DIAGNOSIS

Examine the chest radiograph again for any acute injuries.

View CXR

There is a pneumothorax on the left and haziness in the left upper lobe most likely due to a pulmonary contusion. The left pneumothorax is not obvious because the patient is supine. It is best seen as an air density along the left heart border. It extends inferiorly and is best seen over the left diaphragm along the left heart border.

The arrows below identify the pneumothorax

Her abdominal flat plate is normal, but her pelvis demonstrates bilateral pelvic rami fractures and a fracture of the proximal left femur.

The arrows below point-out the fractures

The pneumothorax and pulmonary contusion here are small and difficult to see and it could have been easily missed. A pulmonary injury of some type should have been suspected based on her grunting respirations and mild hypoxia. A pneumothorax is best seen on chest radiographs with the patient in the upright position. Small pneumothoraces may not be visible on supine chest radiographs. In this case, no other treatment (in addition to oxygen) was required for the pulmonary contusion and the pneumothorax. CT scans of her head, chest and abdomen were completed. Her head CT was normal. Her CT scan confirmed the small, left pneumothorax and left upper lobe pulmonary contusion. Her abdominal CT was normal. Her fractures were managed by an orthopedic surgeon with a good outcome.

Copyrighted:Radiology Cases in Pediatric Emergency Medicine Volume 7, Case 8 Loren Yamamoto, MD, MPH, Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine.Loreny@hawaii.edu

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Last created on 01-07-2006