Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

1. Shades of Black and White Reading Trauma X Rays Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

2. Objectives • Most common initial X rays in the adult trauma patient • Normal and abnormal findings on: • cervical spine • chest • Examples of some ancillary studies

3. Why should you know about all this stuff?

4. Why should you know about all this stuff? • Flight and critical care crew members might intervene based on X rays • Feedback on your clinical patient evaluation • Catch some problems early (even before the doc) • Makes you a better trauma team member • Impress almost anybody

5. “The BIG3” • Cervical spine films • lateral • AP • odontoid (open mouth) • Supine chest film • AP pelvis film Some trauma teams routinely include a lateral lumbosacral spine film, to make the BIG 4

6. Ancillary Radiographic Studies • Extremity X rays • Other plain films • Retrograde urethrogram • Abdominal ultrasound • CT • Arteriography

7. Approach to Reading X rays • Know what normal anatomy looks like • Always take a systematic approach • A little distance can be a good thing • Experience counts

8. A Systematic Approach

9. Cervical Spine X rays

10. The Lateral Film • Is the film satisfactory? • Nothing obscured by jewelry or other opaque objects? • Penetration OK? • An adequate film?

11. A-O junction obscured by nameplate • Occiput and palate not seen • At least the top edge of T1 should be seen Not an adequate film!

12. Curves to Follow

13. Abnormalities in Curves • Malalignment of post. vertebral bodies = more significant than ant. • Spinal canal diameter is significantly narrowed if < 14 mm • Anterior subluxation caused by facet dislocation • < 50% VB width = unilateral • > 50% VB width = bilateral • widening interspinous spaces

14. Symmetry • Symmetry of bones • Intervertebral disc spaces

15. Often due to compression Compression of > 40% normal VB height usually indicates a burst fx with possible fragments into spinal canal Anterior compression may cause a “teardrop” shaped fx Abnormal Symmetry

16. Measurements • Soft tissue spaces • Retropharyngeal space • 7 mm at C2 • < 50% of width of VB at C4 and above • may be 100% width of VB below C4 • Retrotracheal space • 22 mm at C6 • 14 mm in children

17. Soft Tissue Measurements C 2 C 4 C 6 Abnormal measurements may indicate soft tissue swelling from obvious or occult fxs, hematomas, or abscesses

18. Ant. A-D Interval C 1 C 1 Dens (C 2) Anterior Atlanto-dens Interval • 3 mm in adults • 5 mm in children • >3.5 mm = T. L. injury • > 5 mm = T.L. rupture & instability

19. Intervertebral Disc Spaces • Decreased IVD space may indicate herniated disc

20. Atlanto-Occipital Distance • Distance from atlas (C1) to occiput should always be < 5mm • Increased distance may indicate atlanto-occipital dislocation

21. Spinous Processes Anterior-Posterior View • Symmetry/size • Alignment of spinous processes • Smooth, rolling lateral edges

22. Odontoid (Open mouth) View

23. C1 lateral mass C1 lateral mass Dens C2 Odontoid View Close-up

25. Abnormal Cervical Spine Films

26. Normal Atlanto-occipital Disassociation & Fx C1

28. Unilateral Facet Dislocation Bilateral Facet Dislocation

30. Odontoid (C2) fx

32. Shades of Black & White

33. Lateral view of odontoid fx on CT C1

34. C5 compression fx C5 compression fx

35. C6 burst fx/dislocation

36. C 5-6 fracture/dislocation on CT

37. C4 Teardrop Fx

38. Chest X rays

39. A Systematic Approach • The systematic approach involves evaluating: • adequacy of the film • bony structures • mediastinum/major vessels • lung fields • soft tissue • diaphragm/portion of abdomen visible

40. Adequacy of the Film • Do you have it hung up right? • Appropriate X ray penetration • Too light, can’t separate out subtle changes • Too penetrated, can’t evaluate lung fields well • Able to see both costophrenic angles and both apices

41. Bony Structures • Ribs • Fx of first and second ribs imply great force and potential for underlying great vessel, lung and airway damage • Sternum • Clavicles • Scapula • Fx may also imply great force and underlying injuries • Cervical and thoracic spine

42. Mediastinum and Major Vessels • Width of mediastinum • Aortic rupture • Size of cardiac shadow • Hemo or pneumopericardium • Underlying medical problem • Air in mediastinum • Trachea • Tracheal shift

43. Lung Fields • Pneumothorax/Tension Pneumothorax • Hemothorax • Pulmonary Contusion • Atelectasis • Infection • Pulmonary Edema

44. Soft Tissue • Subcutaneous emphysema • Foreign bodies/impaled objects

45. Diaphragm/Abdomen • Diaphragm position • Position of gastric air bubble and/or NG tube • Ruptured diaphragm • Free air under the diaphragm • Ruptured abdominal viscous organ

46. Normal Chest X ray • Adequacy • Bones • Mediastinum/major vessels/trachea • Lung fields • Soft tissue • Abdomen

47. Abnormal Chest X rays

48. Bony Abnormalities • Rib fx’s • Mediast. OK • Pulmonary contusion • Subcu air • Chest tube • NG tube

49. MVC victim

50. Scapular fx Pulmonary contusion