Battlefield radiology

Abstract

With the increasing tempo of military conflicts in the last decade, much has been learnt about imaging battlefield casualties in the acute setting. Ultrasound in the form of focused abdominal sonography in trauma (FAST) has proven invaluable in emergency triage of patients for immediate surgery. Multidetector CT allows accurate determination of battlefield trauma injuries. It permits the surgeons and anaesthetists to plan their interventions more thoroughly and to be made aware of clinically occult injuries. There are common injury patterns associated with blast injury, gunshot wounds and blunt trauma. While this body of knowledge is most applicable to the battlefield, there are parallels with peacetime radiology, particularly in terrorist attacks and industrial accidents. This pictorial review is based on the experiences of a UK radiologist deployed in Afghanistan in 2010.

Figure 1

(a–c) Axial (soft tissue and bone) and sagittal bone CT head of a patient with gunshot wound to the head: nasopharyngeal airway with tip within right frontal lobe (arrows). There are parenchymal contusions and cerebral haemorrhages associated, and multiple skull fractures.

Figure 2

Axial CT angiogram at the level of the popliteal fossa. A bullet (arrow) has fractured the right patella and right lateral femoral condyle coming to rest behind the popliteal vessels. The popliteal artery is patent. This was confirmed at surgery.

Figure 3

(a) Coronal and (b) axial pelvic CT images demonstrating pelvic and perineal soft tissue injuries in a child injured by an improvised explosive device. Note the large perirectal defect (arrows).

Figure 4

Sagittal CT reformat of the thoracolumbar junction demonstrating burst fracture of L1 (arrow). There is retropulsion of the vertebral body producing significant spinal stenosis. The injury resulted from a vehicle being overturned by an improvised explosive device.

Figure 5

Axial CT head of a child injured by improvised explosive device. Complex open skull fracture.

Figure 6

Axial CT through the maxilla in a blast injury patient. Avulsion of upper left fifth tooth (arrow head) and an oral cavity foreign body (arrow).

Figure 7

Axial CT head in a blast injury patient. Traumatic right subdural haematoma (arrows). Note the midline shift and effacement of the right lateral ventricle.

Figure 8

Axial head CT post-intravenous contrast (arterial phase) in a blast injury patient. Right-sided middle cerebral artery is less apparent than the left, suggesting decreased perfusion. This patient has a right-sided subdural haematoma.

Figure 9

Axial CT head of a patient with blast injury to left globe.

Figure 10

Axial CT head of a child with blast injury. Foreign body within left globe (arrow).

Figure 11

(a, b) Axial CT thoracic images demonstrating haemorrhagic pulmonary contusion, traumatic pneumatocoeles and a right-sided pneumothorax (arrow). Note the double-lumen endotracheal tube.

Figure 12

Coronal thoracic CT reformat demonstrating blast fragment lodged between epicardium and diaphragm (arrow). Note the left liver lobe laceration. This fragment traversed the diaphragm from the abdomen into the chest.

Figure 13

Axial abdominal CT (bone windows). Penetrating fragment in right kidney (arrow) from blast injury. The fragment entered posteriorly. At surgery there was no breach of the peritoneum.

Figure 14

Axial head CT (bone windows). Complex right-sided facial fracture. The bullet entered just below the right orbit and exited anterior to the right exterior auditory meatus.

Figure 15

Axial head CT. Gunshot wound to head. Left frontal exit wound. Bullet fragments (arrows) are present within the right cerebral hemisphere. Haemorrhage is present within and around the bullet track.

Figure 16

Axial CT thorax. Traumatic right pulmonary contusion and haemopneumothorax. This was secondary to a penetrating blast fragment to the chest.

Figure 17

(a, b) Axial CT abdomen (bone and soft tissue windows) gunshot wound entering through the L1 lamina and pedicle, then traversing the left renal upper pole, small bowel and colon before exiting through the left anterolateral abdominal wall.

Figure 18

Unenhanced axial abdominal CT performed as CT KUB (kidneys, ureters and bladder) demonstrating oedematous small bowel mesentery and dilated mesenteric veins (arrows). This was confirmed as small bowel volvulus at surgery.