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Musculoskeletal Trauma

  • “Up to 10% of proximal femur fractures may be missed on initial radiographs. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative hip radiographs. Our findings show that modern multislice CT may be comparable with MRI for detecting occult fracture.”
    Investigation of occult hip fractures: the use of CT and MRI.
    Gill SK et al.
    ScientificWorldJournal 2013;2013:830319
  • “Although 64-slice CT detected the majority of occult fractures, it missed four (2%) significant fractures detected by MRI. CT scan is helpful in the diagnosis of occult hip fracture, but one should not completely exclude the diagnosis based on a negative 64-slice CT scan in a patient with persistent, localized hip pain who cannot bear weight.”
    Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography
    Hakkarinen DK et al.
    J Emerg Med 2012 Aug;43(2) 303-7
  • “Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3-4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging.”
    Imaging choices in occult hip fracture
    Cannon J et al.
    J Emerg Med 2009 Aug;37(2):144-52
  • “ Axial carpal dislocations and fracture dislocations result from high-energy dorsopalmar compression of the wrist, producing combined derangement of the distal carpal row and metacarpal arch with resultant flattening of the proximal and distal transverse arches of the wrist.”
    Traumatic Axial Dislocation Injuries of the Wrist
    Reinsmith LE et al.
    Radiology 2013; 207:680-689
  • “ Because of the extreme force of trauma causing these injuries, they may occur in association with perilunate or lunate dislocations or coincide with other complex carpal abnormalities.”
    Traumatic Axial Dislocation Injuries of the Wrist
    Reinsmith LE et al.
    Radiology 2013; 207:680-689
  • “ Advances in MDCT technology enable
    high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced
    image visualization for the noninvasive and accurate diagnosisof vascular, including hematoma, active extravasation,
    vasospasm, stenosis, external compression, occlusion, intimalinjury and dissection, arteriovenous fistulas, and pseudoaneurysm
    formation.”
    State-of-the-art 3DCT angiography assessment of lower
    extremity trauma: typical findings, pearls, and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (2013) 20:175-184
  • “Early venous contrast opacification can be an indirect sign of a traumatic arteriovenous fistula or can be due to trauma-related hyperemia. Arteriovenous fistulas are abnormal communications with shunting ofblood from an artery to a vein that occur after simultaneous damage of the two adjacent vessels. Common causes include penetrating trauma from gunshot injury and stab wounds.”
    State-of-the-art 3DCT angiography assessment of lower
    extremity trauma: typical findings, pearls, and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (2013) 20:175-184
  • “MDCTA allows for rapid, noninvasive and accurate diagnosis of vascular complications in lower extremity trauma. Individualized injection protocols ensure thehighest diagnostic image quality. Several strategies are available to reduce radiation exposure. Familiarity with advanced visualization techniques will increase the radiologist’s ability to accurately identify the various signs and patterns of vascular injuries of lower extremity trauma. By demonstrating the extent, location, and type of injury, MDCTA aids in the characterization of vascular injury and helps to determine the appropriate
    management.”
    State-of-the-art 3DCT angiography assessment of lower
    extremity trauma: typical findings, pearls, and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (2013) 20:175-184
  • “A variety of factors may obscure or mimic vascular injury on MDCTA including inadequate arterial enhancement due to timing of the contrast injection, motion artifacts, inadequate positioning, streak artifacts, dense calcifications, and
    similar density of vessels and bone. Venous injuries may bemissed on a single phase study or in the absence of late phase images.”
    State-of-the-art 3DCT angiography assessment of lower
    extremity trauma: typical findings, pearls, and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (2013) 20:175-184
  • Pitfalls in CTA in Extremity Trauma
    - Poor bolus injection
    - Poor timing of IV injection of contrast
    - Motion artifacts
    - Streak artifacts off foreign matter (bullets)
    - Dense calcifications
    - Bone fragments can obscure bleeding site
    - Venous injuries can be missed on arterial phase acquisition
  • “Advances in MDCT technology enable
    high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced
    image visualization for the noninvasive and accurate diagnosisof vascular injury, including hematoma, active extravasation, vasospasm, stenosis, external compression, occlusion, intimal injury and dissection, arteriovenous fistulas, and pseudoaneurysm formation.”
    State of the art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (epub November 2012
  • “Advances in MDCT technology enable
    high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced
    image visualization for the noninvasive and accurate diagnosisof vascular injury, including hematoma, active extravasation, vasospasm, stenosis, external compression, occlusion, intimal injury and dissection, arteriovenous fistulas, and pseudoaneurysm formation.”
    State of the art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (epub November 2012)
  • Clinical Signs of Vascular Injury
    Hard signs
    - Pulsatile hemorrhage or hematoma
    - Absent distal pulses
    - Overt distal ischemia
    - Audible bruit
    - Palpable thrill
  • Clinical Signs of Vascular Injury
    Soft signs
    - Significant hemorrhage found on history
    - Decreased pulse compared to the contralateral extremity
    - Bony injury or proximity to penetrating wound
    - Neurologic abnormality
  • Arterial Injury: Patterns of Injury
    - Hematoma
    - Active extravasation
    - Vasospasm
    - Stenosis
    - External compression
    - Occlusion
    - Intimal injury and dissection
    - Arteriovenous fistulas
    - Pseudoaneurysm formation
  • “ An advantage of 3D mapping is the ability to display the information in a format that not only simulates a classic catheter angiogram (digital subtraction), but also the capability to display tissue in addition to the vasculature,
    including muscle, soft tissues, and bone. MIP
    and VRT imaging may require segmentation with bone removal, especially when the extremities are involved. VRT is especially valuable when opaque foreign
    matter is present.”
    State of the art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (epub November 2012)
  • “A variety of factors may obscure or mimic vascular injury on MDCTA including inadequate arterial enhancement due to timing of the contrast injection, motion artifacts, inadequate positioning, streak artifacts, dense calcifications, and similar density of vessels and bone. Venous injuries may be missed on a single phase study or in the absence of late phase images.”
    State of the art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls and pitfalls
    Fritz J, Efron DT, Fishman EK
    Emerg Radiol (epub November 2012)

  • “ A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the ab- sence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients.”
    Blunt Thoracic Trauma: An Analysis of 515 Patients
    Shorr RM et al
    Ann Surg Vol 206, No 2,pp 200-205
  • “Sternal fracture is a common injury in a population where restraints are frequently used. Patients with an isolated sternal fracture do not require cardiac monitoring and those under 40 years of age may be cared for in a short stay ward.”
    Sternal fractures: a retrospective analysis of 272 cases.
    J Trauma 1993; 35(1):46-54
    Brookes JG; Dunn RJ; Rogers IR
  • Sternal Fractures are Associated With
    - Pulmonary contusion
    - Retrosternal hematoma
    - Pneumothorax
    - Cardiac contusion (least common)
  • Vascular Trauma: CT Findings

    Arterial injuries

    • Pseudoaneurysm
    • Active arterial hemorrhage
    • AV fistulae
    • Occlusion
    • Intimal injury
    • vasospasm
  • "Given the widespread availability as well as the ease of acquiring CTA in the trauma setting, CTA is increasingly being used as the initial diagnostic evaluation in extremity vascular trauma, replacing digital subtraction angiography in many institutions."

    Extremity CT Angiography: Application to trauma using 64-MDCT
    Sah N et al.
    Emerg Radiol (2009) 16;425-432

     

  • "The use of multiphasic images affords more definitive characterization of areas of "contrast blush" as to the underlying etiologies of contained vascular injuries or active hemorrhage."

    CT of Blunt Abdominal and Pelvic Vascular Injury
    Vi M et al.
    Emerg Radiol (2010) 17;21-29

  • CT Angiography: Potential Limitations in Extremity Trauma
    - Inadequate arterial enhancement
    - Motion artifact
    - Inadequate positioning
    - Streak artifact
  • "By demonstrating the extent, location, and type of injury, CT angiography aids in the decision making process to determine the appropriate management for each injury in each patient."

    Use of 64-Row Multidetector CT Angiography in Blunt and Penetrating Trauma of the Upper and Lower Extremities
    Pieroni S et al.
    RadioGraphics 2009; 29:863-876

  • "Sixty-four-row multidetector CT angiography of the extremities has the ability to demonstrate a variety of vascular injuries such as occlusion, pseudoaneurysm, active extravasation, and intimal dissection."

    Use of 64-Row Multidetector CT Angiography in Blunt and Penetrating Trauma of the Upper and Lower Extremities
    Pieroni S et al.
    RadioGraphics 2009; 29:863-876

  • Vascular Injuries in Pelvic Fractures
    - Active arterial extravasation
    - Occlusion
    - Intimal injury and occlusion
    - Pseudoaneurysm
    - Arterial dissection
    - Arteriovenous fistulae
    - Venous injury
  • Pelvic Fractures: Facts
    - 40% of patients with pelvic fracture have a major bleed
    - Overall mortality up to 15% in this population
    - Death from hemorrhage usually in first 24 hours