K. Trauma

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CLINICAL PROBLEM

INVESTIGATION

RECOMMENDATION {GRADE}

COMMENT
Head: Low Risk of Intracranial Injury
  • Fully orientated
  • No amnesia
  • No loss of consciousness
  • No neurological defects
  • No serious scalp laceration
  • No haematoma
 K1 SXR
CT		 Not indicated
Not indicated		 [C]
[C]		 These patients are usually sent home with head injury instructions to the care of a responsible adult. They may be admitted to hospital if no such adult is available.
Head: Medium Risk of Intracranial Injury
  • Loss of consciousness or amnesia
  • Violent mechanisms of injury
  • Scalp bruise, swelling or laceration down to bone or > 5 cm
  • Neurological symptoms or signs (including headache, vomiting twice or more, return visit)
  • Inadequate history or examination (epilepsy / alcohol / child / etc.)
  • Child below 5 yrs: suspected NAI, ?tense fontanelle, fall more than
    60 cm or on to hard surface
 K2 CT or SXR Indicated [B] CT is increasingly being used as the first and ONLY investigation in this group of patients, to confidently exclude cranial injury.
If no fracture is seen on SXR, patients will usually be sent home with head injury instructions to the care of a responsible adult. If no responsible adult available or if a fracture is present, the patient will usually be admitted.

See Section M (M13) for non accidental injury in children. MRI of brain is the preferred investigation for intracranial injuries in NAI.
Head: High Risk of Intracranial Injury
  • Suspected FB or penetrating injury to skull
  • Disorientated or depressed consciousness
  • Focal neurological symptoms or signs
  • Seizure
  • Skull fracture or sutural diastasis shown on SXR
  • CSF from nose or CSF/blood from ear
  • Unstable systemic state precluding transfer to neurological unit
  • Diagnosis uncertain
K3 CT Indicated [B] These patients will usually have been admitted for observation. If there is any delay in getting CT on an urgent basis, seek neurosurgical opinion.
N.B. CT should be available within 4 hrs of admission in all patients with a skull fracture.
SXR is not required before CT.
Head: Very High Risk of Intracranial Injury
  • Deteriorating consciousness or neurological signs (e.g. pupil changes)
  • Confusion or coma persistent despite resuscitation
  • Tense fontanelle or sutural diastasis
  • Open or penetrating injury
  • Depressed or compound fracture
  • Fracture of skull base
K4 CT Indicated [B] URGENT NEUROSURGICAL AND ANAESTHETIC REFERRAL INDICATED, which should not be delayed by imaging.

N.B. CT should be performed as an emergency (see K3 above).
Face and Orbits
Nasal trauma K5 SXR
XR Facial bones
XR Nasal bones		 Not indicated [B] Unless required by a specialist. Poor correlation between radiological findings and presence of external deformity. Management of the bruised nose will depend on local policy: usually follow-up at an ENT or maxillo-facial clinic will determine the need for XR.
Orbital trauma:
blunt injury		 K6 XR Facial bones Indicated [B] Especially in those where 'blow-out' injury possible. MRI or low dose CT may eventually be required by specialists, especially when XRs or clinical signs equivocal.
Orbital trauma: penetrating injury K7 XR Orbits Indicated [C] When:
1. Radio-opaque intra-ocular FB is a possibility (see A16).
2. Investigation requested by ophthalmologist.
3. Suspicion of damage to orbital walls.
US or CT Specialised investigation [B] US or low dose CT may be required; MRI contraindicated with metallic FB (see A16).
Middle third facial injury K8 XR Facial bones Indicated [B] But patient cooperation essential. Advisable to delay XR in uncooperative patients. In children, XR often unhelpful.
Low dose CT Specialised investigation [B] Discuss with maxillofacial surgeon who may require low dose CT at an early stage.
Mandibular trauma K9 XR Mandible or Orthopantomogram (OPG) Indicated [C] For non-traumatic TMJ problems see B11.
Cervical Spine
Conscious patient with head and/or face injury only K10 XR C spine Not indicated [B] In those who meet all of the following criteria:
1. Fully conscious.
2. Not intoxicated.
3. No abnormal neurological findings.
4. No neck pain or tenderness.
Unconscious head injury (see K3/K4) K11 XR C spine Indicated [B] Must be of good quality to allow accurate evaluation. But radiography may be very difficult in the severely traumatised patient and must avoid manipulation (see also K12).
Neck injury: with pain K12 XR C spine Indicated [B] Cervical spine XRs can be very difficult to evaluate. Radiography also difficult and:
1. Must show C7/T1.
2. Should show odontoid peg (not always possible at time of initial study).
3. May need special views, CT or MRI especially when XR equivocal or complex lesions.
CT or MRI Specialised investigation [B] Discuss with Department of Clinical Radiology.
Neck injury: with neurological deficit K13 XR Indicated [B] For orthopaedic assessment.
MRI Indicated [B] Some constraints with life support systems. MRI best and safest method of demonstrating intrinsic cord damage, cord compression, ligamentous injuries and vertebral fractures at multiple levels. CT myelography may be considered if MRI not available.
Neck injury: with pain but XR initially normal; suspected ligamentous injury K14 XR C spine; flexion and extension Specialised investigation [B] Views taken in flexion and extension (consider fluoroscopy) as achieved by the patient with no assistance and under medical supervision. MRI may be helpful here.
Thoracic and Lumbar Spine
Trauma: no pain, no neurological deficit K15 XR Not indicated [B] Physical examination is reliable in this region. When the patient is awake, alert and asymptomatic, the probability of injury is low.
Trauma: with pain, no neurological deficit or patient not able to be evaluated K16 XR painful area Indicated [B] A low threshold to XR when there is pain/tenderness, a significant fall, a high impact RTA, other spinal fracture present or it is not possible to clinically evaluate the patient. Increasing use of CT and MRI here.
Trauma: with neurological deficit +/- pain K17 XR Indicated [B]  
MRI Indicated [B] Where technically possible. CT often used as patient undergoing CT for other reasons. But MRI best method of demonstrating intrinsic cord damage, cord compression and vertebral fractures at multiple levels.
Pelvis and Sacrum
Fall with inability to bear weight K18 XR pelvis plus lateral XR hip Indicated [C] Physical examination may be unreliable. Check for femoral neck fractures, which may not show on initial XR, even with good lateral views. In selected cases NM or MRI or CT can be useful when XR normal or equivocal.
Urethral bleeding and pelvic injury K19 Retrograde urethrogram Indicated [C] To show urethral integrity, leak, rupture. Consider cystogram if urethra normal and suspicion of bladder leak.
Trauma to coccyx or coccydynia K20 XR coccyx Not indicated routinely [C] Normal appearances often misleading and findings do not alter management.
Upper Limb
Shoulder injury K21 XR shoulder Indicated [B] Some dislocations present subtle findings. As a minimum, orthogonal views are required. US, MRI and CT arthrography all have a role in soft tissue injury.
Elbow injury K22 XR elbow Indicated [B] To show an effusion. Routine follow-up XRs not indicated in 'effusion, no obvious fracture' (see also Section M). Increasing use of CT and MRI here.
Wrist injury K23 XR wrist
NM or MRI		 Indicated
Specialised investigation		 [B]
[B]		 Scaphoid fractures can be invisible at presentation. Most entres repeat XR at 10-14 days if there are strong clinical signs and initial XR negative. Some departments use NM or MRI to exclude fracture earlier than this. Increasing use of MRI as the only examination.
Lower Limb
Knee injury (fall/blunt trauma) K24 XR knee Not indicated routinely [B] Especially where physical signs of injury are minimal. Inability to weight bear or pronounced bony tenderness, particularly at patella and head of fibula, merit radiography.
Ankle injury K25 XR ankle Not indicated routinely [B] Features which justify XR include: the elderly patient, malleolar tenderness, marked soft tissue swelling and inability to bear weight.
Foot injury K26 XR foot Not indicated routinely [B] Unless there is true bony tenderness. Even then the demonstration of a fracture rarely influences management. Only rarely are XRs of foot and ankle indicated together; both will not be done without good reason. Clinical abnormalities are usually confined to foot or ankle.
?Stress fracture K27 XR Indicated [B] Although often unrewarding.
NM or MRI Indicated [B] Provides a means of early detection as well as visual account of the biomechanical properties of the bone. Some centres use US here.
The Foreign Body (FB)
Soft tissue injury:
?FB (metal, glass, painted wood) 		K28 XR Indicated [B] All glass is radio-opaque; some paint is radio-opaque. Radiography and interpretation may be difficult; remove blood-stained dressings first. Consider US, especially in areas where radiography difficult.
Soft tissue injury:
?FB (plastic, wood)		 K29 XR Not indicated [B] Plastic is not radio-opaque: wood is rarely radio-opaque.
US Indicated [B] Soft tissue US may show non-opaque FB.
Swallowed FB suspected in pharyngeal or upper oesophageal region

(For Children see Section M)		 K30 XR Soft tissues of neck Indicated [C] After direct examination of oropharynx (where most FBs lodge), and if FB likely to be opaque. Differentiation from calcified cartilage can be difficult. Most fish bones invisible on XR. Maintain a low threshold for laryngoscopy or endoscopy, especially if pain persists after 24 hrs (see K33). N.B. For possible inhaled FB in Children see Section M (M23).
Swallowed FB: smooth and small (e.g. coin) K31 CXR
AXR		 Indicated
Not indicated routinely		 [B]
[B]		 The minority of swallowed FBs will be radio-opaque. In children a single, slightly over-exposed, frontal CXR to include neck should suffice. In adults, a lateral CXR may be needed in addition if frontal CXR negative. Majority of FBs that impact, do so at crico-pharyngeus. If the FB has not passed (say within 6 days), AXR may be useful for localisation.
Sharp or potentially poisonous swallowed FB: (e.g. ?battery) K32 AXR Indicated [B] Most swallowed foreign bodies that pass the oesophagus eventually pass through the remainder of the gastrointestinal tract without complication. But location of batteries is important as leakage can be dangerous.
CXR Not indicated routinely [B] Unless AXR negative.
Swallowed FB: Large object (e.g. dentures) K33 CXR Indicated [B] Dentures vary in radio-opacity; most plastic dentures are radiolucent. AXR may be needed if CXR negative, as may barium swallow or endoscopy. Lat CXR may be helpful.
Chest
Chest trauma: minor K34 CXR Not indicated routinely [B] The demonstration of a rib fracture does not alter management.
Chest trauma: moderate K35 CXR Indicated [B] Frontal CXR for pneumothorax, fluid or lung contusion. A normal CXR does not exclude aortic injury and arteriography/CT/MRI should be considered.
Stab injury K36 CXR Indicated [C] PA and/or other views to show pneumothorax, lung damage or fluid. US useful for pleural and pericardial fluid.
?Sternal fracture K37 XR lateral sternum Indicated [C] In addition to CXR. Think of thoracic spinal and aortic injuries too.
Abdomen (Including Kidney)
Blunt or stab injury K38 Supine AXR + erect CXR Indicated [B] US valuable for detecting haematoma and possible injury to some organs, e.g. spleen, liver. CT may be needed (see K40-K42).
?Renal trauma K39 Imaging Indicated [B] Discuss with radiologist. In agreement with local policy and availability. US often sufficient for minor local injury. Many centres use a limited IVU, merely to ensure normality of contralateral kidney. Some patients with major injury (see below) undergo CT, making IVU unnecessary. Consider renal artery damage, especially in deceleration injuries; arteriography may be needed
Major Trauma
Major trauma-general screen in the unconscious or confused patient K40 C spine XR
CXR
Pelvis XR
CT head		 Indicated [B] Stabilise patient's condition as a priority. Perform only the minimum XRs necessary at initial assessment. C spine XR can wait so long as spine and cord suitably protected. Pelvic fractures often associated with major blood loss.
See Head Injury K1-K4
Major trauma - abdomen/pelvis K41 CXR, Pelvis XR Indicated [B] Pneumothorax must be excluded. Pelvic fractures which increase pelvic volume often associated with major blood loss.
CT abdo Indicated [B] Sensitive and specific, but time-consuming and may delay Theatre. CT should precede peritoneal lavage. Increasing interest in the use of US in emergency room to show free fluid plus solid organ-injury.
Major trauma - chest K42 CXR Indicated [B] Allows immediate management (e.g. pneumothorax).
CT Chest Indicated [B] Especially useful to exclude mediastinal haemorrhage. Low threshold for proceeding to arteriography.

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