Presentation
High speed car accident.
Patient Data
Bilateral apical pleural capping and widening of the superior mediastinal outline in a supine trauma patient. Appearance suggests aortic injury or substantial upper thoracic spine injury. There is a transverse fracture through the infraspinous portion of the left scapula body.
Pelvic radiograph shows external pelvic binder has been applied. Pelvis is slightly rotated. Comminuted fractures of the right pubic rami, fractured left acetabulum and fractured right sacral ala. There is widening of the pubic symphysis.
Burst type T3 vertebral body fracture and T4 vertebral body fracture with large associated haematoma within the superior mediastinum extending to the apical extra-pleural regions accounting for the appearances on chest x-ray. No aortic intimal flap or contrast extravasation.
The T3 fracture is particularly unstable with horizontally orientated fracture of the posterior elements (bilateral pars interarticularis and lamina) indicating a 3 column injury. Multiple retropulsed bone fragments are present within the spinal canal which may be associated with cord injury or compression particularly if there is any epidural haematoma.
The pelvic CT was performed during the arterial phase to enable assessment for active arterial bleeding. Bilateral pubic rami fractures, left acetabular fracture and right sacral ala fracture through the anterior sacral foramina (Denis zone 2 fracture). There is diastasis of the pubic symphysis. No active arterial bleeding is demonstrated however there is extensive extra-peritoneal pelvic haemorrhage. There is a high probability of a posterior urethral injury or extra-peritoneal bladder injury which could be investigated with cystourethrography.
Additional findings: left scapula fracture, bilateral small haemothoraces with adjacent atelectasis / pulmonary contusion, right first rib fracture, several transverse process fractures.
Case Discussion
This case demonstrates a nice example of apical capping on trauma chest x-ray due to severe upper thoracic spine injury with mediastinal and extra-pleural haematoma. The other major differential diagnosis for this chest x-ray appearance would be thoracic aortic injury which was not present in this case. Description of all chest, thoracic spine and pelvic findings in this patient are found under the 'finding' sections.
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