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Apical capping due to thoracic fractures, pelvic trauma

Case contributed by Dr Andrew Dixon


High speed car accident.

Patient Data

Age: 45 years
Gender: Male

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Trauma Series

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 hematoma 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 oriented 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 hematoma.

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 hemorrhage. 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 hemothoraces 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 hematoma. 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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Case information

rID: 31537
Published: 15th Oct 2014
Last edited: 2nd May 2020
Inclusion in quiz mode: Included

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