Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

PURPOSE: Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. METHODS: A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. RESULTS: After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. CONCLUSIONS: The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Blunt Cerebrovascular Injury-Like Injury Observed in Patients With Craniofacial Self-Inflicted Gunshot Wounds.

BACKGROUND: Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population. METHODS: An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed. RESULTS: Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P  = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P  = 0.02). CONCLUSIONS: Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations.

Preoperative Imaging for Facial Transplant: A Guide for Radiologists.

Facial transplant (FT) is a viable option for patients with severe craniomaxillofacial deformities. Transplant imaging requires coordination between radiologists and surgeons and an understanding of the merits and limitations of imaging modalities. Digital subtraction angiography and CT angiography are critical to mapping vascular anatomy, while volume-rendered CT allows evaluation of osseous defects and landmarks used for surgical cutting guides. This article highlights the components of successful FT imaging at two institutions and in two index cases. A deliberate stepwise approach to performance and interpretation of preoperative FT imaging, which consists of the modalities and protocols described here, is essential to seamless integration of the multidisciplinary FT team. ©RSNA, 2019 See discussion on this article by Lincoln .

Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study.

PURPOSE: Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined. MATERIALS AND METHODS: This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures. RESULTS: Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury. CONCLUSION: CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery. KEY POINTS: • The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

After-Hours Radiology: Challenges and Strategies for the Radiologist.

OBJECTIVE: Because of the increase in the use of 24-hour-a-day 7-day-a-week real-time radiologic interpretation, radiologists more frequently perform after-hours work. The purpose of this article was to examine the challenges arising from after-hours work and describe evidence-based strategies meant to limit the adverse physical and psychologic stresses of after-hours work. CONCLUSION: Working nontraditional hours affects a radiologist's health, social life, professional productivity, and possibly interpretive accuracy. Appropriate attention to these factors and targeted countermeasures can optimize the professional development and personal well-being of radiologists working after hours.

Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography.

OBJECTIVE: The purposes of this study were to assess the diagnostic performance of 40- and 64-MDCT angiography with digital subtraction angiography as the reference standard in the detection of arterial injuries in patients at high risk after penetrating neck trauma and to perform a separate analysis of injuries to the external carotid artery. MATERIALS AND METHODS: In a retrospective evaluation of 53 sets of angiograms from 51 patients with penetrating neck injury, three reviewers unaware of the digital subtraction angiographic findings reviewed the CT angiographic (CTA) images to discern the presence or absence of arterial injuries. Sensitivity and specificity of CTA were calculated per injury, and a separate analysis of external carotid artery injuries was performed. RESULTS: Sensitivity of CTA for detecting arterial injuries ranged from 75.7% (95% CI, 62.3-86.9%) to 82.2% (95% CI, 69.5-92.1%). Specificity ranged from 96.4% (95% CI, 94.0-98.4%) to 98.4% (95% CI, 96.0-100%). CTA was highly sensitive for detection of the subgroup of injuries involving the large-caliber vessels that contribute to cerebral circulation. These sensitivities ranged from 92.8% (95% CI, 66-98.8%) to 100% (95% CI, 76.6-100%) for internal carotid artery injuries and from 88.9% (95% CI, 65.2-98.3%) to 94.4% (95% CI, 72.6-99.0%) for vertebral artery injuries. In contrast, sensitivity of CTA was limited for external carotid artery injuries, ranging from 63.4% (95% CI, 45.5-79.5%) to 70.0% (95% CI, 52.0-85.0%). CONCLUSION: CTA can be used for initial evaluation and may help guide management decisions if an external carotid artery injury is detected. Negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.

Multidetector CT of blunt cervical spine trauma in adults.

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type.

Optimizing trauma multidetector CT protocol for blunt splenic injury: need for arterial and portal venous phase scans.

PURPOSE: To retrospectively compare the diagnostic performance of arterial, portal venous, and dual-phase computed tomography (CT) for blunt traumatic splenic injury. MATERIALS AND METHODS: Informed consent was waived for this institutional review board-approved, HIPAA-compliant study. Retrospective record review identified 120 blunt trauma patients (87 male [72.5%] 33 female [27.5%]; age range, 18-94 years) who had undergone dual-phase abdominal CT within 5 years, including 30 without splenic injury, 30 with parenchymal injury only, 30 with splenic active bleeding, and 30 with intrasplenic pseudoaneurysm. Six radiologists each performed blinded review of 20 different cases, and scored the presence of pseudoaneurysm, active bleeding, parenchymal injury, and hematoma; 20 cases were interpreted by all radiologists. Data analysis included calculation of diagnostic performance measures with confidence intervals, areas under receiver operating characteristic curves, and interobserver agreement/variability. RESULTS: For intrasplenic pseudoaneurysm, arterial phase imaging was more sensitive (70% [21 of 30] vs 17% [five of 30]; P < .0002) and more accurate (87% [78 of 90] vs 72% [65 of 90]; P = .0165) than portal venous phase imaging. For active bleeding, arterial phase imaging was less sensitive (70% [21 of 30] vs 93% [28 of 30]; P = .0195) and less accurate (89% [80 of 90] vs 98% [88 of 90]; P = .0168) than portal venous phase imaging. For parenchymal injury, arterial phase CT was less sensitive (76% [68 of 90] vs 93% [84 of 90]; P = .001) and less accurate (81% [nine of 120] vs 95% [114 of 120]; P = .0008) than portal venous phase CT. For all injuries, dual-phase review was equivalent to or better than single-phase review. CONCLUSION: For CT evaluation of blunt splenic injury, arterial phase is superior to portal venous phase imaging for pseudoaneurysm but inferior for active bleeding and parenchymal disruption; dual-phase CT provides optimal overall performance.

MR imaging and differentiation of cerebral fat embolism syndrome from diffuse axonal injury: application of diffusion tensor imaging.

INTRODUCTION: Cerebral fat embolism syndrome (CFES) mimics diffuse axonal injury (DAI) on MRI with vasogenic edema, cytotoxic edema, and micro-hemorrhages, making specific diagnosis a challenge. The objective of our study is to determine and compare the diagnostic utility of the conventional MRI and DTI in differentiating cerebral fat embolism syndrome from diffuse axonal injury. METHODS: This retrospective study was performed after recruiting 11 patients with severe CFES and ten patients with severe DAI. Three trauma radiologists analyzed conventional MR images to determine the presence or absence of CFES and DAI. DTI analysis of the whole-brain white matter was performed to obtain the directional diffusivities. The results were correlated with clinical diagnosis to determine the diagnostic utility of conventional MRI and DTI. RESULTS: The sensitivity, specificity, and accuracy of conventional MRI in diagnosing CFES, obtained from the pooled data were 76, 85, and 80 %, respectively. Mean radial diffusivity (RD) was significantly higher and the mean fractional anisotropy (FA) was lower in CFES and differentiated subjects with CFES from the DAI group. Area under the receiver operating characteristic (ROC) curve for conventional MRI was 0.82, and for the differentiating DTI parameters the values were 0.75 (RD) and 0.86 (FA), respectively. CONCLUSIONS: There is no significant difference between diagnostic performance of DTI and conventional MRI in CFES, but a difference in directional diffusivities was clearly identified between CFES and DAI.

Emergency radiology eponyms: part 1-Pott's puffy tumor to Kerley B lines.

An eponym is a name based on the name of a person, frequently as a means to honor him/her, and it can be used to concisely communicate or summarize a complex abnormality or injury. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medicine. Many commonly used eponyms applied to extremity fractures should be familiar to most emergency radiologists and have been previously reported. Yet, a number of non-extremity eponyms can be encountered in an emergency radiology practice as well. This other group of eponyms encompasses a spectrum of traumatic and non-traumatic pathology. In this first part of a two-part series, the authors discuss a number of non-extremity emergency radiology eponyms, including relevant clinical and imaging features, as well biographical information of the eponyms' namesakes.

Emergency radiology eponyms: part 2--Naclerio's V sign to Fournier gangrene.

An eponym is a name based on the name of a person, frequently as a means to honor him/her, and it can be used to concisely communicate or summarize a complex abnormality or injury. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medicine. Many commonly used eponyms applied to extremity fractures should be familiar to most emergency radiologists and have been previously reported. Yet, a number of non-extremity eponyms can be encountered in an emergency radiology practice as well. This other group of eponyms encompasses a spectrum of traumatic and nontraumatic pathology. In this second part of a two-part series, the authors discuss a number of non-extremity emergency radiology eponyms, including relevant clinical and imaging features, as well biographical information of the eponyms' namesakes.

Craniofacial gunshot injuries: an unrecognised risk factor for blunt cervical vascular injuries?

OBJECTIVES: To review our institutional experience with cervical arterial injuries remote from the penetrating tract seen in the setting of craniofacial gunshot injuries. METHODS: Institutional Review Board approval was obtained. Our institutional trauma registry was queried over a 5-year period for patients with cervical arterial injuries due to penetrating craniofacial gunshot wounds who underwent CT angiography. Imaging results and clinical notes were reviewed. RESULTS: A total of 427 patients sustained gunshot wounds to the head, face and/or neck, of whom 222 underwent CT angiography yielding 56 patients with 78 vascular injuries. There were five internal carotid artery injuries remote from the wound tract. The incidence of these "indirect" cervical arterial injuries in our patient population was 1.2%, or 2.8% of patients who underwent CT angiography. CONCLUSIONS: The incidence of "indirect" cervical arterial injuries with craniofacial gunshot wounds is comparable to or slightly higher than those seen in pure blunt trauma. Screening patients with craniofacial gunshot injuries with CT angiography may yield unexpected cervical vascular injuries remote from the penetrating tract. The significance and optimal therapy of these injuries are unknown. Additional experience will be needed to determine the significance of "indirect" cervical arterial injuries in the setting of craniofacial gunshot wounds.

Imaging evaluation of penetrating neck injuries.

Penetrating neck injuries are a significant source of morbidity and mortality. Diagnostic imaging plays an integral role in the diagnosis and management of these injuries. Although clinical management of penetrating injuries to the neck remains controversial, many institutions have shifted away from mandatory surgical exploration of most penetrating neck injuries toward use of endoscopy, various imaging modalities, and selective surgery to manage specific injuries diagnosed with these techniques. Much of this shift can be attributed to computed tomographic (CT) angiography, a fast, reliable, and noninvasive procedure that provides a global assessment of the neck, thereby reducing the frequency of nontherapeutic surgical neck explorations and limiting the need for diagnostic conventional angiography. Therefore, radiologists interpreting images from CT angiography should be prepared to provide management recommendations on the basis of the CT angiographic findings. An appreciation of the value, roles, and limitations of multidetector CT angiography and other imaging modalities can position the radiologist as a vital participant in the care of patients with penetrating trauma to the neck.

MDCT diagnosis of penetrating diaphragm injury.

The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries.

Blunt cerebrovascular injuries: does treatment always matter?

BACKGROUND: Blunt cerebrovascular injuries (BCVI) have become an increasingly recognized entity. Stroke as a result of these injuries can have devastating consequences. Optimal screening criteria, diagnostic imaging, and therapy for BCVIs have not been elucidated. Our institution began to apply liberal screening criteria using a whole-body scanning protocol with multidetector computed tomographic (WB-MDCT) scans to diagnose these injuries. The purpose of this study is to describe a single institution's large experience in patients with BCVI in an effort to provide insight into the diagnosis and management of these injuries. METHODS: All patients with a BCVI admitted to the R Adams Cowley Shock Trauma Center during a 30-month period were included in this study. Choice of diagnostic evaluation and treatment regimens were at the discretion of the treating attending physician. Review of medical records and all relevant radiographic studies were retrospectively performed for the purposes of this study. RESULTS: During the study period, there were 12,667 patients admitted to the R Adams Cowley Shock Trauma Center. There were 147 patients identified with 200 carotid or vertebral artery injuries. The incidence of BVCI was 1.2%. Mortality was 13%. Anatomic injury risk factors for BCVI (major facial fractures, skull base fractures, cervical spine fractures or spinal cord injury, or traumatic brain injury) were found in only 78%. Major thoracic injury was found in 63% of patients with carotid artery injuries and cervical spine fractures or spinal cord injury was found in 74% of patients with vertebral artery injuries. The initial screening test employed was a WB-MDCT in 96% of patients of which 84% detected a BCVI. Treatments included endovascular therapy (22%), antiplatelet medications (36%), anticoagulation (10%), and combination therapy with antiplatelet agents and anticoagulation (18%). Thirty percent received no therapy, primarily due to contraindications from concomitant injuries. There were 18 (12%) patients who had a stroke. Of these patients, 8 (44%) had evidence of infarction at admission, 6 were diagnosed within 72 hours, and 4 were diagnosed after 1 week. Stroke-related mortality was 50%, whereas clinical follow-up after hospital discharge demonstrated only one patient with disability as a result of infarction. Of 10 patients who did not have stroke at admission, 3 were fully treated, 5 had specific contraindications to therapy, and 2 had no or false-negative imaging before infarction. Stroke rates for untreated patients were 25.8% and patients treated with any therapy had a stroke rate of 3.9% (p = 0.0003). Radiographic follow-up >1 month after injury demonstrated improvement in over 50% of patients. CONCLUSIONS: BCVIs are not infrequent after blunt trauma. These injuries occur even in the absence of classically described risk factors. Liberal screening with WB-MDCT incorporates detection of these injuries into the initial diagnostic evaluation. Stroke occurs in a substantial number of patients and carries a very high mortality. However, nearly one third of patients with BCVI are not candidates for therapy. Treatment does reduce the risk of infarction in patients with BCVI, but strokes, when they occur, are not preventable.

Imaging of Neck Visceral Trauma.

The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.

Diagnosis of blunt cerebrovascular injuries with 16-MDCT: accuracy of whole-body MDCT compared with neck MDCT angiography.

OBJECTIVE: The objective of our study was to determine whether whole-body 16-MDCT and neck MDCT angiography (MDCTA) can be used to diagnose blunt cerebrovascular injuries with comparable accuracy using angiography as the reference standard. MATERIALS AND METHODS: Retrospective review of radiology reports and prospective clinical observation identified 108 blunt trauma patients examined with either whole-body MDCT or neck MDCTA followed by angiography over a 23-month period. From this group, results from the retrospective interpretations of 77 whole-body MDCT and 48 neck MDCTA examinations were compared with the results extracted from angiography reports to estimate the accuracy of each protocol for detecting blunt cerebrovascular injuries. Fisher's exact test was used to determine any significant difference in the results of those patients scanned with both protocols. RESULTS: Angiography confirmed blunt cerebrovascular injury in 83 patients, with 25 (30%) showing multiple sites of injury. Most injuries were detected in cervical arterial segments. The respective sensitivities of whole-body MDCT and neck MDCTA were 69% (36/52) and 64% (16/25) for cervical internal carotid artery injuries, and specificities were 82% (58/71) and 94% (49/52). Respective sensitivities for cervical vertebral artery injuries were 74% (17/23) and 68% (13/19), and specificities were 91% (60/66) and 100% (40/40). In 17 patients scanned with both protocols, the results were not significantly different (carotid arteries, p = 1.00; vertebral arteries, p = 0.68). CONCLUSION: Whole-body 16-MDCT and neck MDCTA can be used to diagnose blunt cerebrovascular injuries with comparable accuracy. Both show high specificities for cervical arterial injury. The sensitivity of whole-body 16-MDCT is sufficiently high to serve as an initial screening examination for blunt cerebrovascular injuries.

Blunt cerebrovascular injuries: imaging with multidetector CT angiography.

Blunt cerebrovascular injuries (BCVIs) can cause ischemic stroke and are associated with high mortality rates. However, treatment of BCVI can prevent or limit stroke. Although digital subtraction angiography is the diagnostic standard for detecting BCVI, recent studies indicate that multidetector computed tomographic (CT) angiography may be an accurate, rapid, noninvasive diagnostic alternative. Various manifestations of BCVI at multidetector CT angiography include minimal intimal injury, raised intimal flap, dissection with intramural hematoma, pseudoaneurysm, occlusion, transection, and arteriovenous fistula. Multidetector CT angiography can be used to grade and follow up BCVIs, providing significant prognostic information and influencing management decisions. Several other injuries and injury patterns can be used to identify patients with a high likelihood of concurrent BCVI, and these patterns can be used as indications to screen for BCVI. By facilitating early diagnosis and treatment of BCVI, such screening has been shown to improve the clinical outcomes of affected patients. Familiarity with the various imaging manifestations of injury at multidetector CT angiography, as well as with the diagnostic limitations of this modality and the various clinical factors that affect its use, is necessary if it is to be used effectively to diagnose and influence the management of BCVIs.

Imaging of blunt cerebrovascular injuries.

Blunt cerebrovascular injuries are uncommon but potentially devastating injuries that can lead to stroke and death. While uncommon, appreciation of the seriousness of these injuries, a high index of suspicion in high risk patients, and aggressive screening of multitrauma patients leads to early diagnosis of asymptomatic lesions that may be amenable to treatment prior to the onset of ischemia. The radiologist can play a vital role in the early diagnosis, follow-up, and, in some cases, treatment of these challenging injuries.

Imaging of diaphragm injuries.

Diaphragm injuries are uncommon consequences of blunt and penetrating trauma. Early diagnosis and repair prevent potentially devastating complications that typically result from visceral herniation through the posttraumatic diaphragm defect. Although clinical and radiographic manifestations frequently are nonspecific, the stalwarts of trauma imaging--chest radiography and CT--typically demonstrate these injuries. To render the appropriate diagnosis, the radiologist must be familiar with the varied imaging manifestations of injury, and maintain a high index of suspicion within the appropriate clinical setting.