Makhambetchin M. M.

National Scientific Center of Traumatology and Orthopedics named after academician Batpenov N.D.,
the Republic of Kazakhstan

Over the past 20 years, the active equipment of clinics with computed tomography (CT) scanners, the latest anesthesia and respiratory devices, the improvement of the technology for the preparation of donor blood components, and the introduction of modern clinical protocols have been parallel to the growth of the car park and the number of high-energy injuries [1]. In large clinics where patients with polytrauma are concentrated, experience has been formed in the treatment of various severe concomitant injuries. At the same time, the practice of effective treatment of patients with polytrauma does not have such a long history as to be sufficiently covered in the medical literature in all aspects. Polytrauma is one of the most difficult sections of general surgery. The variety of combinations and severity of injuries implies a vast amount of information that will grow in parallel with the development of medicine, and it takes time to stage-by-stage generalizations of its individual aspects in the literature. One of the important approaches in covering the problem of polytrauma is the diagnosis of concomitant closed chest trauma.
Chest injury dominates in the structure of concomitant injuries (a subtype of polytrauma) [2, 3, 4]. Severe concomitant chest injury is accompanied by high mortality [5, 6, 7, 8]. Timely diagnosis and treatment of chest injuries in polytrauma is important both because of the physiological role of the lungs and heart for the whole organism, and because of possible difficulties for timely diagnosis.

It is indisputable that CT should be the diagnostic standard for polytrauma, since it solves almost all the difficulties in diagnosing chest injuries. At the same time, it must be admitted that the role of radiography, even in clinics with the possibility of round-the-clock CT, still remains high, as well as the role of medical institutions where such an opportunity is not available. Often, hemodynamics in patients with polytrauma is unstable, which is a contraindication to CT. After the primary CT scan, where the patient had uncomplicated rib fractures, already in the intensive care unit on artificial ventilation, one or several injuries can develop or manifest simultaneously over time. It is not always possible and irrational to transport a patient with severe concomitant injuries for repeated CT scans during the day instead of an on-site radiograph.

Radiography, widely used in polytrauma, often being the only possible and accessible objective method, is performed for a seriously ill patient in the supine position, which, in the presence of two or more injuries (hemothorax, pneumothorax, pulmonary contusion, atelectasis, diaphragmatic rupture), can be extremely difficult to interpret . It is this fact that makes timely diagnosis difficult, and can contribute to both hyper- and underdiagnosis. An analysis of errors and difficulties in interpreting such radiographs made it possible to identify a number of stereotypes that make diagnosis difficult.

The objective of the report
- to present the main stereotypes of chest X-ray perception that make it difficult to diagnose injuries (pneumothorax, hemothorax, atelectasis, pulmonary contusion, diaphragmatic rupture) in closed chest injury with concomitant injuries.

Complicated radiographs taken in the supine position turned out to be “orphans” in the sense that there are practically no such radiographs either in the surgical or in the radiological widely available literature. Their study hung between radiologists and surgeons. It is difficult for radiologists to interpret such radiographs without a clinical course, and surgeons lack radiographic experience. In addition to the fact that X-ray images in the supine position are difficult to interpret, there are other factors that make emergency care difficult. These include the extremely serious condition of the victims and the limited time and opportunities for examination and decision-making, while minutes of delay can be fatal for a seriously ill patient. In some hospitals, concomitant injury to the chest is a rare pathology, and it is difficult to develop the necessary experience of adequate emergency care before transportation to the next level of trauma centers or the arrival of specialized care.

This article presents a number of stereotypes that impede the correct diagnosis and optimal care for closed chest trauma, which are formed on the basis of the information that dominates in the medical literature, consecrating mainly the experience with treating open and isolated chest injuries.

The stereotypes that will be presented below relate to ten major injuries: pneumothorax, hemothorax, hemopneumothorax, atelectasis, pulmonary contusion, diaphragmatic rupture, pulmonary edema, aspiration, respiratory distress syndrome, fat embolism, which may have similar shading on the radiograph, are difficult to diagnose with simultaneous combination. Meanwhile, the treatment of these injuries is fundamentally different.

Stereotype 1. To expect and look for typical signs of pneumothorax and hemothorax on the X-ray image taken in the supine position, as on the upright X-ray images dominating the literature.

Free air in a pneumothorax appears on x-ray in the supine position in front of the lung, which may occupy the entire width of the posterior part of the hemithorax and appear flattened on x-rays. The typical direct and indirect signs of pneumothorax indicated in Figure 1, coupled with auscultation data, allow it to be identified in a timely manner in the absence of a typical sign - the edge of a compressed, collapsed lung.

Figure 1. a) A typical sign of pneumothorax on radiographs in any position; b) Pneumothorax on the radiograph in the supine position; the arrows indicate the band of enlightenment above the left dome of the diaphragm, which in a day increased to medium size and was drained; c) On the radiograph in the supine position, arrows indicate the shadow of the edge of the lower lobe of the left lung with pneumothorax; a day later, against the background of growing pneumothorax, a complete compression collapse of the left lung developed; d) On the radiograph in the supine position, the arrows indicate the displacement of the mediastinum to the left, the deep right costophrenic sinus with tension right-sided pneumothorax with severe respiratory failure


Free blood in the pleural cavity in the supine position spreads along the posterior wall of the cavity and darkens the entire lung field on the radiograph, hiding the shadows of the edge of the collapsed lung, the shadow of atelectasis, lung contusion, and the exit of the abdominal organs into the pleural cavity through a diaphragm rupture. The intensity of the darkening depends on the amount of blood. The darkening is usually homogeneous, "cloudy", hiding contrasting shadows, while the shadows from bruising of the lung parenchyma, pulmonary edema, respiratory distress syndrome are heterogeneous and more contrasting.
Figure 2 shows the typical signs of hemopneumothorax on X-ray images in the upright position and specific signs of hemopneumothorax on X-ray images in the total supine position.

Figure 2. a) Typical signs of hemopneumothorax on radiographs in a vertical position; the edge of the collapsed lung is indicated by the arrow; the horizontal level of darkening indicates the presence of free air above the liquid; b) On the X-ray in the supine position, there is a total, uniform, «muddy» darkening of the right hemithorax, which indicates a hemothorax that hides the borders of the diaphragm and the heart, but the arrow indicates a clear shadow of the edge of the right borders of the heart, which indirectly indicates the presence of a free air; c) One of the CT scans after radiograph A, where the presence of free air and fluid is clearly visible; d) On the radiograph in the supine position, there is a tense hemopneumothorax on the left, manifested by a shift of the mediastinum to the right, a deep left costophrenic sinus, some flattening of the left dome of the diaphragm; the intensity of darkening indicates a slight hemothorax (800 ml of blood was obtained during thoracocentesis); air was released during thoracocentesis under pressure


Stereotype 2. To trust more radiographs, ignoring auscultation.

Auscultation in polytrauma is especially important when the radiograph is taken in the supine position and CT is not available. The ability to listen to the lungs makes the doctor more effective in both diagnosing and treating polytrauma. Tension pneumothorax, and cardiac tamponade are deadly pathologies that should be detected clinically, and not instrumentally, since one may not have time to provide assistance.
The line of the edge of the collapsed lung on the radiograph can be so delicate that against the background of the entire shadow picture it appears and disappears in a strange way. Figure 3a shows an example of such a pneumothorax. The phenomenon of "non-permanent" shadow on the native radiograph appears more clearly than in the photo in a magazine. Without auscultation, such pneumothorax is more likely to be missed. On the contrary, not all contrasting lines of the "edge of the collapsed" lung are actually such. In Figure 3b-d, the clear lines of the "edge of the collapsed" lung are actually shadows from the dorsal skin fold. Skin folds are easily formed in patients with "flabby" skin when moving the X-ray cassette to the right and left, up and down. With such radiographs without auscultation, there is a high probability of overdiagnosis and vain thoracocentesis with the risk of iatrogenic complications.

Figure 3. a) Pneumothorax with an inconstant shadow of the edge of the collapsed lung (in the circle, the shadow of the edge of the lung, which either appears or disappears); b-d) False pneumothoraxes due to back skin folds


Stereotype 3. To pay attention only to enlightenment and darkening, ignoring the type of laying and assessing the position of the mediastinal shadow.

  True mediastinal shadow displacement on complex radiographs may be a clue to the diagnosis. The shadow of the mediastinum shifts to one side or another when the chest is turned from left to right or from right to left. Such a shift is false, caused by asymmetrical laying, which is possible with polytrauma. Therefore, to assess the position of the mediastinal shadow, it is necessary to firstly assess the symmetry of the stacking. The usual landmarks of symmetry are the position of the sternal ends of the clavicles relative to the spinous processes of the vertebrae. The distance between the sternal end of the clavicle and the shadow of the spinous processes of the thoracic vertebrae should be the same. Another landmark is the width of the right and left half of the chest in comparison. When turning from left to right, the left half is already right - and vice versa.
If there is a reversal, i.e. asymmetric laying, but at the same time the shadow of the mediastinum is in a physiological position, then there is a hidden displacement of the shadow of the mediastinum. If the chest is rotated from left to right, then the mediastinal shadow should shift to the right, and if instead the shadow is in a physiological position, then the mediastinum is actually shifted to the left. A shift to the left causes tension pneumothorax, tension hemopneumothorax, large hemothorax on the right, and exit of the liver or other organs into the right pleural cavity through a rupture of the right dome of the diaphragm or atelectasis on the left.

In Figure 4a, the yellow lines reflect an asymmetrical laying, and a turn from left to right. However, despite this laying, the mediastinal shadow is shifted to the left instead of shifting to the right. It means that on the right something pushes the mediastinum to the left or on the left something pulls the mediastinum towards itself. Left-sided atelectasis, pronounced pneumofibrosis with a decrease in lung volume, and previously undergone lobectomy “can pull on itself”. There are no signs of thoracotomy on the body or on the X-ray image, which would indicate the possibility of a lobectomy. There is also no shadow picture of atelectasis and pneumofibrosis to explain the shift of the mediastinum to the left. Then, on the right, one should look for pneumothorax, which, according to indirect signs, is present (flattening of the dome of the diaphragm, deepening of the costophrenic sinus). In addition to the listed signs, the pneumopericardium also speaks for a tense pneumothorax (the pericardial line can be so contrasted only if there is air in the pericardial cavity).
Figure 4b shows the same asymmetrical laying, turning from left to right. In this case, the shadow of the mediastinum is slightly shifted according to the laying to the right. On the radiograph, there are signs of hemopneumothorax (fluid level and the edge of the collapsed lung), since the mediastinal shadow shift corresponds to the laying, which means that the hemopneumothorax is not strained.
In Figure 4c, according to the location of the clavicles relative to the spinous process of the thoracic vertebrae, the laying is symmetrical, and the shadow of the mediastinum should be in a physiological position. However, it is shifted to the left, the right contours of the spinal column at the level of the heart are “bare”, and the right borders of the heart have shifted to the left. What pushes the mediastinum on the right or pulls the mediastinum towards itself on the left? There are no typical signs of pneumothorax on the right, and there is a total blackout on the left. The latter on the first day after injury may be associated with either hemothorax or atelectasis.
Hemothorax in the first hours of injury is more common than total atelectasis of the entire lung, so the surgeon, without assessing the position of the mediastinal shadow, taking total blackout stereotypically for hemothorax, performed thoracocentesis on the left. The result is an iatrogenic total pneumothorax. With a preliminary assessment of the position of the mediastinal shadow, ascertaining its displacement to the left, and not to the right, as one would expect from a massive hemothorax on the left, the surgeon could question the diagnosis of hemothorax. On the radiograph of Figure 4a, there is a band of enlightenment along the upper left contours of the heart, which is commonly called the “silhouette” symptom in atelectasis.
The next example with mediastinal displacement is shown in Figure 4d. Changes in the lung field on the left are difficult to interpret. As result, we resort to assessing the position of the mediastinal shadow. With asymmetrical styling, according to the position of the collarbones, there is a turn from left to right. The shadow of the mediastinum should shift to the right. The shift is present, but it is excessive for such a reversal. So something is pushing on the left or something is pulling on the right. There are no signs of atelectasis on the right (darkening, lifting of the dome of the diaphragm). There are no typical direct signs of pneumothorax on the left, as well as indirect signs (enlightenment above the dome of the diaphragm, flattening of the dome, deep rib-diaphragmatic sinus).
The diaphragm is not clearly visualized on the left, which, coupled with the shift of the mediastinum to the right, fits into the gap of the diaphragm on the left with the exit of the abdominal organs into the left pleural cavity. The patient received surgery. The rupture of the diaphragm was sutured. Assessment of the position of the mediastinum is especially important in bilateral lesions and complex radiographs and may be a clue to the diagnosis.

Figure 4. a) Tension pneumothorax on the right, which is suspected by the shift of the mediastinal shadow to the left despite the turn from left to right, along the deep costophrenic sinus, pneumopericardium; b) Non-tensioned hemopneumothrax on the left (explanation in the text); c) Total traumatic atelectasis of the left lung, “silhouette” symptom; d) Rupture of the left dome of the diaphragm with the exit of the abdominal organs into the left pleural cavity

Stereotype 4. A complete collapse of the lung is present in tension pneumothorax.

This stereotype occurred in some reprinted textbooks and manuals, which mainly reflect the experience of diagnosing and treating open and isolated chest injuries. It is probably based on the experience of two world wars, where chest trauma was open (bayonet, gunshot) in most cases. However, experience in the treatment of concomitant closed chest injuries in peacetime revealed the following fact: tension pneumothorax in closed injuries, as a rule, proceeds with partial collapse of the lung. Non-tension pneumothorax can be either partial or complete collapse of the lungs. For the first time, the observation of a number of cases of tension pneumothorax with unusual radiographs (with partial collapse of the lungs) was published in Bulletin of Surgery named after I. I. Grekov in 2014 (Vol. 173, No. 4; 57-61). Since then, we have observed the only case of tension pneumothorax in a closed injury with a complete collapse of the lung on the background of bullous disease. All other cases of tension pneumothorax and hemopneumothorax with a closed injury in the picture were manifested by a partial collapse of the lung.
A striking example of these observations is the case of a tension pneumothorax with lung collapse on X-ray by ¼ hemithorax (Fig. 5a). Knowledge of a similar course of tension pneumothorax with a closed injury will allow it to be detected on complex images in the supine position.

Figure 5. a) Tension pneumothorax on the left with partial (by 1/4) collapse of the lung, with a pronounced shift of the mediastinal shadow to the right; b) Tension pneumothorax on the left with partial (by 1/7) collapse of the lung, with a moderate shift of the mediastinal shadow to the right; c) Tension pneumothorax on the left with partial (by 1/4) collapse of the lung, with a pronounced shift of the mediastinal shadow to the right, in the region of the shadow of the edge of the scapula there is a shadow of the edge of the left lung; d) Tense hemopneumothorax on the left with partial (by 1/6) collapse of the lung, with a pronounced shift of the mediastinal shadow to the right



Diagnostic interpretation of plain chest radiographs in severely ill patients in the supine position, when CT is not possible for various reasons, should take into account auscultation (lungs, heart), examination (excursions, signs of trauma), palpation of the ribs, and saturation. Reasoning with the involvement of the above facts must necessarily include the following: the laying, the mediastinum shift according to the laying, and presence of mediastinal shift. If there is a shift, then it is true or false, hidden, reduced or enhanced by the laying. When the image is complicated due to bilateral lesions, reasoning (when CT is not possible) becomes the leading one in the diagnosis of chest injuries.

Funding and conflict of interest information

The study was not sponsored.
The author declares the absence of obvious and potential conflicts of interest related to the publication of this article.


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