Role of the trauma-room chest x-ray film in assessing the patient with severe blunt traumatic injury.

OBJECTIVES: To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances. DESIGN: A retrospective review. SETTING: A regional trauma unit in a tertiary-care institution. PATIENTS: Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done. INTERVENTION: Standard radiography of the chest. MAIN OUTCOME MEASURES: Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings. RESULTS: Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation. CONCLUSIONS: Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room.

Mediastinal invasion by bronchogenic carcinoma: CT signs.

PURPOSE: To determine the accuracy of computed tomographic (CT) signs in assessment of direct mediastinal invasion by primary bronchogenic carcinoma. MATERIALS AND METHODS: In 90 patients with primary bronchogenic carcinoma who underwent CT with thoracic surgical staging and thoracotomy, the pathologic and CT findings in 14 mediastinal structures were compared retrospectively. The degree of contact of the primary tumor with each structure and whether the structure was distorted or contained intraluminal tumor were recorded. A total of 785 mediastinal structures (25 with tumor invasion) were analyzed. RESULTS: When greater than 90 degrees of contact was considered a positive CT finding, the sensitivity of CT was 40% (10 of 25 structures); specificity, 99% (752 of 760 structures); and positive and negative predictive values, 56% and 98%. All structures with > 180 degrees of contact had pathologic involvement, but only 11 of 17 distorted structures (65%) and five of seven structures with intraluminal tumor (71%) were involved. CONCLUSION: CT is insensitive in detection of mediastinal invasion by primary bronchogenic carcinoma. The positive predictive value may be higher, depending on the criteria used.

Tangential fluoroscopic guidance of the anesthetizing needle during transthoracic needle lung biopsy: a randomized controlled clinical trial.

The effectiveness of tangential fluoroscopic guidance of the anesthetizing needle to avoid transgression of the pleura and therefore lower pneumothorax and chest tube insertion rates after transthoracic needle lung biopsy (TNB) was investigated. Tangential guidance was used in 41 patients (group A) and was not used in 51 (group B). The pneumothorax rate was 39% (16 of 41) for group A and 31% (16 of 51) for group B. The chest tube insertion rate was 12% (five of 41) for group A and 4% (two of 51) for group B. None of the differences in rates were significant. Use of this technique does not lower pneumothorax or chest tube insertion rates in patients undergoing TNB.

Thin-walled cystic lesions in bronchioalveolar carcinoma.

In a retrospective study, thin-walled cystic lesions were identified in four patients with proved bronchioalveolar carcinoma (BAC). The radiographic appearances are described, and possible mechanisms of formation of the lesions are discussed. Although such appearances due to BAC have rarely been described in the literature, the authors believe that the differential diagnosis of thin-walled cystic lesions associated with consolidation should include BAC.

Psoas muscle calcification and acute renal failure associated with nontraumatic rhabdomyolysis: CT features.

We present a case of reversible psoas muscle calcification associated with acute renal failure and alcohol intoxication. The CT demonstration of calcification led to the recognition of rhabdomyolysis.

Medial talo-calcaneal coalition. Case report.

Medial talo-calcaneal coalition is an uncommon developmental anomaly consisting of a bony projection arising from the postero-medial aspect of the sustentaculum tali, which may articulate with another bony projection from the medial aspect of the talus. Fibrous, cartilaginous or bony ankylosis may occur. It usually presents in adolescents, and causes pain following exercise. It may cause a lump, and can predispose to flat foot and early osteoarthrosis. This condition is easily overlooked on routine views of the ankle, and may require oblique views and tomography for its detection and clarification.