Trauma and Foreign Body Radiography

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Trauma and Foreign Body Radiography

• Chapter 13

3/01/2012 class ed.
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What is trauma?

• Sudden, unexpected, dramatic, forceful, or
  violent event
• Common types
• Blunt trauma- physical trauma caused to body
  part by impact, injury
• or physical attack
• Blunt Abdominal trauma- physical trauma to
  abdomen
• Penetrating trauma- when object pierces skin,
  enters tissue of body, creating an open wound
• Explosion
• Thermal forces- fire

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Blunt Abdominal Trauma(BAT)

• 50 to 75 percent of all blunt trauma is blunt
  abdominal trauma- mostly car collisions due to
  rapid deceleration by steering wheel or dashboard

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Immobilization

• Many ER pts arrive in immobilization devices
• Do not remove immobilization devices unless
  ordered by Dr.!!!!
• -perform exam with immobilization still in
  place
• 1st images - to rule out injury and show if safe
  to remove immobilization

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Preliminary Considerations in Trauma Radiography

• Speed
• produce quality images in shortest possible time
• Accuracy
• Get it right the 1st time! Or minimal repeats
• Quality
• Quality cannot be sacrificed for speed
• Do not use pt condition as excuse for poor
  quality images!

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Mobile fluoroscopy units

• C-arms may be used in instead of plain images
  for
• Fx. reduction
• Or foreign body localizations

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When Positioning-Do no harm!

• Important not to aggravate pts condition when
  obtaining images
• Provide immobilization support to reduce risk of
  motion
• Move tube and IR, instead of pt, whenever
  possible
• Expect to be exposed to body fluids
• Pay careful attention to pts condition- could
  change at any time!

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Remember Trauma often causes anxiety!

• Use good communication skills with appropriate
  touch and eye contact
• Explain and demonstrate positions, when possible
• Check pt for potential artifacts
• Explain what you are removing and why
• Secure all personal effects using proper
  procedure for your facility
• Use short exposure times --why?

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SID

• When SID not specified for a projection,
  Merrills Atlas recommends 48?? ?
• 60?? to 72?? SID recommended for projections with
  increased OID
• Why?

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Radiation Protection

• Shield all pediatric pts and pts of reproductive
  age
• Unless it will compromise exam!
• Use tight collimation
• Optimum technique factors
• (high mA, low time)

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If backboard is present, unavoidable artifacts
may be seen
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Crosstable Lateral Cervical Spine

• Perform 1st and check with physician before
  proceeding with other projections!
• Dorsal decubitus position, horizontal beam
• Shoulders relaxed
• Head -no rotation- ask pt to look straight ahead
  without moving head or neck
• Vertical IR placed at top of shoulder in holder

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Anterior Subluxation of C5 and C6
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Lateral Cervicothoracic Spine(Swimmers)

• Required if C7 and top of T1 not demonstrated on
  lateral C-spine
• Trauma- usually Dorsal decubitus position
• Pt supine -no rotation
• Ask pt to raise arm opposite x-ray tube over head

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Swimmers

• Demonstrates
• - lower cervical
• -upper thoracic
• Vertebrae in profile between shoulders

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AP Axial Cervical Spine

• Pt supine
• Usually immobilized with collar and spine board
• Place IR under spine board, if present, centered
  to C4
• Head and shoulders - no rotation
• Ask pt to look straight ahead
• Do not rotate head

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AP Axial Cervical Spine

• CR directed 15 - 20 degrees cephalad to enter MSP
  and C4
• Image demonstrates C3-T1 or T2
• Include all soft tissues

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AP Axial Cervical Spine
Trauma complete dislocation at C2-C3 11 yr old
girl died on table
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AP Axial Oblique Cervical Spine

• Head and shoulders without rotation
• Ask pt to look straight ahead
• Do not rotate head
• CR has double angle
• 45 degrees lateromedially
• 15 to 20 degrees which way?
• Use a grid?

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AP Axial Oblique Cervical Spine
Which projection?
Which formina demonstrated?
(RPO, Left)
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Thoracic and Lumbar Spine

• Dorsal decubitus positions performed 1st
• Vertical grid IR
• Top of IR 1.5?? to 2?? above shoulders for
  thoracic spine
• Centered to level of iliac crests for lumbar
  spine
• Have pt cross arms on anterior chest

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Trauma Lateral Lumbar Spine
CR and IR positioned for trauma lateral
projection of lumbar spine using dorsal decubitus
position
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Compression Fracture of
L2
T12
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Trauma AP Chest

• Pt. supine
• Obtain help to place cassette under pt.
• Top of IR placed about 1.5?? to 2?? above
  shoulders
• Arms abducted
• MCP parallel to IR
• Use maximum SID to reduce heart magnification

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Trauma AP Chest (contd)

• Ensure chin extended out of anatomy of interest
• CR directed perpendicular to center of IR
• Enters pt at MSP at about 3?? below jugular notch
• Exposure on 2nd full inhalation, if possible

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Trauma AP Chest (contd)

• Image must demonstrate lung fields in their
  entirety
• Minimal rotation and distortion present

Collapsed lung
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Lateral Decubitus Chest X-ray
If pts condition permits, position pt lying on
affected side
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Trauma Lateral Chest

• If air-fluid levels are suspected, use dorsal
  decubitus position

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Penetrating wounds to Abdomen

• Stabbings, gunshots
• Mark entrance and exit wounds, if present
• Align shoulders and hips in same plane

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Bullet Wound (IVP)
Demonstrate entire abdomen Pubic symphysis must
be visible at lower border
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When the pt. arrives-

• If transfer to x-ray table not possible, obtain
  lifting help to place IR with grid directly under
  pt
• Monitor pt closely for status change during
  procedures!

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Why take a Decubitus Abdomen?
Rule out free air
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Which decub is this?
Left (right would confuse free air with stomach
gas)
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Pelvis

• Pelvic fxs have high risk of hemorrhage pay
  close attention to pt for status change!
• Obtain lift help for IR placement under pt if
  transfer to x-ray table is not possible
• IR centered 2?? above pubic symphysis or 2??
  below ASIS

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Pelvis (contd)

• Lower limbs usually not rotated internally 15
  degrees in trauma cases
• Ensure arms not in anatomy of interest!
• Suspend respiration
• Demonstrate entire pelvis and prox. femora

Skippy
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Trauma AP Pelvis
Note fracture of left ilium and separation of
pubic bones
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Trauma AP Pelvis
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Contrast studies

• Why is a study of the urinary system often
  ordered?
• Suspected pelvic fxs often result in injury to
  urinary system

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Cranium

• Pts with head trauma are often referred to CT
  1st- Why?
• Much more information
• Standard x-ray routine
• AP and lateral
• Generally, pt is supine

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Trauma AP Cranium

• AP projection
• for anterior cranium
• AP axial projection- (aka?)
• Towne (for posterior cranium)
• Obtain lift help for IR placement if transfer to
  x-ray table is not possible
• C-spine injury should be ruled out first!

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Trauma AP Cranium (contd)

• Check for rotation and tilt
• CR centered perpendicular - nasion
• IR is to center of CR

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Trauma AP Cranium (contd)

• Demonstrates anterior cranium with petrous ridges
  filling orbits

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Trauma AP Axial Cranium (Towne)

• CR angled how many degrees?
• 30 deg. Caud
• 2 - 2 ½ above glabella
• Demonstrates posterior cranium
• Foramen magnum in center

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Trauma AP Axial Cranium (Towne)

• Check for rotation and tilt of head
• OML perpendicular to IR
• If IOML used, what must CR angle be changed to ?
• 37 degrees caudad!

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Trauma Lateral Cranium

• Elevate head on radiolucent support
• C-spine injury ruled out 1st!
• Place vertical IR centered to cranium
• Make sure interpupillary line is perpendicular to
  IR and MSP is vertical
• Horizontal CR enters center of IR and pt at 2??
  above EAM

dorsal decubitus position
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Trauma Lateral Cranium
Multiple fxs in frontal bone -2 gunshot wounds
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Facial Bones

• Often referred to CT first
• Anticipate profuse bleeding and use universal
  precautions

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Acanthioparietal Facial Bones

• Also known as?
• - Reverse waters
• Image demonstrates facial bones and maxillary
  sinuses
• Facial bones should be symmetric

opaque right maxillary sinus evidence of fx
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Modified Waters- reverse

• For orbits and facial bones
• Leave Pt. as is on guerney or table
• Angle CR cephalic if necessary to accommodate
  for lack of pt cooperation flexing neck

Normal modified waters
Reverse modified waters with compensating angle
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Alternate Waters Method
Do not angle pts head unless safe!
Extend head so acanthiomeatal line is 30 deg to
image receptor if pt. can cooperate
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Upper and Lower Limbs

• Obtain lift help for IR placement
• Injured limbs should be lifted with support at
  both jts (Move IR and CR, not injured limb when
  possible!)
• Lift only enough to place IR
• Do not attempt to rotate severely injured limbs
  for true positions
• 2 projections at 90 degrees apart
• Must demonstrate both adjacent jts
• (Take 2 separate projections if need be)

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Many projections can be reversed or modified

• Most trauma pts. arrive in supine position
• radiograph pt. as is!
• Move as little as possible

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Reversing or Modifying Extremity Projections

• Obtain x-table lateral or decubitus images if pt.
  is unable to stand or rotate body part to desired
  position

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Foot Trauma
Foot Trauma
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Foot Trauma
GSW
Dislocation Tarsal bones
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Foreign Body

• Any alien object that enters body by puncture or
  natural orifice
• May have to be surgically removed
• To localize radiographically- obtain 2 views at
  right angles to each other

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Technical Considerations

• Why use small focal spot?
• Why must screens clean?
• How might exposure factors be adjusted to display
  soft tissue?
• Why is positioning crucial to determine depth of
  penetrating injury?
• Why is marking entry points for penetrating
  foreign objects helpful?

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Radiographic Localization Techniques

• Penetrating foreign bodies (bullet)
• Direct CR through foreign body
• Obtain right angle views, PA or AP and lateral
• Indicate site of puncture wound
• Obtain additional projections as indicated by Dr.

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Aspirated (in lungs) or Swallowed Objects

• Children- often do on purpose!
• Adults - usually accidental
• Mentally disturbed patients
• Compulsively swallow objects

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Aspirated or Swallowed Objects contd

• Respiratory System
• Include entire neck and chest
• Digestive System
• Include neck, chest and abdomen

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Aspirated Foreign Body
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Swallowed Foreign Body
Implied by absence of air
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Swallowed Foreign Body