Case #05 Radiologic Findings:

Image #1, taken at 11:44 a.m., shows a right tension hemothorax with significant collapse of all three lobes. There is a fracture of the 11th posterior rib with a bone fragment displaced towards the 10th rib. A bullet fragment is seen at the level of the 5th posterior rib. The right hemidiaphragm is obscured by blood in the pleural space, and there is obvious damage to the lung tissue. It is unclear from this film whether there is diaphragmatic or subdiaphragmatic injury. The left lung appears normal although it is slightly compressed and leftward mediastinal shift is seen. The right heart border is not seen and is difficult to assess secondary to the mediastinal shift.   Go To Image #1
Image #2, taken at 12:27 p.m., is after chest tube placement. The tension hemothorax has been reduced. There is now a small pneumothorax. The right hemidiaphragm is still obscured. The mediastinal shift is resolved, and the right heart border is clearly seen, indicating that the right middle lobe is well-aerated, and that the majority of the injury was to the right lower lobe.   Go To Image #2
Image #3 (4:55 p.m.) shows a very small pneumothorax. No other changes are noted.   Go To Image #3
A CT with intravenous contrast (1:55p.m.), further defines the extent of the injury, and is used to assess the right hemidiaphragm. The bullet fragment is seen in the anterior soft tissues. Extensive right lower lobe contusion is seen. Injury to the right middle lobe is seen, and the path of the bullet can be traced. There is no evidence of pneumothorax. The 11th rib fracture is well-visualized. No evidence of liver or diaphragmatic injury is seen.   Go To Image #4