1. Trauma and Foreign Body Radiography
Chapter 13
Trauma and Foreign Body Radiography
online ed.

2. Blunt trauma- physical trauma caused to body part by impact, injury
What is trauma?
Sudden, unexpected, dramatic, forceful, or violent event
Common types:
Blunt trauma- physical trauma caused to body part by impact, injury
or physical attack
Blunt Abdominal trauma- physical trauma to abdomen
Penetrating trauma- when object pierces skin, enters tissue of body, creating an open wound
Explosion
Thermal forces- fire

3. Blunt Abdominal Trauma (BAT)
50% to 75 percent of all blunt trauma is blunt abdominal trauma- mostly car collisions due to rapid deceleration by steering wheel or dashboard

4. Immobilization Many ER pts arrive in immobilization devices
Do not remove immobilization devices unless ordered by Dr.!!!!
-perform exam with immobilization still in place
1st images - to rule out injury and show if safe to remove immobilization

5. Preliminary Considerations in Trauma Radiography
Speed
produce quality images in shortest possible time
Accuracy
Get it right the 1st time! Or minimal repeats
Quality
Quality cannot be sacrificed for speed
Do not use pt condition as excuse for poor quality images!

6. Mobile fluoroscopy units
C-arms may be used in instead of plain images for:
Fx. reduction
Or foreign body localizations

7. When Positioning- Do no harm!
Important not to aggravate pt’s condition when obtaining images
Provide immobilization support to reduce risk of motion
Move tube and IR, instead of pt, whenever possible
Expect to be exposed to body fluids
Pay careful attention to pt’s condition- could change at any time!

8. Remember: Trauma often causes anxiety!
Use good communication skills with appropriate touch and eye contact
Explain and demonstrate positions, when possible
Check pt for potential artifacts
Explain what you are removing and why
Secure all personal effects using proper procedure for your facility
Use short exposure times --why?

9. SID
When SID not specified for a projection, Merrill’s Atlas recommends 48 ?
60 to 72 SID recommended for projections with increased OID
Why?

10. Radiation Protection
Shield all pediatric pts and pts of reproductive age
Unless it will compromise exam!
Use tight collimation
Optimum technique factors
(high mA, low time)

11. If backboard is present, unavoidable artifacts may be seen

12. Crosstable Lateral Cervical Spine
Perform 1st and check with physician before proceeding with other projections!
Dorsal decubitus position, horizontal beam
Shoulders relaxed
Head -no rotation- ask pt to look straight ahead without moving head or neck
Vertical IR placed at top of shoulder in holder

13. Lateral Cervicothoracic Spine (Swimmers)
Required if C7 and top of T1 not demonstrated on lateral C-spine
Trauma- usually Dorsal decubitus position
Pt supine -no rotation
Ask pt to raise arm opposite x-ray tube over head

14. Vertebrae in profile between shoulders
Swimmer’s
Demonstrates:
lower cervical
upper thoracic
Vertebrae in profile between shoulders

15. AP Axial Cervical Spine
Pt supine
Usually immobilized with collar and spine board
Place IR under spine board, if present, centered to C4
Head and shoulders - no rotation
Ask pt to look straight ahead
Do not rotate head

16. AP Axial Cervical Spine
CR directed degrees cephalad to enter MSP and C4
Image demonstrates C3-T1 or T2
Include all soft tissues

17. AP Axial Oblique Cervical Spine
Head and shoulders without rotation
Ask pt to look straight ahead
Do not rotate head
CR has double angle
45 degrees lateromedially
15 to 20 degrees which way?
Use a grid?

18. AP Axial Oblique Cervical Spine
Which projection?
Which formina demonstrated?
(RPO, Left)

19. Thoracic and Lumbar Spine
Dorsal decubitus positions performed 1st
Vertical grid IR
Top of IR 1.5 to 2 above shoulders for thoracic spine
Centered to level of iliac crests for lumbar spine
Have pt cross arms on anterior chest

20. Trauma Lateral Lumbar Spine
CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position

21. Trauma AP Chest Pt. supine Obtain help to place cassette under pt.
Top of IR placed about 1.5 to 2 above shoulders
Arms abducted
MCP parallel to IR
Use maximum SID to reduce heart magnification

22. Trauma AP Chest (cont’d)
Ensure chin extended out of anatomy of interest
CR directed perpendicular to center of IR
Enters pt at MSP at about 3 below jugular notch
Exposure on 2nd full inhalation, if possible

23. Trauma AP Chest (cont’d)
Image must demonstrate lung fields in their entirety
Minimal rotation and distortion present
Collapsed lung

24. Lateral Decubitus Chest X-ray
If pt’s condition permits, position pt lying on affected side

25. Trauma Lateral Chest
If air-fluid levels are suspected, use dorsal decubitus position

26. Penetrating wounds to Abdomen
Stabbings, gunshots
Mark entrance and exit wounds, if present
Align shoulders and hips in same plane

27. Bullet Wound (IVP) Demonstrate entire abdomen
Pubic symphysis must be visible at lower border

28. When the pt. arrives-
If transfer to x-ray table not possible, obtain lifting help to place IR with grid directly under pt
Monitor pt closely for status change during procedures!

29. Why take a Decubitus Abdomen?
Rule out free air

30. Left (right would confuse free air with stomach gas)
Which decub is this?
Left (right would confuse free air with stomach gas)

31. Pelvis
Pelvic fxs have high risk of hemorrhage – pay close attention to pt for status change!
Obtain lift help for IR placement under pt if transfer to x-ray table is not possible
IR centered 2 above pubic symphysis or 2 below ASIS

32. Pelvis (cont’d)
Lower limbs usually not rotated internally 15 degrees in trauma cases
Ensure arms not in anatomy of interest!
Suspend respiration
Demonstrate entire pelvis and prox. femora

33. Note: fracture of left ilium and separation of pubic bones
Trauma AP Pelvis
Note: fracture of left ilium and separation of pubic bones

34. Contrast studies Why is a study of the urinary system often ordered?
Suspected pelvic fxs often result in injury to urinary system

35. Cranium Pts with head trauma are often referred to CT 1st Why?
Much more information
Standard x-ray routine
AP and lateral
Generally, pt. is supine

36. Trauma AP Cranium AP projection AP axial projection- (aka?)
for anterior cranium
AP axial projection- (aka?)
Towne (for posterior cranium)
Obtain lift help for IR placement if transfer to x-ray table is not possible
C-spine injury should be ruled out first!

37. Trauma AP Cranium (cont’d)
Check for rotation and tilt
CR centered perpendicular - nasion
IR is to center of CR

38. Trauma AP Cranium (cont’d)
Demonstrates anterior cranium with petrous ridges filling orbits

39. Trauma AP Axial Cranium (Towne)
CR angled how many degrees?
30 deg. Caud
2 - 2 ½ “ above glabella
Demonstrates posterior cranium
Foramen magnum in center

40. Trauma AP Axial Cranium (Towne)
Check for rotation and tilt of head
OML perpendicular to IR
If IOML used, what must CR angle be changed to ?
37 degrees caudad!

41. Trauma Lateral Cranium
Elevate head on radiolucent support
C-spine injury ruled out 1st!
Place vertical IR centered to cranium
Make sure interpupillary line is perpendicular to IR and MSP is vertical
Horizontal CR enters center of IR and pt at 2 above EAM
dorsal decubitus position

42. Trauma Lateral Cranium
Multiple fxs in frontal bone -2 gunshot wounds

43. Facial Bones Often referred to CT first
Anticipate profuse bleeding and use universal precautions

44. Acanthioparietal Facial Bones
Also known as?
- Reverse waters
Image demonstrates facial bones and maxillary sinuses
Facial bones should be symmetric
opaque right maxillary sinus – evidence of fx

45. Modified Waters- reverse
For orbits and facial bones
Leave Pt. “as is” on guerney or table
Angle CR cephalic if necessary to accommodate for lack of pt cooperation flexing neck
Normal modified waters
Reverse modified waters with compensating angle

46. Alternate Water’s Method
Do not angle pt’s head unless safe!
Extend head so acanthiomeatal line is 30 deg to image receptor if pt. can cooperate

47. Upper and Lower Limbs Obtain lift help for IR placement
Injured limbs should be lifted with support at both jts (Move IR and CR, not injured limb when possible!)
Lift only enough to place IR
Do not attempt to rotate severely injured limbs for true positions
2 projections at 90 degrees apart
Must demonstrate both adjacent jts
(Take 2 separate projections if need be)

50. Many projections can be reversed or modified
Most trauma pts. arrive in supine position
radiograph pt. as is!
Move as little as possible

51. Reversing or Modifying Extremity Projections
Obtain x-table lateral or decubitus images if pt. is unable to stand or rotate body part to desired position

52. Foot Trauma

53. Any alien object that enters body by puncture or natural orifice
Foreign Body
Any alien object that enters body by puncture or natural orifice
May have to be surgically removed
To localize radiographically- obtain 2 views at right angles to each other

54. Technical Considerations
Why use small focal spot?
Why must screens clean?
How might exposure factors be adjusted to display soft tissue?
Why is positioning crucial to determine depth of penetrating injury?
Why is marking entry points for penetrating foreign objects helpful?

55. Radiographic Localization Techniques
Penetrating foreign bodies (bullet)
Direct CR through foreign body
Obtain right angle views, PA or AP and lateral
Indicate site of puncture wound
Obtain additional projections as indicated by Dr.

56. Aspirated (in lungs) or Swallowed Objects
Children- often do on purpose!
Adults - usually accidental
Mentally disturbed patients
Compulsively swallow objects

57. Aspirated or Swallowed Objects cont’d
Respiratory System
Include entire neck and chest
Digestive System
Include neck, chest and abdomen

58. Aspirated Foreign Body

59. Swallowed Foreign Body
Implied by absence of air