Supine Chest Radiograph Research Articles

The prevalence and significance of missed scapular fractures in blunt chest trauma.

Recent concepts regarding surgical management of fractures of the glenoid and scapular neck provide a new imperative to their early recognition. The initial routine supine chest radiograph obtained in patients with major blunt chest trauma provides the earliest opportunity to identify scapular fractures. A retrospective analysis of 100 patients with major blunt chest trauma who were discharged with the diagnosis of scapular fracture was performed to determine (1) the frequency with which the diagnosis of scapular fracture was made on the initial chest radiograph and (2) the prevalence and type of regional injuries that could serve to identify which of these patients are most likely to have sustained scapular fracture(s). The scapular fracture was diagnosed on the initial chest radiograph in only 57 (57%) of 100 patients and, although present, was not recognized in 43 (43%) of 100. In the group in which the fractures were not recognized, the fracture was visible and frankly overlooked in 31 (72%) of 43. The fracture was not included on the examination in eight (19%) of 43; and it was obscured by superimposed structures or artifacts in four (9%) of 43. Ipsilateral regional injuries were present in 88 (88%) of 100. These included multiple upper rib fractures in 40 (40%), clavicular fractures in 17 (17%), acromioclavicular separation in six (6%), and "other" in 26 (26%). "Other" included subcutaneous emphysema, pneumothorax, pleural effusion, and pulmonary contusion. The presence of ipsilateral regional skeletal injuries and soft-tissue injuries after major blunt chest trauma should prompt a diligent search for concomitant scapular fractures.

Spinal fractures in blunt chest trauma.

In a series of 100 consecutive patients with mediastinal hemorrhage following blunt chest trauma, fractures and dislocations of the lower cervical, thoracic, and upper lumbar spine were causative of the mediastinal hemorrhage in nine patients. Spinal injury was clinically suspected in seven patients because of quadriplegia or paraplegia. However, in the two patients who were neurologically intact a spinal injury was not clinically suspected. In the initial triage of a patient with blunt chest trauma, the supine chest radiograph can play a key role in the identification of a potentially unstable spinal injury and the prevention of subsequent spinal cord injury.

Free pleuroperitoneal liquid movement indicating diaphragmatic tear

An unusual radiological feature, not mentioned in the literature, is reported. It has been observed in a patient with traumatic rupture of the diaphragm associated with intra-abdominal bleeding. This injury produced a free pleuroperitoneal movement of liquid demonstrated in the supine and erect chest radiographs. Since there is an associated abdominal injury in most cases of rupture of the diaphragm, this radiological sign might be more common. The importance of supine and erect chest radiography is reinforced in cases of multiple injuries.

Mediastinal hemorrhage: an evaluation of radiographic manifestations.

Eleven common radiographic signs of mediastinal hemorrhage were evaluated by two observers for the following three patient groups: normal subjects, patients with mediastinal hemorrhage and no arterial injury, and patients with major thoracic arterial injury. Supine chest radiographs were studied in all cases. Four major conclusions can be made based upon these findings. M/C ratio (mediastinal width to chest width), tracheal deviation, left hemothorax, paraspinal line widening, and aorto-pulmonary window opacification do not reliably separate these three groups of patients. The diagnosis of mediastinal hemorrhage may be made if the aortic contour is abnormal or if one of the following signs is positive: abnormal mediastinal width, apical cap, widening of the right paratracheal stripe, or deviation of the nasogastric tube. If either the right paratracheal stripe is widened or the nasogastric tube is deviated, the diagnosis of aortic rupture can be made with a 24% probability; if both signs are negative, there is a 98% probability that aortic rupture is absent. Due to interobserver variation, there is good agreement between observers for the following four signs only: transverse mediastinal width, tracheal deviation, nasogastric tube deviation, and right paratracheal stripe widening.

The right paratracheal stripe in blunt chest trauma.

Supine chest radiographs and thoracic arteriograms were obtained in 102 consecutive patients with blunt chest trauma. The initial chest radiographs were reviewed retrospectively without knowledge of the arteriographic findings, and measurements of the right paratracheal stripe were obtained. All patients with right paratracheal stripes less than 5 mm in width had normal arteriograms. In those patients in whom the right paratracheal stripe measured 5 mm or greater, arteriography revealed major arterial injury in 22.9% of cases. It is concluded that measurement of the right paratracheal stripe on supine 102-cm radiographs provides a reliable and quantitative indicator of mediastinal hemorrhage, allowing early arteriographic evaluation.

The deep sulcus sign.

On a supine chest radiograph, the only sign of pneumothorax may be a deep lateral costophrenic angle on the involved side. Seven cases where this finding was present are reviewed and the importance of this sign to radiologists and clinicians is stressed.

Medial herniation of the parietal pleura: a useful sign of pneumothorax in supine neonates

In a series of 235 consecutive infants with respiratory distress syndrome, pneumothorax was demonstrated radiographically in 20. On anteroposterior supine chest radiographs of such infants, the intrapleural gas tends to seek an anteromedial position within the involved hemithorax. When the pneumothorax is large, the gas may cause the ipsilateral mediastinal pleura to bulge and herniate across the anterior mediastinum into the contralateral hemithorax. This was seen in 12 or the 14 right pneumothoraces, but only in two of the 10 left ones. The gas-containing sac appeared radiologically as a crescent-shaped lucency medial to the upper thoracic spine which was sharply delineated laterally by the mediastinal pleural layers and the somewhat atelectatic contralateral lung. In some patients treated with a chest tube, the gas disappeared more slowly from the herniated portion of the pleural sac than from elsewhere in the pleural space. Therefore, in addition to being a useful confirmatory sign of pneumothorax, this finding is also important in assessing the completeness of pleural drainage.

THE EXPERIMENTAL PRODUCTION OF SUPERIOR VENA CAVAL OBSTRUCTION. TRIAL OF DIFFERENT THERAPY SCHEDULES.

The large number of variables in any clinical problem demands careful organization of an investigative program to yield meaningful results. The evaluation of different therapy schedules and plans in superior vena caval obstruction patients is particularly vexing. The neoplastic etiology may range from exquisitely sensitive lymphomas to moderately responsive well differentiated bronchogenic cancers. The onset may vary from the acute and dramatic to the slow and chronic, with different degrees of collateral circulation and edema. Philosophies as to the use of irradiation alone or combined with chemotherapeutic agents run the gamut of clinical opinion, depending upon the radiotherapist, the internist, and the thoracic surgeon consulting on the case. The emergency nature of the presentation of acute caval obstruction requires a consistent and well defined approach to effect rapid relief of symptoms. The varied opinions as to proper therapy coupled with the relatively small numbers of cases led to the search for a biological model to simulate the clinical problem. After a number of attempts with different animals and tumors, the successful experimental production of the superior vena caval obstruction syndrome was accomplished. A number of different studies were designed to answer specific problems, and the results of this program have served as a guide for modifying our clinical treatment plan. Method of Study Sprague-Dawley female rats of approximately 150-gram weight were the animals used. The tumor utilized was the Rochester strain of the Murphy-Sturm lymphosarcoma, a tumor of rapid growth and radioresponsiveness. Although termed a lymphoma, its histologic characteristics simulate very anaplastic carcinomas. Donor rats with approximately seven- to ten-day old flank tumors were sacrificed. Healthy-appearing sections of tumor were morcellated in isotonic saline; a small amount of this mixture was then implanted percutaneously under the superior sternum with a No. 15 trocar (Fig. 1). Other rats from the same group underwent implantation in the flank and served as controls. Ether anesthesia was used during these procedures. The animals with mediastinal tumor implants were followed daily by supine chest radiographs and clinical observation. When the superior mediastinal shadow had widened 3 mm. or more and the clinical picture of an acute superior vena caval obstruction developed, various therapeutic measures were undertaken. Observation continued both by chest radiograph and by clinical observation. Each separate group studied included 10 to 15 animals. Without exception, the animals all survived the implant and appeared normal for at least the next forty-eight to seventy-two hours. Tumor takes were greater than 90 per cent in all groups studied. In this particular strain, spontaneous tumor regression occurred in only 1 or 2 per cent of the animals.