Download PDF
Semin Musculoskelet Radiol 2013; 17(04): 371-379
DOI: 10.1055/s-0033-1356466
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Polytrauma: Optimal Imaging and Evaluation Algorithm

Lucas L. Geyer
1   Department of Clinical Radiology, University Hospitals LMU Munich, Munich, Germany
,
Markus Koerner
2   Radiologie Mühleninsel, Landshut, Germany
,
Stefan Wirth
1   Department of Clinical Radiology, University Hospitals LMU Munich, Munich, Germany
,
Fabian G. Mueck
1   Department of Clinical Radiology, University Hospitals LMU Munich, Munich, Germany
,
Maximilian F. Reiser
1   Department of Clinical Radiology, University Hospitals LMU Munich, Munich, Germany
,
Ulrich Linsenmaier
3   Institut für Röntgendiagnostik & Strahlentherapie, Klinikum München Pasing, Munich, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
07 October 2013 (online)

Also available at
    Permissions and Reprints

Abstract

Traumatic injuries are the leading cause of death in adults < 45 years of age. Musculoskeletal trauma accounts for a substantial number of injuries in patients sustaining polytrauma. The diagnostic work-up of those patients is challenging, complex, and requires a structured and interdisciplinary workflow. Multidetector CT (MDCT) is considered the imaging modality of choice due to remarkable technical developments in recent years. Besides the evaluation of cranial, chest, and abdominal injuries, MDCT allows for integrated imaging of musculoskeletal trauma within a single CT examination. In this context, CT angiography facilitates the detection of coexisting vascular injuries after trauma of the skeleton. In addition, recent technologies (e.g., dual-energy CT) provide promising applications such as metal artifact reduction. This article summarizes the basic principles of interdisciplinary management of polytrauma patients, reviews recent advances of CT technology that have enabled comprehensive trauma imaging, provides appropriate scan protocols, and discusses the radiologic evaluation of musculoskeletal findings.

Keywords

MDCT - whole-body CT - CT angiography - multiple trauma - musculoskeletal trauma
 

  • References

  • 1 Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367 (9524) 1747-1757
    CrossrefPubMedGoogle Scholar
  • 2 Mutschler W, Kanz KG. Interdisciplinary shock room management: responsibilities of the radiologist from the trauma surgery viewpoint [in German]. Radiologe 2002; 42 (7) 506-514
    CrossrefPubMedGoogle Scholar
  • 3 Balogh ZJ, Reumann MK, Gruen RL , et al. Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet 2012; 380 (9847) 1109-1119
    CrossrefPubMedGoogle Scholar
  • 4 Pape HC, Probst C, Lohse R , et al. Predictors of late clinical outcome following orthopedic injuries after multiple trauma. J Trauma 2010; 69 (5) 1243-1251
    CrossrefPubMedGoogle Scholar
  • 5 Ringburg AN, Polinder S, van Ierland MC , et al. Prevalence and prognostic factors of disability after major trauma. J Trauma 2011; 70 (4) 916-922
    CrossrefPubMedGoogle Scholar
  • 6 Trentz O. Polytrauma: pathophysiology, priorities and management. In: Rüedi T, Murphy WM, , eds. AO Principles of Fracture Management. Stuttgart, Germany: Thieme; 2000: 661-673
    Google Scholar
  • 7 Baker SP, O'Neill B, Haddon Jr W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14 (3) 187-196
    CrossrefPubMedGoogle Scholar
  • 8 Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 2002; 52 (3) 420-425
    CrossrefPubMedGoogle Scholar
  • 9 Cowley RA. The resuscitation and stabilization of major multiple trauma patients in a trauma centre environment. Clin Med 1976; 83: 16-22
    PubMedGoogle Scholar
  • 10 Kanz KG, Körner M, Linsenmaier U , et al. Priority-oriented shock trauma room management with the integration of multiple-view spiral computed tomography [in German]. Unfallchirurg 2004; 107 (10) 937-944
    CrossrefPubMedGoogle Scholar
  • 11 Löw R, Düber C, Schweden F, Lehmann L, Blum J, Thelen M. Whole body spiral CT in primary diagnosis of patients with multiple trauma in emergency situations [in German]. Rofo 1997; 166 (5) 382-388
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Leidner B, Adiels M, Aspelin P, Gullstrand P, Wallén S. Standardized CT examination of the multitraumatized patient. Eur Radiol 1998; 8 (9) 1630-1638
    CrossrefPubMedGoogle Scholar
  • 13 Linsenmaier U, Pfeifer KJ. Disputed concept in polytrauma: whole-body spiral CT as primary diagnosis [in German]. Rofo 1998; 168: 306
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Linsenmaier U, Pfeifer KJ. Commentary and remarks from Germany–Imaging of trauma patients in Germany. Emerg Radiol 1999; 6 (2) 74-76
    CrossrefPubMedGoogle Scholar
  • 15 Linsenmaier U, Rieger J, Brandl T , et al. New method for fast spiral CT of trauma patients—RUSH CT. Emerg Radiol 2000; 7 (3) 135-141
    CrossrefPubMedGoogle Scholar
  • 16 Novelline RA, Rhea JT, Rao PM, Stuk JL. Helical CT in emergency radiology. Radiology 1999; 213 (2) 321-339
    CrossrefPubMedGoogle Scholar
  • 17 Dawson P, Lees WR. Multi-slice technology in computed tomography. Clin Radiol 2001; 56 (4) 302-309
    CrossrefPubMedGoogle Scholar
  • 18 Klöppel R, Schreiter D, Dietrich J, Josten C, Kahn T. Early clinical management after polytrauma with 1 and 4 slice spiral CT [in German]. Radiologe 2002; 42 (7) 541-546
    CrossrefPubMedGoogle Scholar
  • 19 Linsenmaier U, Kanz KG, Rieger J, Rock C, Pfeifer KJ, Reiser M. Structured radiologic diagnosis in polytrauma [in German]. Radiologe 2002; 42 (7) 533-540
    CrossrefPubMedGoogle Scholar
  • 20 Philipp MO, Kubin K, Hörmann M, Metz VM. Radiological emergency room management with emphasis on multidetector-row CT. Eur J Radiol 2003; 48 (1) 2-4
    CrossrefPubMedGoogle Scholar
  • 21 Linsenmaier U, Kanz KG, Mutschler W, Pfeifer KJ. Radiological diagnosis in polytrauma: interdisciplinary management [in German]. Rofo 2001; 173 (6) 485-493
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Siebers C, Stegmaier J, Kirchhoff C , et al. Analysis of failure modes in multislice computed tomography during primary trauma survey [in German]. Rofo 2008; 180 (8) 733-739
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Huber-Wagner S, Lefering R, Qvick LM , et al; Working Group on Polytrauma of the German Trauma Society. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373 (9673) 1455-1461
    CrossrefPubMedGoogle Scholar
  • 24 Kanz KG, Paul AO, Lefering R , et al; Trauma Registry of the German Trauma Society. Trauma management incorporating focused assessment with computed tomography in trauma (FACTT)—potential effect on survival. J Trauma Manag Outcomes 2010; 4: 4
    CrossrefPubMedGoogle Scholar
  • 25 Geyer LL, Körner M, Reiser M , et al. Value of conventional radiography and ultrasound during initial treatment of traumatized patients. Notfall Rettungsmedizin 2010; 13 (6) 428-435
    PubMedGoogle Scholar
  • 26 Krötz M, Bode PJ, Häuser H, Linsenmaier U, Pfeifer KJ, Reiser M. Interdisciplinary shock room management: personnel, equipment and spatial logistics in 3 trauma centers in Europe [in German]. Radiologe 2002; 42 (7) 522-532
    CrossrefPubMedGoogle Scholar
  • 27 Alkadhi H, Baumert B, Wildermuth S, Bloch KE, Marincek B, Boehm T. Coronal thick CT reconstruction: an alternative for initial chest radiography in trauma patients. Emerg Radiol 2005; 12 (1–2) 3-10
    CrossrefPubMedGoogle Scholar
  • 28 Leschka S, Alkadhi H, Boehm T, Marincek B, Wildermuth S. Coronal ultra-thick multiplanar CT reconstructions (MPR) of the pelvis in the multiple trauma patient: an alternative for the initial conventional radiograph. Rofo 2005; 177 (10) 1405-1411
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Wirth S, Körner M, Treitl M , et al. Computed tomography during cardiopulmonary resuscitation using automated chest compression devices—an initial study. Eur Radiol 2009; 19 (8) 1857-1866
    CrossrefPubMedGoogle Scholar
  • 30 Mann FA, Cohen WA, Linnau KF, Hallam DK, Blackmore CC. Evidence-based approach to using CT in spinal trauma. Eur J Radiol 2003; 48 (1) 39-48
    CrossrefPubMedGoogle Scholar
  • 31 Linsenmaier U, Krötz M, Häuser H , et al. Whole-body computed tomography in polytrauma: techniques and management. Eur Radiol 2002; 12 (7) 1728-1740
    CrossrefPubMedGoogle Scholar
  • 32 Wurmb T, Frühwald P, Brederlau J , et al. The Würzburg polytrauma algorithm. Concept and first results of a sliding-gantry-based computer tomography diagnostic system [in German]. Anaesthesist 2005; 54 (8) 763-768 , 770–772
    CrossrefPubMedGoogle Scholar
  • 33 Park SJ, Kim JK, Kim KW, Cho KS. MDCT Findings of renal trauma. AJR Am J Roentgenol 2006; 187 (2) 541-547
    CrossrefPubMedGoogle Scholar
  • 34 Marmery H, Shanmuganathan K. Multidetector-row computed tomography imaging of splenic trauma. Semin Ultrasound CT MR 2006; 27 (5) 404-419
    CrossrefPubMedGoogle Scholar
  • 35 Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56 (2) 314-322
    CrossrefPubMedGoogle Scholar
  • 36 Holmes JF, Offerman SR, Chang CH , et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med 2004; 43 (1) 120-128
    CrossrefPubMedGoogle Scholar
  • 37 Stuhlfaut JW, Soto JA, Lucey BC , et al. Blunt abdominal trauma: performance of CT without oral contrast material. Radiology 2004; 233 (3) 689-694
    CrossrefPubMedGoogle Scholar
  • 38 Sampson MA, Colquhoun KB, Hennessy NL. Computed tomography whole body imaging in multi-trauma: 7 years experience. Clin Radiol 2006; 61 (4) 365-369
    CrossrefPubMedGoogle Scholar
  • 39 Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury—a prospective study in 200 patients. Radiology 2004; 231 (3) 775-784
    CrossrefPubMedGoogle Scholar
  • 40 Anderson SW, Lucey BC, Varghese JC, Soto JA. Sixty-four multi-detector row computed tomography in multitrauma patient imaging: early experience. Curr Probl Diagn Radiol 2006; 35 (5) 188-198
    CrossrefPubMedGoogle Scholar
  • 41 Foster BR, Anderson SW, Uyeda JW, Brooks JG, Soto JA. Integration of 64-detector lower extremity CT angiography into whole-body trauma imaging: feasibility and early experience. Radiology 2011; 261 (3) 787-795
    CrossrefPubMedGoogle Scholar
  • 42 Körner M, Reiser M, Linsenmaier U. Imaging of trauma with multi-detector computed tomography [in German]. Radiologe 2009; 49 (6) 510-515
    CrossrefPubMedGoogle Scholar
  • 43 Ruchholtz S, Waydhas C, Schroeder T, Piepenbrink K, Kühl H, Nast-Kolb D. The value of computed tomography in the early treatment of seriously injured patients [in German]. Chirurg 2002; 73 (10) 1005-1012
    CrossrefPubMedGoogle Scholar
  • 44 Karlo C, Gnannt R, Frauenfelder T , et al. Whole-body CT in polytrauma patients: effect of arm positioning on thoracic and abdominal image quality. Emerg Radiol 2011; 18 (4) 285-293
    CrossrefPubMedGoogle Scholar
  • 45 Bayer J, Pache G, Strohm PC , et al. Influence of arm positioning on radiation dose for whole body computed tomography in trauma patients. J Trauma 2011; 70 (4) 900-905
    CrossrefPubMedGoogle Scholar
  • 46 Loewenhardt B, Buhl M, Gries A , et al. Radiation exposure in whole-body computed tomography of multiple trauma patients: bearing devices and patient positioning. Injury 2012; 43 (1) 67-72
    CrossrefPubMedGoogle Scholar
  • 47 Hoppe H, Vock P, Bonel HM, Ozdoba C, Gralla J. A novel multiple-trauma CT-scanning protocol using patient repositioning. Emerg Radiol 2006; 13 (3) 123-128
    CrossrefPubMedGoogle Scholar
  • 48 Ptak T, Rhea JT, Novelline RA. Radiation dose is reduced with a single-pass whole-body multi-detector row CT trauma protocol compared with a conventional segmented method: initial experience. Radiology 2003; 229 (3) 902-905
    CrossrefPubMedGoogle Scholar
  • 49 Fanucci E, Fiaschetti V, Rotili A, Floris R, Simonetti G. Whole body 16-row multislice CT in emergency room: effects of different protocols on scanning time, image quality and radiation exposure. Emerg Radiol 2007; 13 (5) 251-257
    CrossrefPubMedGoogle Scholar
  • 50 Nicolaou S, Eftekhari A, Sedlic T , et al. The utilization of dual source CT in imaging of polytrauma. Eur J Radiol 2008; 68 (3) 398-408
    CrossrefPubMedGoogle Scholar
  • 51 Gunn ML, Kohr JR. State of the art: technologies for computed tomography dose reduction. Emerg Radiol 2010; 17 (3) 209-218
    CrossrefPubMedGoogle Scholar
  • 52 McCollough CH, Bruesewitz MR, Kofler Jr JM. CT dose reduction and dose management tools: overview of available options. Radiographics 2006; 26 (2) 503-512
    CrossrefPubMedGoogle Scholar
  • 53 Harrieder A, Geyer LL, Körner M , et al. Evaluation of radiation dose in 64-row whole-body CT of multiple injured patients compared to 4-row CT [in German]. Rofo 2012; 184 (5) 443-449
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Maxfield MW, Schuster KM, McGillicuddy EA , et al. Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients. J Trauma Acute Care Surg 2012; 73 (6) 1406-1411
    CrossrefPubMedGoogle Scholar
  • 55 Kool DR, Blickman JG. Advanced Trauma Life Support. ABCDE from a radiological point of view. Emerg Radiol 2007; 14 (3) 135-141
    CrossrefPubMedGoogle Scholar
  • 56 Geyer LL, Wirth S, Linsenmaier U , et al. Diagnostic value of two-plane CT scout views for preliminary emergency evaluation of traumatic injuries and correct tube placement prior to whole body MDCT imaging in major trauma. ASER 2011 Annual Scientific Meeting and Postgraduate Course; September 15, 2011; Key Biscayne, FL
    PubMedGoogle Scholar
  • 57 Eurin M, Haddad N, Zappa M , et al. Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan. Injury 2012; 43 (1) 73-77
    CrossrefPubMedGoogle Scholar
  • 58 Pfeifer R, Pape HC. Missed injuries in trauma patients: a literature review. Patient Saf Surg 2008; 2: 20
    CrossrefPubMedGoogle Scholar
  • 59 Geyer LL, Körner M, Linsenmaier U , et al. Incidence of delayed and missed diagnoses in whole-body multidetector CT in patients with multiple injuries after trauma. Acta Radiol 2013; ; March 12 ( Epub ahead of print)
    PubMedGoogle Scholar
  • 60 Körner M, Krötz M, Kanz KG , et al. Development of an accelerated MSCT protocol (Triage MSCT) for mass casualty incidents: comparison to MSCT for single-trauma patients. Emerg Radiol 2006; 12 (5) 203-209
    CrossrefPubMedGoogle Scholar
  • 61 Körner M, Geyer LL, Wirth S, Reiser MF, Linsenmaier U. 64-MDCT in mass casualty incidents: volume image reading boosts radiological workflow. AJR Am J Roentgenol 2011; 197 (3) W399-W404
    CrossrefPubMedGoogle Scholar
  • 62 Bardenheuer M, Obertacke U, Waydhas C, Nast-Kolb D. Epidemiology of the severely injured patient. A prospective assessment of preclinical and clinical management. AG Polytrauma of DGU [in German]. Unfallchirurg 2000; 103 (5) 355-363
    CrossrefPubMedGoogle Scholar
  • 63 Pieroni S, Foster BR, Anderson SW, Kertesz JL, Rhea JT, Soto JA. Use of 64-row multidetector CT angiography in blunt and penetrating trauma of the upper and lower extremities. Radiographics 2009; 29 (3) 863-876
    CrossrefPubMedGoogle Scholar
  • 64 Haapamäki VV, Kiuru MJ, Mustonen AO, Koskinen SK. Multidetector computed tomography in acute joint fractures. Acta Radiol 2005; 46 (6) 587-598
    CrossrefPubMedGoogle Scholar
  • 65 Geijer M, El-Khoury GY. MDCT in the evaluation of skeletal trauma: principles, protocols, and clinical applications. Emerg Radiol 2006; 13 (1) 7-18
    CrossrefPubMedGoogle Scholar
  • 66 Watura R, Cobby M, Taylor J. Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries. Br J Radiol 2004; 77 (Spec No 1): S46-S63
    CrossrefPubMedGoogle Scholar
  • 67 Bohndorf K, Kilcoyne RF. Traumatic injuries: imaging of peripheral musculoskeletal injuries. Eur Radiol 2002; 12 (7) 1605-1616
    CrossrefPubMedGoogle Scholar
  • 68 Hakkarinen DK, Banh KV, Hendey GW. Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography. J Emerg Med 2012; 43 (2) 303-307
    CrossrefPubMedGoogle Scholar
  • 69 Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G. AG Polytrauma der DGU. Spinal fractures in multiply injured patients: an analysis of the German Trauma Society's Trauma Register [in German]. Unfallchirurg 2007; 110 (11) 946-952
    CrossrefPubMedGoogle Scholar
  • 70 Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976) 1996; 21 (4) 492-499
    PubMedGoogle Scholar
  • 71 Daffner RH, Hackney DB. ACR Appropriateness Criteria on suspected spine trauma. J Am Coll Radiol 2007; 4 (11) 762-775
    CrossrefPubMedGoogle Scholar
  • 72 Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005; 58 (5) 902-905
    CrossrefPubMedGoogle Scholar
  • 73 Link TM, Schuierer G, Hufendiek A, Horch C, Peters PE. Substantial head trauma: value of routine CT examination of the cervicocranium. Radiology 1995; 196 (3) 741-745
    CrossrefPubMedGoogle Scholar
  • 74 Herzog C, Ahle H, Mack MG , et al. Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy?. Eur Radiol 2004; 14 (10) 1751-1760
    PubMedGoogle Scholar
  • 75 Sciubba DM, Petteys RJ. Evaluation of blunt cervical spine injury. South Med J 2009; 102 (8) 823-828
    CrossrefPubMedGoogle Scholar
  • 76 Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001; 50 (3) 457-463 ; discussion 464
    CrossrefPubMedGoogle Scholar
  • 77 Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?. Radiology 2005; 237 (1) 106-113
    CrossrefPubMedGoogle Scholar
  • 78 Chaput CD, Walgama J, Torres E , et al. Defining and detecting missed ligamentous injuries of the occipitocervical complex. Spine (Phila Pa 1976) 2011; 36 (9) 709-714
    PubMedGoogle Scholar
  • 79 Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology 2005; 234 (3) 733-739
    CrossrefPubMedGoogle Scholar
  • 80 American College of Radiology. ACR Appropriateness Criteria®: Suspected Spine Trauma (updated 2012). Available at: http://www.acr.org/∼/media/ACR/Documents/App Criteria/Diagnostic/SuspectedSpineTrauma.pdf . Accessed March 11, 2013
    PubMedGoogle Scholar
  • 81 Seekamp A, Burkhardt M, Pohlemann T. Shock trauma room management of pelvic injuries. A systematic review of the literature [in German]. Unfallchirurg 2004; 107 (10) 903-910
    CrossrefPubMedGoogle Scholar
  • 82 Berg EE, Chebuhar C, Bell RM. Pelvic trauma imaging: a blinded comparison of computed tomography and roentgenograms. J Trauma 1996; 41 (6) 994-998
    CrossrefPubMedGoogle Scholar
  • 83 Harley JD, Mack LA, Winquist RA. CT of acetabular fractures: comparison with conventional radiography. AJR Am J Roentgenol 1982; 138 (3) 413-417
    CrossrefPubMedGoogle Scholar
  • 84 Uyeda J, Anderson SW, Kertesz J, Soto JA. Pelvic CT angiography: application to blunt trauma using 64MDCT. Emerg Radiol 2010; 17 (2) 131-137
    CrossrefPubMedGoogle Scholar
  • 85 Anderson SW, Soto JA, Lucey BC, Burke PA, Hirsch EF, Rhea JT. Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT. Radiology 2008; 246 (2) 410-419
    CrossrefPubMedGoogle Scholar
  • 86 Gupta R, Phan CM, Leidecker C , et al. Evaluation of dual-energy CT for differentiating intracerebral hemorrhage from iodinated contrast material staining. Radiology 2010; 257 (1) 205-211
    CrossrefPubMedGoogle Scholar
  • 87 Bamberg F, Dierks A, Nikolaou K, Reiser MF, Becker CR, Johnson TR. Metal artifact reduction by dual energy computed tomography using monoenergetic extrapolation. Eur Radiol 2011; 21 (7) 1424-1429
    CrossrefPubMedGoogle Scholar
  • 88 Lee YH, Park KK, Song HT, Kim S, Suh JS. Metal artefact reduction in gemstone spectral imaging dual-energy CT with and without metal artefact reduction software. Eur Radiol 2012; 22 (6) 1331-1340
    CrossrefPubMedGoogle Scholar