Here’s one from my old-timer collection of actual celluloid x-rays! If I give you the history, I will probably give away the diagnosis. So let’s see if you can do it without.
This xray is a classic for a specific trauma surgical injury. Give it your best shot! Here’s a hint to focus your attention: look at the thoracoabdomen, not the pelvis.
This image is especially appropriate for surgical residents / registrars.
Answer in the next post!
Blunt thoracic aortic injury (BTAI) is one of those high-acuity, low-occurrence events that trauma professionals cannot afford to miss. These injuries are a ticking time bomb that is just waiting to blow up your patient.
Diagnostic techniques have evolved over the years. Back in the old days (before CT angiography), we always performed a screening chest x-ray and used the “pager test.”
In those days, the x-rays were processed on celluloid and placed on a light box on the wall. We would place our pager against the film. If the aortic arch was wider than the length of the pager, the patient had a wide mediastinum, and we had to rule out BTAI. And in those days, contrast angiography was the only test available. This was a major production, and we did lots of them. Most were negative.
My, how we have advanced. We have now added contrast-enhanced CT (CECT) and transesophageal ultrasound (TEUS) to our armamentarium. The question now is, what is the best screening test?
A group of Italian clinicians performed a systematic review and meta-analysis of these modalities to determine which had the best diagnostic accuracy.
Here are the factoids:
| Modality | # studies | Sensitivity | Specificity | AUC (ROC) |
| Chest x-ray | 11 | .87 | .56 | .85 |
| Angiography | 16 | .97 | .99 | 1.00 |
| CECT | 34 | .98 | .97 | 1.00 |
| TEUS | 16 | .94 | .99 | .99 |
Bottom line: Basically, angiography, CECT, and TEUS were equivalent. Chest x-ray had poor sensitivity and specificity. So back in the day, we probably made a lot of errors.
When multiple tests have similar performance, the preferred test should be chosen based on availability, ease of use, and bonus information the study may provide. Hands down, the winner is contrast-enhanced chest CT. This is commonly performed in major trauma patients already and provides a wealth of diagnostic information. It is well-tolerated and relatively inexpensive.
The final answer, then, is contrast-enhanced CT. And I would add one little extra. As I’ve written about previously, our current criteria for identifying blunt carotid and vertebral injury (BCVI) miss about 25% of injuries. They are readily seen on CECT, though. It is relatively simple to modify the CECT chest protocol to capture the neck arteries with the same contrast dose. I strongly recommend updating your imaging protocol so that, whenever you obtain a CECT chest, the CECT neck is automatically added.
Reference: Defining the criterion standard for detecting blunt traumatic aortic injuries: A systematic review and meta-analysis of diagnostic test accuracy. J Trauma Acute Care Surg. 2025 Aug 1;99(2):279-288. doi: 10.1097/TA.0000000000004642. Epub 2025 May 20. PMID: 40390169.
This xray is a classic for a specific trauma surgical injury. Give it your best shot! Tweet of leave comments with your impressions.
This image is especially appropriate for surgical residents / registrars.
Answer in the next post!
Blunt injury to the carotids or vertebrals (BCVI) is a little more common than originally thought, affecting about 1% of blunt trauma patients. We have many tools available to help us diagnose the problem: duplex ultrasound, CT angiography (CTA), MR angiography (MRA), and even good old conventional 4 vessel angiography.
But which one is “best?” This is a tough question, because there is always some interplay between clinical accuracy and cost. The surgical group at the Medical College of Wisconsin – Milwaukee did a nice job teasing some answers from existing literature on the topic. The authors tried to take a comprehensive look at costs, including money spent to prevent stroke, the cost of complications of therapy, and the overall cost to society if the patient suffers a stroke.
Here are the factoids:
Bottom line: The “best” test for patients at risk for blunt cerebrovascular injury is the CT angiogram. It minimzes the stroke rate, and provides information on all four vessels supplying the brain, which is probably why the duplex ultrasound has a higher miss rate (can’t see the vertebrals or into the skull). But how do you decide who is at risk for this problem? Tune in to the next post!
Reference: Screening for Blunt Cerebrovascular Injuries is Cost-Effective. J Trauma 70(5):1051-1057, 2011.
This xray is a classic for a specific trauma surgical injury. Give it your best shot! Tweet of leave comments with your impressions.
This image is especially appropriate for surgical residents / registrars.
Answer tomorrow!