XRs - Thoracic

Initial Review

- confirm correct patient
- scan for suspected pathology
- use pt findings to focus the XR review, and use XR findings to enhance physical exam.


a) large airway injury: presence of interstitial / pleural air
b) tracheal lacerations: pneumomediastinum, pneumothorax, subcutaneous emphysema, pneumoperitoneum.
c) bronchial disruption: massive pneumothorax with persistant air leak.

Pleural Spaces and Lungs

a) collections / haemothorax
b) air / pneumothorax.
c) lung infiltrates: contusion, haematoma, aspiration etc.
d) lung parenchyma: laceration (consolidation)


a) air/blood blurring demarcations
b) air/blood in pericardium: enlarging cardiac silhouette.
c) aortic rupture: widened mediastinum, #s 1st/2nd ribs, aortic knob obliteration, tracheal devation to right, pleural cap, elevation of R mainstem bronchus, obliteratioon of space between pulmonary area and aorta, deviation of oesophagus (NG tube) to R.


Rupture requires a high index of suspicion - initial XR is not sensitive.
a) elevation (can go to 4th ICS with expiration)
b) disruption (stomach, bowel cas, NG tube above)
c) irregular or obscured (overlying fluid).
d) contralateral medistinal shift
e) widening of cardiac silouette (if abdo contents herniate into it)
f) pleural effusion


a) clavicle: #, associated great vessel injury.
b) scapula: #, associated airway, vessel, pulmonary injury.
c) ribs 1-3: #, associated pneumothorax, major airway, great vessel injury
d) ribs 4-9: #, flail chest (2 or more contiguous ribs in 2 places), associated pneumothorax, haemothorax, pulmonary contusion
e) ribs 9-12: #, flail chest, associated pneumothorax, pulm contusion, spleen, liver, kidney injury.
f) sternum: # / dislocation, associated myocardial contusion, great vessel injury.

Soft tissues

a) displacement or disruption of tissue planes
b) subcutaneous air

Tubes / lines

ETT, chest tubes, central access lines, NG, others.


Possible Cause
Resp distress, no XR signs
CNS injury, aspiration, asphyxia
Rib #
Pneumothorax, pulm contusion
# upper thorax
Airway/great vessel injury
# ribs 9-12
Abdo injury
>2#s, >2 places
Flail chest, pulm contusion
Scapular #
Great vessels, pulm cont, brach plex.
Sternal #
Blunt cardiac injury
Mediastinum wide
Great vessel, sternal #, T-spine
Persisting pneumothrx
Bronchial tear
Mediastinal air
Oesoph, tracheal, pneumoperitoneum
Loculated air in chest
Diaphragmatic rupture
NG tube in chest
Diaphragm/oesoph rupture
Air fluid level
Haemopneumothx, oesoph rupture
Disrupted diaphragm
Abdo visceral injury
Free air under diaphragm
Rupture hollow abdo viscus