-
jury, and tenderness to chest wall palpation (20).
The chest radiograph is the primary initial
screening examination performed in thoracic
trauma, although some centers also perform
focused assessment in sonography for trauma
(FAST) (21). The major advantages of FAST are
that it is rapid, it is deployed at the bedside, and
it does not impart ionizing radiation. It may help
in identifying pathologic pericardial and intra-
thoracic free fluid and potentially pneumothorax.
In addition, some literature suggests that lung
US might be superior to chest radiography in
the detection of rib fractures, although this may
be due to focal US evaluation at the location of
patient pain (22). A positive FAST examination
in an unstable patient can indicate the need for
urgent surgery, potentially displacing the need for
additional initial imaging studies.
Chest radiographs are widely used as screen-
ing examinations in thoracic trauma, as they are
inexpensive and noninvasive and can be acquired
at the bedside (21). Conventional posteroanterior
and lateral chest radiographs may be appropriate
in low-risk patients who are hemodynamically
stable and can tolerate the examination. More
often, a portable anteroposterior (AP) chest
radiograph is obtained owing to patient condi-
tion and ease of acquisition. Chest radiography
can identify rib fractures, foreign bodies and/or
ballistic fragments, contusions, pneumothorax,
hemothorax, and mediastinal injuries, which
can subsequently be further evaluated at CT. In
stable patients in whom a subtle pneumothorax is
questioned, inspiratory and expiratory views can
be helpful. Expiratory views reduce lung volume,
increase lung density, and make otherwise subtle
pneumothoraces more conspicuous.
Contrast-enhanced CT with multiplanar
reformations (eg, coronal and sagittal images,
three-dimensional reconstruction) is the standard
imaging tool in the evaluation of trauma patients
owing to its widespread availability, speed of
acquisition, and ability to simultaneously evaluate
contiguous body regions (23,24). Moreover, CT
provides greater sensitivity and specificity than
chest radiography in the detection and extent of
pulmonary injuries (9). In unstable patients in
whom urgent surgical intervention is necessary,
chest radiography and CT can be performed
after life-threatening injuries have been stabilized
(damage control surgery).
Depending on the type of CT scanner avail-
able, a collimation of at least 1.25 mm (four-
section and 16-section) or 0.6 mm (64-section)
is recommended (23). Single-phase imaging
acquisition in trauma may be performed from
the thoracic inlet through the pelvis, with an
approximately 70-second delay (corresponding
to the portal venous phase in most patients with
normal cardiovascular function). Some institu-
tions use a multiphasic protocol, wherein images
are obtained from the thoracic inlet through
the abdomen in the systemic arterial phase,
followed by a portal venous phase acquisition
through the abdomen and pelvis. This multipha-
sic imaging approach may improve the identifi-
cation and characterization of vascular injuries
with the arterial phase (pseudoaneurysm, dis-
section, active contrast material extravasation),
while maintaining adequate abdominopelvic
organ evaluation with the portal venous phase
(25–27). Specifically, when active bleeding is
suspected in the initial phase of a multiphasic
examination, a subsequent delayed acquisition
may be confirmatory (23).
MRI and nuclear medicine examinations are
not routinely performed in thoracic trauma ow-
ing to limited availability, prolonged acquisition
time, and overall inferior performance in the
setting of trauma. However, MRI can be used
to help assess posttraumatic complications of
cardiac and vascular trauma when patients have
been stabilized (28).
Pulmonary Parenchymal Injury
The most common types of lung parenchymal in-
jury are contusions, lacerations, and hematomas,
each having characteristic imaging appearances.
A less common type of lung injury is herniation,
which occurs when a sudden increase in intratho-
racic pressure forces lung tissue through a chest
wall defect, one that is either preexisting or the
result of acute trauma (29). Lung contusions,
lacerations, and hematomas result from varying
degrees of injury to the pulmonary alveoli and
interstitium. In contusions, blood and edema fill
injured alveoli and interstitial tissues, but the un-
derlying lung parenchyma remains visibly intact.
Lacerations, by contrast, result from disruption
in lung tissue such that rounded or ovoid cavities
form, in which variable amounts of blood and/or
1324  September-October 2021 radiographics.rsna.org

Figure 1.  Pulmonary contusions in a 27-year-old woman following a motor vehicle collision (MVC). (a) An-
teroposterior (AP) chest radiograph shows diffuse haziness over much of the right lung, with relative sparing
of the right apex (oval). In the setting of blunt trauma, this is concerning for extensive pulmonary contusions.
(b) Corresponding axial chest CT image obtained on the same day shows typical features of contusions, with
regions of ground-glass attenuation (arrowhead) in the right upper and lower lobes, crossing the major fis-
sure. Note the 2 mm of subpleural sparing (arrow) of the affected lung.

gas accumulate. In severe trauma, lacerations and
contusions may coexist, but the lacerations may
be obscured by contusions on initial chest radio-
graphs (16). Lung hematomas are lacerations
that entirely fill with blood, resulting in masslike
consolidation at radiography and CT. The radio-
logic and clinical implications of these lung tissue
injury types are discussed in greater detail further
in the article.
Contusions
Pulmonary contusions are the most common
type of pulmonary parenchymal injury, occur-
ring in up to 75% of blunt chest trauma cases
(29–32). MVCs are the most common mecha-
nism leading to pulmonary contusion (33).
Important but less common causes include falls
from height, blasts, and athletic and penetrating
injuries (31,33).
The characteristic radiologic feature of lung
contusions on chest radiographs is that of focal
patchy or diffuse nonsegmental hazy airspace
opacites (16,29,31,32,34) (Fig 1). Contusions
tend to occur at the site of injury (although
contrecoup injuries are also encountered) and
in the relatively mobile lung bases, which are
more subject to maximal shearing forces (29,32).
Opacities may become consolidative when bleed-
ing is more extensive, in which case air broncho-
grams may be evident when regional airways are
clear (29,35). Contusions may not be visible at
radiography in the first 6 hours following trauma
but peak in conspicuity and extent within 48–76
hours (16,29,31,34,35). Uncomplicated contu-
sions resolve within 1–2 weeks at radiography
(16,31,32,34). CT has greater sensitivity for
pulmonary contusions and can aid in detection
immediately after injury. However, contusions
that are initially visible at CT but not at radiog-
raphy are usually of little clinical significance,
and detection with CT in these cases rarely
affects management (31,32). On CT images,
lung contusions typically appear as regions of
ground-glass attenuation, classically with 1–3
mm of subpleural sparing (29,31,32,34,35).
Unlike aspiration or respiratory infection, the
distribution of contusions does not respect lobar
or segmental boundaries, as the tissue injury
occurs along the trajectory of transmitted energy
transfer as opposed to an endobronchial route
(16,29,32,34,35) (Fig 1b). As at radiography,
contusions at CT resolve in 1–2 weeks.
Minor lung contusions are often asymp-
tomatic, and treatment is generally support-
ive (31–34). More severe injury can result in
impaired alveolar gas exchange and altered lung
compliance, leading to hypoxia, dyspnea, tachy-
pnea, and tachycardia (31–34). In one study,
mechanical ventilation was required in patients
with contusions involving more than 28% of
lung volume (36). The most common complica-
tions of pulmonary contusions include ARDS
and pneumonia, which occur at a rate propor-
tional to the degree of severity (14,31,37,38).
In one study, 82% of patients with lung contu-
sions involving more than 20% of the total lung
volume developed ARDS (vs 22% with <20%
involvement) and 50% developed pneumonia
(vs 28%) (39). Opacities that persist beyond
1–2 weeks or increase in size or extent after 2–3
days should raise the suspicion for infection
(pneumonia and abscess), ARDS, or aspiration
RG  •  Volume 41  Number 5 Lewis et al  1325

Figure 2.  Pulmonary laceration in a 38-year-old man after a thoracic gunshot wound. (a) AP chest radiograph obtained at presenta-
tion shows a hazy opacity (arrow) in the left upper lobe, reflecting laceration obscured by pulmonary contusions. (b) Axial CT image
obtained on the same day better shows the pulmonary laceration cavity filled with blood and air (arrows), with surrounding contusion
(*). (c) AP radiograph obtained 8 days later shows that the laceration is visible as a well-circumscribed opacity (arrow), as the contusions
have resolved. Note the persistent pneumothorax (arrowhead), possibly from a bronchopleural fistula, a potential complication of large
pulmonary lacerations.

(16,29,34). Failure of resolution often results
from complicating factors, such as superim-
posed infection, atelectasis, aspiration, or blood
clot within a laceration (23).
Lacerations
Pulmonary lacerations comprise up to 12% of
lung injuries in blunt chest trauma. The most
common cause of lacerations is penetrating
injuries, such as stab or bullet wounds. How-
ever, high-energy blunt trauma can also produce
significant lacerations (40). As with contusions,
younger patients are more susceptible to this type
of injury owing to a more pliable chest wall (19).
The spherical or elliptical configuration of lacera-
tions is due to the unique elastic recoil properties
of lung tissue that cause the normal lung to pull
away in all directions from the laceration itself.
This appearance contrasts to the typically linearly
oriented lacerations seen in solid organs (5,19).
The traumatic laceration cavity can fill with air
(pneumatocele), blood (hematocele or hema-
toma), or both air and blood (hematopneumato-
cele). The number and appearance of lacerations
range from a solitary cavity (most common)
to numerous small lacerations that produce a
Swiss cheese appearance (5,18,19). In the acute
setting, lacerations are often obscured on initial
chest radiographs by surrounding contusions and
become more conspicuous over the next 48–72
hours as the contusions resolve (5,18,19,40).
However, nearly all lacerations can be detected
acutely at CT (5,19) (Fig 2).
In contrast to contusions, lacerations can take
weeks to months to resolve and usually result in
pulmonary parenchymal scarring (40,41). Com-
plicated lacerations that are the result of high-
velocity penetrating and missile injuries have a
significant amount of surrounding destruction
and tissue necrosis and may not respond to con-
servative medical therapy, consequently persist-
ing for months and possibly requiring surgical
resection (40,42).
Four types of lacerations have been described
according to mechanism of injury, CT findings,
location of associated rib fracture, or surgical
findings: compression rupture, compression
shear, rib penetration tear, and adhesion tear
(19) (Fig 3).
Type 1 laceration (compression rupture) is
the most common type and is the result of sud-
den compressive force to the chest wall, which
causes rupture of the air-containing lung (5,19).
These lacerations typically occur within the cen-
tral and deep portions of the lung (5).
Type 2 laceration (compression shear) occurs
when there is a direct blow to the more pliable
lower hemithorax causing the paravertebral lung
parenchyma to compress and shift across the
rigid vertebral column. These lacerations are
often paraspinal in location (5,19).
Type 3 laceration (rib penetration tear) ap-
pears as a peripheral cavity adjacent to a rib
fracture. The laceration is caused by penetration
of the lung parenchyma by the fractured rib. A
Type 3 laceration is commonly associated with
a pneumothorax (5,19).
Type 4 laceration (adhesion tear) is often
peripheral and due to a preexisting adhesion or
surgical site that precludes normal pulmonary
motion (5,19). This type is rarely described at
imaging but may be evident at surgery or autopsy.
1326  September-October 2021 radiographics.rsna.org

Figure 3.  Pulmonary laceration types 1–3. (a) Axial CT image in a 27-year-old man shows three
centrally located intraparenchymal lacerations (arrows), type 1, compression rupture (pneuma-
tocele and hematopneumatocele). Note the surrounding ground-glass attenuation, reflecting
contusions (arrowhead) and moderate pneumothorax (*). (b) Axial CT image in a 33-year-old
man shows a paravertebral air-filled laceration (pneumatocele; arrow), type 2, compression shear
laceration (pneumatocele). (c) Axial CT image in a 24-year-old man shows a peripheral air-filled
laceration (pneumatocele; arrow) subjacent to the thoracic ribs, type 3, rib penetration tear.

Complications of pulmonary lacerations follow-up (45). Pulmonary artery pseudoaneu-

are uncommon and include abscess forma-
tion (Fig 4), enlargement of the laceration by
the ball-valve effect, and bronchopleural fistula
with persistent air leak (18,43). Pulmonary
vascular injuries including arteriovenous fistula
or pseudoaneurysm are another uncommon
complication of both penetrating and nonpen-
etrating trauma (44). Pulmonary artery pseu-
doaneurysms are focal rounded or lobular areas
of contrast material pooling, which correspond
to pulmonary arterial enhancement, unlike sys-
temic arterial pseudoaneurysms, which demon-
strate peak enhancement during arterial phase
imaging. An arteriovenous fistula is diagnosable
on the basis of early enhancement of the pulmo-
nary veins. The abnormal fistulous connection
may or may not be directly visible, depending on
its size. Treatment options include pulmonary
resection, endovascular embolization, or con-
servative treatment with clinical and radiologic
rysm is rare and may self-resolve owing to low
pulmonary arterial pressures (44,45).
Hematomas
Pulmonary hematoma is defined as a confluent
region of intraparenchymal blood that obscures
the underlying pulmonary anatomy (Fig 5).
Hematoma is the result of the accumulation of
blood in injured alveolar and interstitial spaces
and is often the result of a pulmonary laceration
filling with blood (hematocele). Hematocele is
used synonymously with hematoma in clinical
practice, although the term hematoma is usually
reserved for subjectively larger and often solitary
lesions. Unlike pulmonary contusion, in which
alveolar and interstitial tissues remain rela-
tively intact, a hematoma is a larger collection
of blood that indicates more severe damage to
the lung. Causes of lung hematoma are similar
to previously described causes of other types of
RG  •  Volume 41  Number 5 Lewis et al  1327

Figure 4.  Complications of pulmonary trauma in a 33-year-old man after an MVC. (a) AP chest radiograph obtained at pre-
sentation shows a left chest tube with hazy opacity (arrow) of the left lower lobe, a finding in keeping with pulmonary contu-
sion. (b) Subsequent axial chest CT image shows a diffuse left lower lobe contusion (*) and focal laceration with pneumotocele
(arrow). (c) Follow-up axial contrast-enhanced CT image obtained 4 days later shows an enlarging left pleural effusion (*) and
focal hypoattenuation (arrow) in the collapsed left lower lobe, compatible with the development of a pulmonary abscess in
the region of prior laceration. (d) Axial CT image obtained after antibiotic treatment and video-assisted thoracoscopic surgery
shows resolution of the effusion and abscess, with scant pneumothorax (arrowhead) and regions of resolving parenchymal
injury with atelectasis and/or scarring (arrow).

parenchymal trauma, but these can also occur
spontaneously in a patient undergoing antico-
agulation therapy in the absence of trauma.
At CT, an early pulmonary hematoma appears
as an irregular mass with indistinct borders. As it
matures, a hematoma becomes a solid homoge-
neous mass with circumscribed margins (46). The
resolution time of hematomas at imaging varies,
and while most resolve gradually within 5 weeks,
some can take up to a year after injury, potentially
causing a diagnostic dilemma in which they may
be mistaken for a neoplasm (40). In this instance,
it is imperative that the radiologist correlate with
patient history. Serial imaging that demonstrates
a progressive decrease in size can assist in mak-
ing the correct diagnosis of a pulmonary hema-
toma (18). If the pulmonary nodule in question
remains stable after 4 weeks, without evidence of
resolution, further evaluation may be warranted to
exclude malignancy (14,43,47,48). At CT, hema-
tomas have been demonstrated to decrease in size
more slowly than air-filled lacerations (pneumato-
celes) at a rate of less than 0.5 cm in 3 weeks (19).
Hematomas may cavitate and become secondarily
infected, leading to abscess (43). Surgery is indi-
cated in cases of large parenchymal destruction,
bleeding from a major vessel, or bronchovascular
fistula (49).
Pneumothorax
Pneumothorax, an abnormal collection of air in
the pleural space, is commonly seen after both
blunt and penetrating trauma. An open wound
may result in air entering the pleural space from
the outside environment (an open pneumotho-
rax or sucking chest wound), whereas in closed
trauma, a pneumothorax is the result of lung pa-
renchymal or airway injury that allows air to leak
into the pleural space (50).
On radiographs, the main imaging finding
of pneumothorax is a thin discrete radiopaque
line paralleling the chest wall, peripheral to
1328  September-October 2021 radiographics.rsna.org

Figure 5.  Pulmonary hematoma in a 56-year-

old man after an MVC. (a) Axial CT image (lung
window) shows ground-glass opacities (arrow-
head) representing contusion, with adjacent
blood-filled laceration (arrow) representing he-
matoma. (b) Axial CT image (soft-tissue window)
shows a well-defined soft-tissue area of attenua-
tion (arrow) within the pulmonary parenchyma,
consistent with hematoma. (c) Portable AP chest
radiograph shows a masslike opacity (arrow) in
the left lower lobe, corresponding to the pulmo-
nary hematoma.

which vessel markings are absent (Fig 6). Unless

adhesions or loculations are present, air in the
pleural space will travel to the least dependent
portions of the thoracic cavity. In acute trauma,
chest radiographs may be obtained in the su-
pine, semierect, or upright position, which may,
therefore, change the location and sensitivity for
detection of small pneumothoraces.
Upright posteroanterior radiographs have
more than 90% sensitivity for detection of pneu-
mothorax, which generally accumulates along
the apical and lateral portions of the lungs.
However, on supine radiographs, up to 50% of
pneumothoraces may be inapparent (51). It is
important for radiologists to be familiar with
findings that may be present but subtle on su- Figure 6.  Pneumothorax in a 94-year-old man af-
pine radiographs (5,51,52): ter a fall. Upright posteroanterior chest radiograph
shows a small left pneumothorax, as indicated by a
1. Deep sulcus sign: increased lucency with thin radiopaque line (arrows), with absence of pe-
an inferiorly displaced lateral costal margin as ripheral vascular markings. Mildly displaced acute
air accumulates within the lateral subpulmonic eighth and ninth left rib fractures and subcutaneous
pleural recess (Fig 7). emphysema (oval) are also depicted. Note the inci-
dental bilateral pleural plaques, indicative of asbes-
2. Double diaphragm sign: accumulated air tos-related pleural disease (*).
in the subpulmonic recess that results in two
distinct diaphragm interfaces (Fig 7).
3. Sharp mediastinal interface: air along the Failure to recognize subtle findings of a pneu-
medial pleura outlines the mediastinum and cre- mothorax at radiography may be identified later
ates a sharper than expected border. This border if CT is performed or when the patient clinically
may have a lobulated appearance owing to out- decompensates owing to the development of ten-
lining of the epipericardial fat (floating cardiac sion physiology (51). A tension pneumothorax
fat pad sign) (Fig 7). is due to a one-way valve mechanism that allows
RG  •  Volume 41  Number 5 Lewis et al  1329

Figure 7.  Pneumothorax in a 46-year-old man following blunt chest trauma. (a) Supine AP chest radiograph shows
displaced left rib fractures, subcutaneous emphysema, and subtle pneumothorax. There is a significant basilar pneu-
mothorax with several imaging clues: deep sulcus sign (black arrowhead), double diaphragm sign (white arrowheads),
and a well-defined left heart border with floating fat pad sign (arrow). Multiple opacities are depicted throughout the
left lung, compatible with a combination of contusions and lacerations in the setting of trauma. (b) Axial CT image
obtained on the same day as a shows a large pneumothorax (*); a radiograph can significantly underestimate pneu-
mothorax size. Two intraparenchymal lacerations are depicted in the left lower lobe, with pneumatocele (arrow) and
hematopneumatocele (arrowhead).

return to the heart), likely due to loss of negative

intrapleural pressure on the affected side (5,53).

Quantification and Management of

Figure 8.  Posteroanterior chest radiograph
in a 29-year-old man with shortness of breath
shows findings of tension pneumothorax,
including collapse of the ipsilateral lung (*),
contralateral mediastinal deviation (arrow-
heads), and inversion of the ipsilateral dia-
phragm (arrow).
air into but not out of the pleural space, thereby
allowing the pleural pressure to exceed atmo-
spheric pressure. Findings at chest radiography
that may suggest a tension pneumothorax include
collapse of the ipsilateral lung, contralateral me-
diastinal deviation, and inversion of the ipsilateral
diaphragm (50,53) (Fig 8). Note that tension
pneumothorax is a clinical diagnosis, and patients
may have mediastinal deviation without clini-
cal signs of tension physiology (impaired venous
Pneumothorax
The Advanced Trauma Life Support guidelines
recommend that all pneumothoraces be treated
with tube thoracostomy (54). However, in prac-
tice, small pneumothoraces are often managed
with observation alone (55). The effectiveness of
treatment is generally monitored with sequential
radiographs. CT is performed to troubleshoot per-
sistent pneumothorax and verify proper thoracos-
tomy tube placement. Several different methods
for quantifying the volume of pneumothoraces at
imaging have been published but suffer from poor
interobserver agreement (56). Bou Zein Eddine et
al (55) found that when using a cutoff of 35 mm
(measured from lung to chest wall in the largest air
pocket), only 9% of patients failed initial observa-
tion. Persistence of air within the pleural space de-
spite drainage may suggest air leak, tracheobron-
chial injury, bronchopleural fistula, or lack of lung
reexpansion owing to underlying parenchymal in-
jury or chronic disease (ie, emphysema or fibrosis).
Surgery is indicated when there is a persistent or
massive air leak or lack of lung reexpansion despite
pleural drainage (49).
Hemothorax
Hemothorax occurs in approximately one-
third of patients with thoracic trauma, often in
combination with pneumothorax (57). Causes
of traumatic hemothorax include venous bleed-
ing; injury to chest wall arteries, such as the
1330  September-October 2021 radiographics.rsna.org
Figure 9.  Arterial injury in an 86-year-old woman with
displaced posterior rib fractures, with hemothorax ow-
ing to intercostal arterial injury after trauma. (a) Axial
CT image shows a right pleural fluid collection (*) mea-
suring 32 HU, a finding in keeping with acute blood
products. Note the right chest tube and subcutane-
ous emphysema. (b) Axial CT image obtained during
the early arterial phase shows the hemothorax with an
acute displaced posterior rib fracture (arrowhead) and
an adjacent focus of contrast material extravasation (ar-
row). (c) Axial CT image obtained during the delayed
venous phase at the same level as b shows enlargement
of the initial focus of contrast material extravasation and
additional regions of contrast extravasation (arrows).
intercostal or internal thoracic arteries; injury to
the heart, aorta, or other large thoracic vessel;
or upper abdominal injury resulting in hemo-
peritoneum with the passage of blood through a
diaphragmatic defect. Although usually detected
at presentation, hemothorax can be delayed in
approximately one-third of patients. Predisposing
factors for delayed hemothorax include displace-
ment and posterior location of rib fractures (58).
Signs of hemothorax at radiography include
blunting of the costophrenic angle, obscuration of
the hemidiaphragm, homogeneous opacity of the
hemithorax, fluid within the interlobar fissures, or
an apical cap. However, supine portable radio-
graphs cannot help distinguish between simple
pleural effusions and blood and may miss pleural
collections less than approximately 175 mL (59).
Thoracic FAST has a sensitivity equivalent to or
greater than that of radiography (59,60). CT has
the highest sensitivity for hemothorax and can
also provide clues about time frame. Pleural fluid
with values of 30–70 HU or layering blood in the
pleura (hematocrit sign) suggests acute blood
products (5). As noted earlier, multiphasic CT
can be helpful in the detection of active bleeding.
A focal blush of contrast material in an arterial
phase that increases in size at delayed imaging
indicates active extravasation due to uncontained
arterial injury (Fig 9).
An important mimic of hemothorax is an ex-
trapleural hematoma, present in approximately
7% of cases of traumatic thoracic injury in one
series (61). Inward displacement of extrapleural
fat at CT, appreciated as a line of fat deep rela-
tive to the collection of blood, is a key feature
(Fig 10). Extrapleural hematomas typically do
not respond to chest tube placement and may
require surgical evacuation.
Thoracostomy tube placement is the standard
of care for hemothorax, although patients with
small or radiographically occult hemothorax
may be managed expectantly (62). Prompt evac-
uation of significant hemothorax is important
to improve lung function and prevent complica-
tions such as empyema, trapped lung, or fibro-
thorax (63). Fibrothorax is an intermediate- to
long-term complication caused by organization
of pleural blood products with resulting rindlike
pleural thickening and calcification, resulting in
restricted lung expansion and associated restric-
tive physiology. Trapped lung can occur owing
to thickening of the visceral pleura caused by
pleural inflammation and fibrinous adhesions.
Despite first-line treatment with chest tube
drainage, retained hemothorax can occur in
approximately 4%–20% of cases, defined as
persistent pleural blood products 72 hours after
chest tube placement, usually due to organiza-
RG  •  Volume 41  Number 5 Lewis et al  1331

Figure 10.  Extrapleural hematoma and hemothorax follow-

ing an MVC in a 61-year-old man. Axial noncontrast chest
CT image shows an ovoid fluid collection with a dependent
hematocrit level (arrowhead) in the posterior left hemithorax.
Linear fat (arrows) surrounding the collection represents dis-
placed extrapleural fat, a key sign differentiating extrapleural
hematoma from blood in the pleural space. Additional high-
attenuation pleural fluid is depicted medial and lateral to the
extrapleural fat, representing a hemothorax (*).

Figure 11.  Tracheal injury in a 32-year-old man after a thoracic gunshot wound. (a) AP radiograph shows entry and exit sites,
indicated by externally applied paper clips. The AP bullet trajectory would be expected to involve midline structures such as the
trachea. Paramediastinal haziness is depicted, reflecting pulmonary contusions (arrows). (b) Axial contrast-enhanced chest CT image
shows extensive diffuse pneumomediastinum. Note the small anterior tracheal wall defect (arrow). Tracheal injury from a penetrating
wound would likely be associated with injury to other adjacent mediastinal structures as well. Therefore, a detailed examination of
the mediastinum along the ballistic trajectory is warranted. (c) Parasagittal contrast-enhanced reformatted CT image shows extensive
anterior and posterior pneumomediastinum (arrows) from the visualized neck to the root of the aorta. Note the small anterior tracheal
wall defect (arrowhead), accounting for the mediastinal air.

tion of blood products. CT can be helpful for
discerning retained hemothorax and character-
izing possible loculation. Treatment of retained
hemothorax can include instillation of fibrolytics
through a thoracostomy tube. Video-assisted
thorascopic surgery with decortication or open
thoracotomy can be performed for treatment of
refractory cases (64).
Airway Injury
Blunt and penetrating trauma can uncommonly
involve injury to the central airways (65). Given
the central location and essential function of large
airways, severe injury can be acutely life threat-
ening, which can preclude imaging evaluation.
Trauma patients who have survived to imaging
evaluation are more likely to have a bronchial
injury than a tracheal injury. Imaged injury to the
thoracic trachea is more likely to be from blunt
trauma (66). Overall, penetrating or blunt trauma
with tracheobronchial injuries is frequently associ-
ated with injuries to surrounding structures (67).
Both the cartilaginous and membranous por-
tions of the trachea as well as central bronchi can
be injured in trauma (Fig 11). Tracheal injury
from blunt trauma is most common around the
carina and more commonly involves the poste-
riorly located membranous trachea, which lacks
cartilaginous protective support (68,69). Blunt
trauma can also lead to disruption or shear injury
of a main bronchus, with the right main bron-
chus more commonly involved than the left. This
tendency is thought to be due to the shorter path
of the right main bronchus through the mediasti-
num, providing less protective support conferred
to the left main bronchus, which has a longer
intramediastinal path.
The most common sign of blunt traumatic in-
jury to the central airways is pneumomediastinum.
However, air in the mediastinum can also originate
1332  September-October 2021 radiographics.rsna.org
Figure 12.  Macklin effect in a 28-year-old man who presented to the emergency department with chest pain. (a) Chest
radiograph shows pneumomediastinum (arrow) and air in the left supraclavicular space (arrowhead). (b) Subsequent axial
CT image shows pneumomediastinum (arrowhead) and air dissecting along the bronchovascular sheath (arrow), known
as the Macklin effect.
from lung parenchymal injury, with air dissect-
ing centrally (the Macklin effect) (Fig 12) (70). A
detailed evaluation of lung parenchyma (including
a search for interstitial air) and an evaluation of
central airways walls may help discriminate airway
injury versus lung injury as the cause of pneumo-
mediastinum. While esophageal injury can also
manifest with pneumomediastinum, the associated
pneumomediastinum is typically localized to the
periesophageal region, and the volume of gas is
less than that of airway injury owing to relatively
lower intraluminal esophageal pressures. Peri-
esophageal fluid is also typically present, whereas
in airway injury, it is usually absent (71).
If warranted, CT esophagography with enteric
contrast material has an accuracy at least equal to
if not superior than that of fluoroscopic esopha-
gography, with a sensitivity of 59%–100% and
specificity of 80%–100% in assessing for leak (72).
CT esophagography can increase access and de-
crease time to diagnosis when compared with con-
ventional fluoroscopy, especially in patients who
present after hours or on the weekend (72).When
present, tracheal injury can be directly visualized
at CT more commonly than not, but a sizeable
minority of tracheal injuries remain occult at CT
(29% in one series) (73). In some cases, bron-
choscopy is required to make a definitive diagnosis
(69). Pneumothorax can result from central airway
injury, usually from a bronchial injury with an
associated pleural disruption. Traumatic airway
injury is sometimes a delayed diagnosis (65),
with potential manifestations including infection,
airway stricture, or persistent air leaks. Although
uncommon, trauma patients may also sustain a
tracheal injury secondary to traumatic intubations
or other iatrogenic injury (66).
Prompt identification and surgical repair of pri-
mary airway injuries are necessary to avoid chronic
complications, including ventilatory failure, me-
diastinitis, sepsis, airway stenosis, bronchiectasis,
recurrent pulmonary infections, and permanent
impairment of pulmonary function (73). When not
initially identified, follow-up imaging may demon-
strate persistent deep cervical emphysema, pneu-
momediastinum (specifically, paratracheal air),
chronic lung collapse, or persistent pneumothorax.
In addition, herniation of an endotracheal tube
balloon cuff beyond the tracheal wall is indicative
of injury (74).
Grading Pulmonary Trauma
The American Association for the Surgery of
Trauma (AAST) Organ Injury Scale (OIS) was
originally published for the spleen, liver, and
kidney in 1989, with the addition of the lung
injury scale in 1994. The grading system is widely
accepted by trauma surgeons and used to classify
and categorize traumatic organ injury (Table). The
AAST OIS illustrates severity, facilitates clini-
cal management, and aids in assessing prognosis
(74). Of additional importance, standard AAST
OIS categorization of injuries allows convenient
data extraction from trauma registries for the
purposes of conducting research and managing
patient care. The formal AAST OIS was designed
based on injuries detected at surgery, which are
not always adaptable to imaging. We have modified
the descriptions of the AAST lung injury scale to
make them more applicable to imaging. Note that
hemothorax is graded according to the thoracic
vascular scale and is not included in the lung OIS.
Conclusion
Thoracic injury is common in the setting of blunt
and penetrating trauma, and injury to the lungs,
pleura, and airways is a leading cause of trauma-
related mortality and morbidity. Imaging,
RG  •  Volume 41  Number 5 Lewis et al  1333

AAST Organ Injury Scale for Lung Injury

Grade Injury Type Description of Injury

I Contusion Unilateral contusion, segmental or subsegmental involvement
II Contusion Unilateral contusion, lobar involvement
Laceration Peripheral laceration, with or without simple pneumothorax
III Contusion Unilateral contusion with more than single lobe involvement or bilateral contusions
Laceration Persistent laceration (>72 hours); injury to distal airways, with or without air leak
Hematoma Intraparenchymal hematoma (nonexpanding)
IV Laceration Major laceration (segmental or lobar) with imaging findings suggestive of air leak
Hematoma Expanding intraparenchymal hematoma (expanding over consecutive imaging ex-
aminations or with active contrast material extravasation)
Vascular injury Primary branch intrapulmonary vessel disruption
V Vascular injury Hilar vascular injury (contained, without active contrast material extravasation)
VI Vascular injury Transection of pulmonary hilum or hilar vessel injury with uncontained bleeding
(active contrast material extravasation)
Source.—Reference 74.
Note.—AAST = American Association for the Surgery of Trauma.

10. Truesdell W, Gore A, Primakov D, et al. Ballistic and

particularly FAST, radiography, and CT, plays a
crucial role in the initial evaluation and manage-
ment of patients who present with chest trauma.
In this article, we explore the unique pathophysiol-
ogy and imaging appearances of thoracic injury as
they apply to the lung parenchyma, pleural space,
and airways. Radiologists who interpret trauma
images should be aware of not only the usual
appearance of these types of injury but also the
expected evolution of imaging features as these
injuries heal, as well as potential complications for
which imaging plays an important role.
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