Franco Guida

Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the ‘gold standard’ for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.

Multidetector computed tomography in the diagnosis and management of renal trauma.

Renal injuries fall within the broad and complex subject of retroperitoneal trauma. Although their computed tomography (CT) features have been known for a while, the timing, diagnostic approach and management are still debated. In addition, some areas of uncertainty remain regarding timing, indications and imaging modalities to be used in the follow-up of these patients. The purpose of this paper is to review the impact of CT on the management of renal trauma, stressing the importance of this technique and the role of the radiologist in the timing of decisions. Finally, we discuss the diagnostic approach to the follow-up of renal trauma.RiassuntoI traumi renali rientrano nel complesso e vasto capitolo dei traumi retroperitoneali. Nonostante la semeiotica in tomografia computerizzata (TC) del trauma sia nota da tempo, ancora oggi si discute sui tempi, l’approccio diagnostico e le modalità di gestione. Inoltre, qualche linea d’ombra rimane sui tempi, le indicazioni e le metodiche di imaging da utilizzare nel follow-up. Scopo di questo lavoro è rivedere l’impatto della TC sulla gestione del trauma renale, sottolineando l’importanza della metodica ed il ruolo decisivo del radiologo nel timing decisionale. Infine verrà discusso l’approccio diagnostico nel follow-up dei traumi renali.

Imaging of Drug Smuggling by Body Packing

Body packing, pushing, and stuffing are hazardous practices with complex medicolegal and social implications. A radiologist plays both a social and a medicolegal role in their assessment, and it should not be limited only to the identification of the packages but must also provide accurate information about their number and their exact location so as to prevent any package remains in the body packer. Radiologists must also be able to recognize the complications associated with these risky practices. Imaging assessment of body packing is performed essentially through plain abdominal X-ray and computed tomography scans. Ultrasound and magnetic resonance imaging, although with some advantages, actually have a limited use.

Errors in Imaging Assessment of Polytrauma Patients

Although the use of multidetector computed tomography (MDCT) has increased the diagnostic quality by reducing the number of missed diagnoses in polytraumatized patients, errors remain a common phenomenon in emergency room setting. MDCT errors, contributing more commonly to missed or delayed diagnoses in polytrauma patients, are diagnostic errors commonly related to perceptual errors or to nonvisual errors. However, in some cases, misdiagnoses can be attributed to technical and methodological errors leading to incomplete or poor-quality imaging. Knowledge of common patterns of error is the most effective way to avoid future errors. The purpose of this article is to highlight the most frequent types of diagnostic errors in evaluating with MDCT of polytrauma patients.

Errors in Polytrauma

In the managing of traumatized patients, and even more so in dealing with normal dynamic diagnostics, an error can increase the rate of mortality and morbidity. While procedural or clinical-diagnostic errors are more frequent in medical facilities that are not dedicated to trauma, they can involve patients in highly specialized trauma centers as well. The occurrence of these errors, in a wider sense, can be explained by the different dynamics in relation to the seriousness of the trauma (dyminor or major). Most diagnostic errors (dydowngrading of an injury) in radiology occur using traditional imaging studies, i.e., plain films and ultrasound, because of their intrinsic low resolution and/or limited field of view. On the other hand, the use of MDCT in trauma patients requires the adoption of tailored protocols and skill to highlight subtle or even minimal signs of injuries, especially in the subclinical status [1].

Traumatic Injuries: Mechanisms of Lesions

The effects of each trauma are strongly related to the mechanisms of lesions. Forensic medicine distinguishes two main trauma categories: blunt and penetrating in nature.

MDCT Imaging of Blunt Traumatic Bowel and Colonic Perforation

The intestine represents the third most frequently involved structure in blunt abdominal trauma (BAT) after the liver and the spleen. Injuries of the small bowel and of the colon are relatively uncommon, being found in approximately 3–5 % of patients undergoing laparotomy and in about 1 % of patients evaluated with computed tomography. In the broad spectrum of intestinal injuries from BAT, small bowel and colonic perforations represent a significant condition for several reasons. Clinical assessment alone of patients with suspected intestinal injury from BAT is associated with unacceptable diagnostic delays. Prompt identification and proper classification of small bowel and colonic injuries by multidetector computed tomography represent crucial issues in the management of patients with BAT. Their prognosis is significantly influenced by a timely diagnosis in the cases requiring immediate surgical interventions. The radiologist may identify specific and nonspecific signs of traumatic bowel perforation, suggesting the opportunity of conservative treatment in the cases of mild and moderate, noncomplicated, or self-limiting injuries or addressing to surgery when necessary.

Foreign Bodies and Penetrating Injuries

Penetrating wounds include a wide spectrum of injuries ranging from clinically less important superficial wounds to life-threatening lesions of parenchymal organs or hollow viscera, skeletal damage, or feared vascular injuries leading to fatal bleeding. In the last decades, multidetector computed tomography (MDCT) imaging represents the ‘gold standard’ in the evaluation of patients with penetrating wounds. A correct multiphasic post-contrastographic MDCT study provides important diagnostic information such as the detection of foreign bodies and its trajectory, detection and staging of parenchymal organs, and hollow viscera injuries as well as the detection of active bleeding, differentiating hemorrhage from contained vascular lesions and from collecting system injuries. The radiologist’s role relies on the early and definite characterization of injuries, thus directing the patient toward the most appropriate and timely management. In this context, CT can help select the patient that can be safely treated nonoperatively, reduce the number of unnecessary/nontherapeutic laparotomies, or guide toward a selective interventional approach.