1. Routine Radiology of the Trauma Patient
Chantal VCA 440

2. Introduction
The purpose of this presentation is to remind us that though fractures resulting from HBC or HRS can be immediately eye-catching, once stabilized it may be the least of the animals concern. What is not immediately apparent is that this patient could be on the verge of a cardiorespiratory crisis due to a tension pneumothorax or hemorrhaging into it’s abdomen due to a ruptured spleen. Thus, it is essential that a series of survey radiographs be taken and the following are the major problems to watch for:

3. What to look for in the thorax
Pulmonary contusions
Hemothorax
Pneumomediastinum
Pneumothorax
Traumatic diaphragmatic hernia
In the thorax, there are 5 more common problems secondary to high velocity trauma, such as: pulmonary contusions, hemothorax, pneumomediastinum, pneumothorax and traumatic diaphragmatic hernia.

4. Pulmonary Contusions How it happens: Radiographic Signs: What’s next?
Hemorrhage into the lung parenchyma
Tearing and crushing injury
Radiographic Signs:
Patchy, focal or generalized
Alveolar pattern
May not be visible right away
What’s next?
Be conservative with fluids
Respiratory support
+/- Coagulation tests
Direct trauma to the chest can cause tearing and crushing injuries to the lungs, resulting in bleeding into the parenchyma. These pulmonary contusions, radiographically, will appear as patchy, focal or generalized, areas of aveolar pattern. However they may not be visible immediately post-trauma. If necessary to treat for shock, be especially conservative with fluids as this may result in pulmonary edema, as well as hemorrhage due to the preexisting capillary damage. Respiratory support may also be necessary due to the imbalance in ventilation and perfusion caused by the hemorrhage.

5. Pulmonary Contusions
Here’s another example of pulmonary contusions, where the hemorrhage is more localized in proximity to the adjacent rib fractures.

6. Hemothorax

7. Hemothorax How it happens: Radiographic signs: What’s next?
Trauma to arteries /veins
Damage to heart, lungs, thymus, or diaphragm
Ruptured herniated abdominal viscera
Radiographic signs:
Pleural effusion
Diffuse or ventral
Scalloping/fissures
What’s next?
Thoracocentesis
+/- Surgical exploration
Oxygen, transfusion, fluids
Direct trauma to the chest could also cause damage to any number of vessels or structures within the thorax resulting in hemorrhaging into the pleural cavity. Radiographically, this would appear as pleural effusion differing in severity from mild scalloping of the ventral lungs and interlobar fissures to a diffuse radiopacity silhouetting with the heart. With a case as such as this, it would be important to drain the fluid via thoracocentesis and provide support.

8. Pneumomediastinum How it happens: Radiographic signs: What’s next?
Ruptured alveoli, trachea, or esophagus
Tracheal avulsion
Radiographic signs:
Distinction of structures normally not seen
Tracheal wall outlined
SQ emphysema
What’s next?
Repair rents
Monitor for progression
Wrenching or perforation of the neck can result in tracheal or esophageal rupture causing leakage of air into the folds of the mediastinum and fascial planes of the neck. Also trauma to the chest can rupture alveoli or avulse the trachea from the mainstem bronchi. Air in the mediastinum is evident as it allow distinction of normally unseen structures such as the azygous vein and the tracheal walls. It is important to recognize this conditon as it may progress to a hazardous pneumothorax.

9. Pneumomediastinum
Here is the extension of the pneumomediastinum throughout the neck. This view can be helpful in localizing the source of incoming air.

10. Pneumothorax

11. Pneumothorax How it happens: Radiographic signs: What’s next?
Chest wall rent
Lung rupture
Extension of pneumomediastinum
Radiographic signs:
Retracted lungs
+/- collapse
Raised heart
+/-Small heart
+/-flat caudal diaphragm
+/-mediastinal shift
What’s next?
Thoracocentesis
Without a doubt, one of the most importing things to recognized radiographically is pneumothorax, especially when under tension. This can occur due to rents made in the chest wall, ruptured lungs or preexisting bulla, or as an extension of a pneumomediastinum as mentioned before. On film, this will be recognized by radiolucent spaces between the chest wall and lung (symbolizing retraction), a raised cardiac silhouette, and possibly collapsed lungs, displaced mediastinum or diaphragm, and decreased heart size. Upon visualizing a pneumothorax it is important to drain the air off the chest by thoracocentesis, especially if under tension.

12. Pneumothorax
This portrays a good example of lung collapse and cardiac elevation from the sternum.

13. Traumatic Diaphragmatic Hernia
How it happens:
Rapid increase in intra- abdominal pressure
Rent in the muscular portion
Radiographic signs:
+/-Pleural effusion
+/-Gas filled loops, liver stomach,spleen
+/-Loss of diaphragmatic outline
+/-Asymmetric on VD/DV
+/-Missing viscera from abdomen
What’s next?
Contrast study to definitively diagnose
Finally, when surveying the thorax, it is important to note the presence of any traumatic diaphragmatic hernias. This can be seen by complete or partial loss of the diaphragmatic outline, possibly visualizing visceral structures within the thorax or noticing missing viscera from the abdomen, and noting the asymmetry of the diaphragm on vd/dv. However, if suspected, hernias should be confirmed by performing contrast studies such as the UGI, as seen in the next slide.

14. The UpperGI
You can now see the small intestines entering the thorax.

15. What to look for in the abdomen
Hemoperitoneum
Renal avulsion
Uroperitoneum
Traumatic hernias
Conditions that may be overlooked in the abdomen could be : hemoabdomen, renal avulsion, uroperitoneum and traumatic hernias.

16. Hemoperitoneum How it happens: Radiographic signs: What’s next?
Ruptured spleen
Ruptured liver
Disrupted vasculature
Avulsed bladder
Radiographic signs:
Peritoneal effusion
Focal or diffuse
Decreased serosal detail
What’s next?
U/S
Abdominocentesis
Direct trauma to the abdomen can cause rupture and subsequent hemorrhage of viscera, such as the spleen or liver, or disruption of intra-abdominal vasculature. This would result in peritoneal effusion which would indicated radiographically by a focal or diffuse decrease in serosal detail. The hemorrhage can be definitively diagnosed by abdominocentesis and localized using ultrasound.

17. Hemoperitoneum
This is the DV of the last case depicting a focal area of decreased serosal detail in the left abdomen in the region of the spleen.

18. Renal Avulsion Radiographic signs: What’s next?
Focal decreased serosal detail
Missing kidney
Mass in caudal abdomen
What’s next?
U/S
On occasion, an animal could be traumatized in such a way to cause avulsion of a kidney from the body wall. Radiographically, this may not be diagnostic, though a decrease in serosal detail may be noted as well as the disappearance of the kidney. Ultrasound would be required to further evaluate.

19. Renal Avulsion
This was the U/S taken of this cat. As you can see the kidney is sitting by the bladder.

20. Renal Avulsion Right Kidney Left (avulsed) Kidney
With the doppler, it can be noted that the avulsed kidney has been detached from its vasculature.

21. Uroperitoneum How it happens: Radiographic signs: What’s next?
Ruptured bladder
Avulsed/torn ureter
Urethral tear
Radiographic signs:
Diffuse decreased serosal detail
Focal detail loss in the RPS
What’s next?
Abdominocentesis
IVP (EU)
Cystogram
Urethrogram
Commonly associated with pelvic fractures, uroperitoneum is radiographically similar to hemoabdomen, though can be differentiated via abdominocentesis. However, this condition can be caused by either ruptured bladder, avulsed or torn ureters, or torn urethra. Thus contrast studies are imperative to further localize the problem.

22. Ruptured Bladder The urethrocystogram
Contrast can be seen leaking from the bladder.

23. Avulsed or Ruptured Ureter
The Excretory Urogram:
The ureter appears to have avulsed from the trigone of the bladder in this case, though could also occur at the renal pelvis or as a midbody tear.

24. Ruptured Urethra
The Urethrogram
Note the disruption of the urethra.

25. Traumatic Hernia How it happens: Radiographic signs: What’s next?
Rapid increase in intra- abdominal pressure
Rent in the body wall, inguinal canal, or perineal wall
Radiographic signs:
Extra-abdominal mass
Disruption of the body wall
+/-Containing gas-filled loops of intestines
+/-Missing abdominal viscera
What’s next?
U/S mass
Surgical repair
As with diaphragmatic hernias, the rapid increase in intra-abdominal pressure can cause a rent in the musculature of the body wall. Less commonly, these can also occur in the inguinal or perineal regions. These will appear as an extra-abdominal mass, possibly containing abdominal viscera which may appear radiographically. Ultrasound can be used to further identify contents of the hernia. Surgical repair will be necessary.

26. Traumatic Hernia
Here’s an example of body wall herniation.

27. In summary Breath Stabilize
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