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Predicting failure of nonoperative management (NOM) in splenic trauma remains elusive. Shock index (SI) is an indicator of physiologic burden in an injury but is not used as a prediction tool. The purpose of this study was to determine if elevated SI would be predictive of failure of NOM in patients with a blunt splenic injury.Adult patients admitted to a level-1 trauma center from January 2011 to April 2017 for NOM of splenic injury were reviewed. Patients were excluded if they underwent a procedure (angiography or surgery) prior to admission. The primary outcome was requiring intervention after an initial trial of noninterventional management (NIM). An SI 0.9 at admission was considered a high risk. Univariate and multivariate analyses were used to identify predicators of the failure of NOM. Findings were subsequently verified on a validation cohort of patients.Five hundred and eighty-five patients met inclusion criteria; 7.4% failed NIM. On an univariate analysis, findings of pseudoaneurysm or extra-arterial contrast on computed tomography did not differentiate successful NIM versus failure (8.1% versus 14.0%, P = 0.18). Age, the American Association for the Surgery of Trauma injury grade, and elevated SI were included in multivariate modeling. Grade of injury (OR 3.49, P = 0.001), age (OR 1.02, P = 0.009), and high SI (OR 3.49, P = 0.001) were each independently significant for NIM failure. The risk-adjusted odds of failure were significantly higher in patients with a high risk SI (OR 2.35, P 0.001). Validation of these findings was confirmed for high SI on a subsequent 406 patients with a c-statistic of 0.71 (95% CI 0.62-0.80).Elevated SI is an independent risk factor for failure of NIM in those with splenic injury. SI along with age and computed tomography findings may aid in predicting the failure of NIM. Trauma providers should incorporate SI into decision-making tools for splenic injury management.

To describe a systematic method to quantify the severity of renal infarction injury and assess its association with post-traumatic renal function after blunt trauma.We retrospectively reviewed all patients who suffered an AAST grade IV renal infarction injury without active bleeding secondary to blunt trauma between 1/2010 and 10/2020. Only patients with a pre-traumatic eGFR within 12 months of injury and post-traumatic eGFR within 3-12 months were included. Percentage of renal ischemia was defined as: (ischemic volume/total volume) × 100%. Two radiologists reviewed computed tomography images to determine ischemic and overall cross-sectional areas using the polygon region of interest tool. These areas were multiplied by slice thickness to obtain ischemic and total volumes. Intraclass correlation coefficient was used to assess consistency between radiologists. Linear regression analyses were used to assess the association between percentage of renal ischemia and post-traumatic renal function.Thirty-five of 140 (25.0%) patients met inclusion criteria. The median (IQR) pre-trauma eGFR was 107.7 ml/min/1.73mCT-based volume calculation of renal ischemia may be utilized to quantify kidney injury and be associated with post-traumatic renal function loss.

To evaluate whether volumetric measurements of segmental vascular injuries (SVIs) based on computed tomography (CT) imaging obtained during an initial trauma survey correlate with future nuclear medicine (NM) split renal function. A retrospective review was performed of renal trauma patients treated at a level 1 trauma center between 2008 and 2015. Patients with unilateral SVIs on initial CT imaging with follow-up NM renal scans were evaluated. CT-based split renal function was calculated by assessing the ratio of ipsilateral uninjured kidney volume to bilateral total uninjured kidney volume by two separate radiologists. Eight patients with unilateral SVIs on initial CT trauma evaluation underwent follow-up NM renal scans at a mean of 4 months (range 2–6) after injury. Mean NM split renal function of the injured kidney was 43% (range 22–57). Based on the CT volumetric measurements of the affected kidney, mean percent injured was 23% (range 7–62) with a calculated mean split renal function of 44% (range 23–60). Calculated mean CT split function correlated with NM split function (R = 0.89). Intraclass correlation measuring inter-rater reliability for CT volumetric measurements was 0.94 (95% confidence interval 0.72–0.99). Volumetric measurements based on CT imaging obtained during the initial trauma evaluation correlated with future NM split renal function after SVIs with high inter-rater reliability. This method utilizes pre-existing imaging and avoids additional radiation exposure, work burden, and financial cost from a NM scan. Further evaluation is required to assess feasibility with more complex injuries.

A variety of tubes, lines and other devices are often identified on imaging studies. While some of these may be familiar and well understood by many radiologists, others may be new or less familiar, and may limit the ability of the radiologist to confirm appropriate placement or identify erroneous placement needing correction. This paper demonstrates and discusses a number of these devices, and offers numerous images of the devices external to the patient, to provide a better understanding and visualization of their components.

Background Current algorithms for the management of blunt lower extremity trauma recommend additional imaging in patients presenting with soft signs of vascular injury and an ankle–brachial index (ABI) less than 0.9. The aim of this study is to analyze lower extremity computed tomography angiographies (CTAs) to determine the incidence and characteristics of patients sustaining vascular injury from blunt lower extremity trauma. We hypothesized that a lower ABI threshold can avoid unnecessary imaging without missing clinically significant vascular injury. Methods A single-center, retrospective review of all consecutive patients who presented to a level 1 trauma center with blunt lower extremity trauma and underwent a CTA from January 2015 to December 2017 was conducted. Baseline demographics, clinical features, and outcomes were recorded. Patients without documented ABIs were excluded. A receiver operating characteristic curve was used to define the ABI threshold. Results One hundred twenty-five patients (133 injured limbs) met inclusion criteria. The mean age was 44 years (range 9–96), and 74% of the patients were male. A vascular abnormality was identified on CTA in 65 limbs (48.9%), of which only 8 (12%) required intervention. The ABIs in these 8 injured limbs were between 0 and 0.6. An ABI threshold of 0.6 maximized the balance between sensitivity (100%) and specificity (87%) and missed no injuries requiring revascularization. Conclusions The ABI remains useful in evaluating blunt lower extremity trauma. A lower ABI threshold in patients presenting with soft signs of vascular injury after blunt trauma may avoid unnecessary imaging without missing vascular injuries requiring intervention. Further prospective studies are needed to validate the safety and effectiveness of a lower ABI threshold.

BACKGROUND Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

Due to increased use of computed tomography (CT) and ultrasonography, technological advances in equipment design, and increased availability of imaging equipment in the emergency department, imaging studies have revolutionized the assessment of the trauma patient in the past three decades. This review examines commonly used imaging modalities in trauma evaluation, initial and additional imaging, brief introduction to CT, and an overview of CT image processing and reviewing a CT scan. Head imaging, spine imaging, chest imaging, and abdominal and pelvic imaging are presented, along with injury grading, solid-organ injury appearances and specific abdominal solid-organ injuries, urinary system injury, penetrating trauma, unexplained intraperitoneal fluid, vascular injury and musculoskeletal injury. Figures show lateral view of the cervical spine; volume rendering of the pelvis; CT windows; CT imaging of acute intracranial bleeding, herniation in acute subdural hemorrhage, post-traumatic pseudoaneurysm of descending thoracic aorta, subscapular hematoma of the liver, liver laceration, pseudoaneurysm of the liver, shattered kidney and the nonperfused right kidney attributable to a traumatic renal artery injury, tigroid spleen, a focus of gas and stranding adjacent to the lateral wall of the ascending colon, extravasated urinary contrast (white material) surrounding the proximal right indicating ureteral laceration or transection, intraperitoneal bladder rupture, and contrast extravasation in the liver; magnetic resonance imaging versus CT of shear injuries; and magnetic resonance imaging in the setting of cervical spine trauma. This review contains 18 highly rendered figures, 23 tables, and 83 references. Keywords:Trauma, computed tomography, radiography, magnetic resonance imaging, ultrasonography, imaging study

Objective To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. Material and Methods Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. Results A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. Conclusion Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.

In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction.We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction.From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions.Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

INTRODUCTION AND OBJECTIVE:A multi-institutional nomogram incorporating clinical and radiologic factors has been previously developed to predict bleeding interventions after high-grade renal trauma...

INTRODUCTION AND OBJECTIVE:Emergency Department (ED) discharge practices are subject to inter-provider variation that can limit the implementation of evidence-based medicine. We convened a multi-di...

Fractures of the distal clavicle represent 15-30% of all clavicle fractures. The local osseoligamentous anatomy and deforming forces result in increased risk of delayed union and nonunion than fractures in other parts of the clavicle. These factors also contribute to challenges in fracture repair. Understanding these injuries and their imaging features enhances care and ensures patients are directed to appropriate management. We review the anatomy of the distal clavicle and surrounding ligaments, options for radiographic evaluation, relevant classification systems, and current concepts in management. Illustrative examples of specialized views are provided. Pediatric acromioclavicular joint pseudosubluxation is also reviewed, with findings specific to that injury.

Author(s): Keihani, Sorena; Rogers, Douglas M; Putbrese, Bryn E; Anderson, Ross E; Stoddard, Gregory J; Nirula, Raminder; Luo-Owen, Xian; Mukherjee, Kaushik; Morris, Bradley J; Majercik, Sarah; Piotrowski, Joshua; Dodgion, Christopher M; Schwartz, Ian; Elliott, Sean P; DeSoucy, Erik S; Zakaluzny, Scott; Sherwood, Brenton G; Erickson, Bradley A; Baradaran, Nima; Breyer, Benjamin N; Fick, Cameron N; Smith, Brian P; Okafor, Barbara U; Askari, Reza; Miller, Brandi D; Santucci, Richard A; Carrick, Matthew M; Allen, LaDonna; Norwood, Scott; Hewitt, Timothy; Burks, Frank N; Heilbrun, Marta E; Gross, Joel A; Myers, Jeremy B; in conjunction with the Trauma and Urologic Reconstruction Network of Surgeons | Abstract: BackgroundIn 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.MethodsData on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.ResultsOf the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).ConclusionAbout one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.Level of evidencePrognostic and Epidemiological Study, level III.

The aims of this article are to describe the events of a recent mass casualty incident (MCI) at our level 1 trauma center and to describe the radiology response to the event. We also describe the findings and recommendations of our radiology department after-action review. An MCI activation was triggered after an amphibious military vehicle, repurposed for tourist activities, carrying 37 passengers, collided with a charter bus carrying 45 passengers on a busy highway bridge in Seattle, WA, USA. There were 4 deaths at the scene, and 51 patients were transferred to local hospitals following prehospital scene triage. Nineteen patients were transferred to our level 1 trauma center. Eighteen casualties arrived within 72 min. Sixteen arrived within 1 h of the first patient arrival, and 1 casualty was transferred 3 h later having initially been assessed at another hospital. Eighteen casualties (94.7 %) underwent diagnostic imaging in the emergency department. Of these 18 casualties, 15 had a trauma series (portable chest x-ray and x-ray of pelvis). Whole-body trauma computed tomography scans (WBCT) were performed on 15 casualties (78.9 %), 12 were immediate and performed during the initial active phase of the MCI, and 3 WBCTs were delayed. The initial 12 WBCTs were completed in 101 min. The mean number of radiographic studies performed per patient was 3 (range 1-8), and the total number of injuries detected was 88. The surge in imaging requirements during an MCI can be significant and exceed normal operating capacity. This report of our radiology experience during a recent MCI and subsequent after-action review serves to provide an example of how radiology capacity and workflow functioned during an MCI, in order to provide emergency radiologists and response planners with practical recommendations for implementation in the event of a future MCI.

Objective Current guidelines recommend additional imaging when the ankle-brachial index (ABI) is ≤0.9 after extremity trauma; however, the accuracy of this 0.9 threshold compared with other values has not been evaluated. The primary aim of this study was to compare the safety and effectiveness of various ABI thresholds in predicting lower extremity vascular injuries after penetrating trauma. We hypothesized that a lower ABI threshold can be used safely to avoid unnecessary imaging. Methods A retrospective cohort study was performed at a single level I trauma center from January 2015 to December 2017. All patients who presented with penetrating lower extremity trauma and who underwent computed tomography angiography (CTA) were reviewed. Patients taken directly to the operating room without first undergoing CTA or those without documented ABIs were excluded. Demographic information, clinical features of presentation, interventions performed, and outcomes were recorded. P values were obtained using the Kolmogorov-Smirnov test, and a receiver operating characteristic curve was created to compare various ABI thresholds. Results A total of 47 patients (81% male), with a mean age of 29 years (range, 14-59 years), met inclusion criteria. Of the 17 limbs (36%) with a vascular abnormality seen on CTA, 6 (35%) required an intervention. The distribution of ABIs in injured limbs requiring revascularization was significantly lower (P = .006) than in those that did not require intervention. An ABI threshold of 0.7 is most accurate, with the highest combined sensitivity (83%) and specificity (91%) for detecting vascular injuries requiring revascularization. In addition, the negative predictive value was no different between a threshold of 0.7 (98%) and a threshold of 0.9 (97%), with both thresholds missing one vascular injury (pseudoaneurysm) requiring repair. Conclusions The ABI remains reliable in distinguishing between limbs with and limbs without vascular injury requiring revascularization after penetrating lower extremity trauma. A lower threshold can safely be used without compromising the negative predictive value of a screening ABI. Applying a threshold of 0.7 to our cohort would have avoided 51% (24) of the CTA studies performed without missing additional vascular injuries requiring repair.

"Acute abdomen" includes spectrum of medical and surgical conditions ranging from a less severe to life-threatening conditions in a patient presenting with severe abdominal pain that develops over a period of hours. Accurate and rapid diagnosis of these conditions helps in reducing related complications. Clinical assessment is often difficult due to availability of over-the-counter analgesics, leading to less specific physical findings. The key clinical decision is to determine whether surgical intervention is required. Laboratory and conventional radiographic findings are often non-specific. Thus, cross-sectional imaging plays a pivotal role for helping direct management of acute abdomen. Computed tomography is the primary imaging modality used for these cases due to fast image acquisition, although US is more specific for conditions such as acute cholecystitis. Magnetic resonance imaging or ultrasound is very helpful in patients who are particularly sensitive to radiation exposure, such as pregnant women and pediatric patients. In addition, MRI is an excellent problem-solving modality in certain conditions such as assessment for choledocholithiasis in patients with right upper quadrant pain. In this review, we discuss a multimodality approach for the usual causes of non-traumatic acute abdomen including acute appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. A brief review of other relatively less frequent but important causes of acute abdomen, such as perforated viscus and bowel ischemia, is also included.

Growing numbers of patient with advanced imaging being transferred to trauma centers has resulted in increased numbers of outside CT scans received at trauma centers. This study examines the degree of agreement between community radiologists’ interpretations of the CT scans of transferred patients and trauma center radiologists’ reinterpretation. All CT scans of emergency transfer patients received over a 1 month period were reviewed by an emergency radiologist. Patients were classified as trauma or non-trauma and exams as neuro or non-neuro. Interpretive discrepancies between the emergency radiologist and community radiologist were classified as minor, moderate, or major. Major discrepancies were confirmed by review of a second emergency radiologist. Discrepancy rates were calculated on a per-patient and per exam basis. Six hundred twenty-seven CT scans of 326 patients were reviewed. Major discrepancies were encountered in 52 (16.0%, 95% CI 12.2–20.5) patients and 53 exams (8.5%, 95% CI 6.5–10.5). These were discovered in 46 trauma patients (21.6%, 95% CI 16.4–27.9) compared to six non-trauma patients (5.3%, 95% CI 2.2–11.7) (P

Background. Older trauma patients often undergo computed tomography (CT) as part of the initial work-up. CT imaging can also be used opportunistically to measure bone density and assess osteoporosis. Methods. In this retrospective cohort study, osteoporosis was ascertained from admission CT scans in women aged ≥65 admitted to the ICU for traumatic injury during a 3-year period at a single, safety-net, level 1 trauma center. Osteoporosis was defined by established CT-based criteria of average L1 vertebral body Hounsfield units Results. The study cohort consisted of 215 women over a 3-year study period, of which 101 (47%) had evidence of osteoporosis by CT scan criteria. There were no differences in injury severity score, hospital length of stay, cost, or discharge disposition between groups with and without evidence of osteoporosis. Only 55 (59%) of the 94 patients with osteoporosis who survived to discharge had a documented osteoporosis diagnosis and/or corresponding evaluation/treatment plan. Conclusion. Nearly half of older women admitted with traumatic injuries had underlying osteoporosis, but 41% had neither clinical recognition of this finding nor a treatment plan for osteoporosis. Admission for traumatic injury is an opportunity to assess osteoporosis, initiate appropriate intervention, and coordinate follow-up care. Trauma and acute care teams should consider assessment of osteoporosis in women who undergo CT imaging and provide a bridge to outpatient services.

The authors describe our experience in planning, organizing, and running a radiology CME conference at a hotel (rather than at a stand-alone conference or convention center). Much of the information described should also be useful for other medical and nonmedical conferences. This experience should provide new conference organizers with useful information to ensure a more efficient and successful conference, so there are fewer "If I knew then what I know now" moments over the years.

Importance Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Duodenal diverticula are common and are often incidentally found during routine imaging. Complications can occur but few require surgical intervention. We present a review of duodenal diverticula and their complications.

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

Many excellent studies on shoulder imaging from a radiologic perspective have been published over the years, demonstrating the anatomy and radiologic findings of shoulder trauma. However, it may not always be clear what the surgeon, who bears the responsibility for treating the injured patient, really needs to know about the injury to predict outcomes and plan management. The authors review the relevant osseous, soft-tissue, and vascular anatomy and describe the clinically relevant concepts that affect management. Familiarity with the Neer classification system for proximal humerus fractures can have a significant impact on treatment. The length and displacement of the medial humeral metaphyseal fragment helps predict the risk of ischemia in proximal humerus fractures. The Nofsinger approach for measuring the area of glenoid fossa bone loss can help the surgeon determine the need for surgical repair of a bony Bankart lesion. The size of Hill-Sachs and reverse Hill-Sachs lesions is also an important predictor of stability. The Ideberg classification system for intraarticular fractures of the glenoid fossa, combined with information on instability and joint incongruity, helps determine the need for surgical fixation of glenoid fossa fractures. Awareness of what matters to the surgeon can help radiologists better determine where to focus their attention and efforts when describing acute shoulder trauma.

Isolated blunt abdominal trauma (BAT) represents about 5% of annual trauma mortality from blunt trauma. As part of multiple-site injury (polytrauma), BAT contributes another 15% of trauma mortality. 1 Exsanguination accounts for 80 to 90% of acute deaths from abdominal injury. More than 75% of such cases are amenable to surgery, and recent years have seen safe extension of nonoperative, image-guided treatments to most victims of blunt-force trauma. 2-21 Early recognition and treatment decisions have been greatly impacted by increasingly sophisticated cross-sectional imaging and image-guided, minimally invasive therapies. 22-32

BACKGROUND: Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.OBJECTIVE: To review results of resection in the setting of acute necrotizing lung infections.METHODS: A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.RESULTS: Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n=17), hemoptysis (n=5), air leak (n=7), septic shock requiring pressors (n=8) and inability to oxygenate adequately (n=7). Twenty-four patients were ventilated pre-operatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n=4), thoracoscopic decortication (n=4) and open decortication (n=2). Procedures included pneumonectomy (n=4), lobectomy (n=18), segmentectomy (n=2), wedge resection (n=4) and debridement (n=7). There were three (8.5%) postoperative deaths – two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.CONCLUSIONS: Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.

An 80 year-old man presented to his primary care physician with painless gross hematuria. He reported having intermittent episodes of pink urine containing small clots for about three months. He was initially treated with a single course of ciprofloxacin for presumed urinary tract infection. His symptoms did not improve with antibiotic therapy and he was then referred to our institution for a computed tomography (CT) urogram. CT urogram showed a 4 x 3.6 centimeter (cm) infiltrating solid mass along the left lateral posterior wall of the urinary bladder (Figure-1). Tumor also extended along the bladder dome. Prostate enlargement and bladder diverticula were also present. He was referred to the urology service and subsequently underwent transurethral resection of bladder tumor (TURBT) with fulguration. No intraoperative complications were noted and he returned to the recovery room in satisfactory condition on continuous bladder irrigation. Pathologic examination revealed a 5 cm transitional cell carcinoma with high grade growth pattern invading the deep muscular layer. On postoperative day one, the patient reported abdominal pain and general discomfort. Physical exam revealed a grossly distended abdomen which was tender to palpation with positive guarding and decreased bowel sounds. He Symptomatic Extraperitoneal Bladder Perforation Following Transurethral Bladder Surgery: Imaging with CT Urography _______________________________________________

Treatment goals in severe midfacial trauma are restoration of function and appearance. Restoration of function is directed at multiple organ systems, which support visual acuity, airway patency, mastication, lacrimation, smelling, tasting, hearing, and facial expression. Victims of blunt facial trauma expect to look the same after surgical treatment as before injury. Delicate soft tissues of the midface often make cosmetic reconstructive surgery technically challenging. Generally, clinical evaluation alone does not suffice to fully characterize facial fractures associated with extensive swelling, and the deeper midface is not accessible to physical examination. Properly performed computed tomography (CT) overcomes most limitations of presurgical examination. Thus, operative approaches and sequencing of surgical repair are guided by imaging information displayed by CT. Restoration of function and appearance relies on recreating normal maxillofacial skeletal anatomy, with particular attention to position of the malar eminences, mandibular condyles, vertical dimension and orbital morphology. Due to its pivotal role in surgical planning, CT scans obtained for the evaluation of severe midfacial trauma should be designed to easily depict the imaging information necessary for clinical decision making. Learning objectives: 1. Understand the facial skeletal buttress system; 2. Understand how the pattern of derangement of the buttress system determines the need for and choice of operative approach for repair of fractures in the middle third of the face; 3. Understand the role and importance of CT and CT reformations in the detection and classification of the pattern of buttress system derangement.

Radiologists are familiar with the use of radiographs, computed tomography, magnetic resonance imaging and ultrasound in the acute clinical setting. However, there are some specific clinical scenarios which may be found in nuclear medicine imaging problem-solving tools. These clinical scenarios and imaging techniques are less frequent, and the referring clinician from the emergency department may not consider these alternatives. It is important for the radiologist to be aware of these techniques to be able to guide the clinician to use those tools, which may result in optimal patient care. In this article, we will discuss those nuclear medicine studies which have application in the setting of an emergency radiology practice.

Objective: To develop a simple clock drawing score system for patients with Alzheimer's disease, that correlates with the MMSE (Folstein Mini Mental Status Examination).1 Design: A retrospective analysis of 88 patients with the diagnosis of Alzheimer's disease Setting: Outpatient Memory Disorder Institute of a large community teaching hospital. Measurements: MMSE score and two different clock drawing ratings. The MMSE and the clock drawing scoring were performed by different raters. We present a “simple clock scoring system” and compared it with a previously published scoring system by Sunderland et al,2 referred to as the standard score system. Results: There is a strong correlation between the “new score system” and the standard scoring (Pearsons Correlation Coefficient r = 0.91, p < 0.001). However, when both systems were evaluated in a multivariate linear regression analysis, the “ simple score system “ was a significant predictor of Folstein MMSE (P < 0.01), while the standard scoring system was not. Conclusion: The “simple score system” is an easy to use, accurate predictor of the MMSE score, in patients with the diagnosis of Alzheimer's disease.

The aim of this study is to describe the frequency, computed tomographic angiography (CTA) imaging appearance, management, and outcome of patients who present with minimal thoracic aortic injury. This retrospective study was Institutional Review Board-approved. Eighty-one patients with blunt traumatic aortic injuries (BTAI) were identified between 2004 and 2008, comprising 23 patients with minimal aortic injury (MAI) (mean age, 43.2 years ±18.2 years; 12 males and 11 females) and 58 patients with non-minimal aortic injury (mean age, 42.6 years ±22.7 years). CTA imaging was reviewed for each patient to differentiate those with MAI from those with non-MAI BTAI. Inclusion criteria for MAI on CTA were: post-traumatic abnormality of the internal contour of the aorta wall projecting into the lumen, intimal flap, intraluminal filling defect, intramural hematoma, and no evidence of an abnormality to the external contour of the aorta. Relevant follow-up imaging for MAI patients was also reviewed for resolution, stability, or progression of the vascular injury. The electronic medical record of each patient was reviewed and mechanism of injury, injury severity score, associated injuries, type and date of management, outcome, and days from injury to last medical consultation. Minimal aortic injury represented 28.4 % of all BTAI over the study period. Mean injury severity score (37.1), age (43.2 years), and gender did not differ significantly between MAI and non-MAI types of BTAI. Most MAI occurred in the descending thoracic aorta (16/23, 69 %). Without operative or endovascular repair, there was no death or complication due to MAI. One death occurred secondary to MAI (4.4 %) in a patient who underwent endovascular repair and surgical bypass, compared with an overall mortality rate of 8.6 % in the non-MAI BTAI group (p = 0.508). The most common CT appearance of MAI was a rounded or triangular intra-luminal aortic filling detect (18/23 patients, 78 %). In a mean of 466 days of clinical follow-up, no complications were observed in survivors treated without endovascular repair or operation. Minimal aortic injury is identified by multi-detector row CT in more than a quarter of cases of BTAI and has a low mortality. Conservative management is associated with an excellent outcome.