Faculty Bibliography

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. ^©RSNA, 2018.

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

In the setting of mass casualty incidents (MCI), hospitals need to divert from normal routine to delivering the best possible care to the largest number of victims. This should be accomplished by activating an established hospital Disaster Management Plan (DMP) known to all staff through prior training drills. Over the recent decades, imaging has increasingly been used to evaluate critically ill patients. It can be used as well to increase the accuracy of triaging MCI victims, since over-triage and under-triage can severely impact resource availability and mortality rates. This manuscript emphasizes the importance of including the radiology department in hospital preparations for an MCI, and highlights factors expected to influence performance during hospital DMP activation including issues pertinent to effective simulation, such as establishing proper learning objectives. After action reviews including performance evaluation and debriefing on issues is invaluable following simulation drills and DMP activation, in order to improve subsequent preparedness. Historically, most hospital DMPs have not adequately included radiology department operations and they have not or to little extent been integrated in the DMP activation simulation. This manuscript aims to increase awareness of the need for radiology department engagement in order to increase radiology department preparedness for DMP activation after an MCI occurs.

Tension pneumoperitoneum is a rare entity that occurs when free air under pressure accumulates in the abdominal cavity compromising visceral function and blood flow. The case of a 23-year-old man whose chest was run over by the wheels of a truck is presented. He arrived with a severely distended abdomen, significant thoracic trauma, hypoxemia, and elevated airway pressures following intubation. Imaging studies revealed massive intraperitoneal free air. He was treated with a decompressive laparotomy but was not found to have a hollow viscus nor diaphragmatic injury. We hypothesize a possible, as yet unpublished, mechanism: secondary to the patient's rib fractures and significant torso soft tissue shearing, a defect in the parietal pleura allowed air to track from the thorax inferiorly along subcutaneous and fascial planes, eventually entering into the peritoneal cavity through a violated parietal peritoneum. We present a review of the literature on tension pneumoperitoneum. 2013 The Author(s)

BACKGROUND: Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate. METHODS: This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute. RESULTS: Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30 degrees of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. CONCLUSIONS: Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

OBJECTIVE: The pregnant trauma patient requires imaging tests to diagnose maternal injuries and diagnostic tests to evaluate the viability of her pregnancy. This article will discuss abdominal trauma in pregnancy and the specific role of diagnostic imaging. Radiation concerns in pregnancy will be addressed. CONCLUSION: Trauma is the leading cause of nonobstetric maternal mortality and a significant cause of fetal loss. Both major and minor trauma result in an increased risk of fetal loss. In major trauma, when there is concern for maternal injury, CT is the mainstay of imaging. The risks of radiation to the pregnancy are small compared with the risk of missed or delayed diagnosis of trauma. In minor trauma, when there is no concern for maternal injury but there is concern about the pregnancy, ultrasound is performed but is insensitive in diagnosing placental abruption. External fetal monitoring is used to dictate patient care.

Maxillofacial skeletal injuries account for a large proportion of emergency department visits and often result in surgical consultation. Although many of the principles of detection and repair are basic, the evolution of technology and therapeutic strategies has led to improved patient outcomes. This article aims to provide a review of the imaging aspects involved in maxillofacial trauma and to delineate its relevance to management

Purpose: A pilot study was performed to assess the feasibility of a single pass spiral technique to image the head and face, or head, face, and cervical spine in the emergency setting. Materials and Methods: 23 patients requiring emergency imaging of head, face and cervical spine, and 5 patients for head and face were enrolled. Radiation dose (DLP) was measured and compared with isolated CT head and face and cervical spine acquisitions. Time to perform the single spiral scan was also measured. The quality of spiral CT heads was compared with 21 consecutive trauma axial CT heads on a five point scale in a blinded fashion. Results: Average DLP for single spiral CT head, face, and cervical spine was 2581.24, compared with DLP of 2867.22 for these performed separately. Average DLP for single pass head and face (including mandible) CT was 1749.45, compared with standard 2 scan DLP of 1887.81. Time to scan a single pass CT head, face, and cervical spine ranged from 4.4 to 5.8 s. Quality of spiral head CTcomparedwith axial in trauma patients showed no significant difference. Conclusion: Single pass emergency CT head & face, and head, face, & cervical spine is both time and radiation efficient without reduction in image quality