case_images: PMC9724140_01
case_images: Axial (a and b) and coronal (c) reconstructions of the cervical spine CT showing comminuted fractures of the left superior and inferior facets of C4 (black arrow) and left lamina of C4 (white arrow). Sagittal (d) reconstruction shows a small avulsion fracture of the anterosuperior margin of the C4 vertebral body (black arrow). These fractures represent an unstable cervical spine injury.
case_images: SAJR-26-2516-g002.jpg
case_images: PMC9724140_01_SAJR-26-2516-g002.jpg
case_images: F0002
case_images: A junior consultant identified a fracture of the C4 vertebra on the CT pan-scan, which, in retrospect, was visible on the initial CT (Figure 2a-d).
case_images: PMC9724140_02
case_images: Sagittal reconstruction of the initial CT of the cervical spine (a) showing the C4 spinous process fracture (black arrow). The follow-up CT (b) shows worsened retrolisthesis of the C4 on C5 vertebra with an anterior teardrop fracture of the C4 vertebra (white arrow). This fracture is visible in (a) but was called a 'fractured osteophyte' (white arrowhead). The axial (c) and coronal (d) reconstructions of the scan show how the degenerative cervical spine changes may make diagnosing fractures challenging - the teardrop fracture is pointed out by the white arrow in (c) and may have been misinterpreted as an osteophyte (white arrowhead). The black arrowhead in (c) demonstrates a right lamina fracture, and the black arrow again points out the spinous process fracture.
case_images: SAJR-26-2516-g003.jpg
case_images: PMC9724140_02_SAJR-26-2516-g003.jpg
case_images: F0003
case_images: Upon review, the senior consultant detected a missed C4 spinous process fracture - a stable injury - but no other abnormalities (Figure 3a). A follow-up CT pan-scan was requested to confirm that there were no thoracolumbar spine fractures that could have explained the patient's worsening neurological symptoms, and a different consultant radiologist detected retrolisthesis of C4 on C5 (Figure 3b-d). Secondary interpretation of the initial CT was performed by this same consultant, who noted an anterior teardrop fracture of the C4 vertebra (Figure 3b-d), making the cervical spine injury unstable.
case_images: PMC9724140_03
case_images: Paramidline sagittal (a and b) reconstructions of a cervical spine CT showing a fracture of the right inferior facet of the C6 vertebra (black arrow), a fracture of the right superior facet of the C7 vertebra (white arrow) and a fracture of the anterosuperior margin of the body of C7 (black arrowhead). A midline sagittal reconstruction (c) demonstrates reversed cervical spine lordosis but no listhesis. Associated prevertebral soft tissue swelling is present (white asterisk). Note that the patient was 'scanned skew' (d).
case_images: SAJR-26-2516-g004.jpg
case_images: PMC9724140_03_SAJR-26-2516-g004.jpg
case_images: F0004
case_images: A junior consultant then reviewed the CT and noted several vertebral fractures that were missed initially (Figure 4a-d). Associated prevertebral soft tissue swelling was also noted (Figure 4a-d).
case_images: PMC9724140_04
case_images: Axial CT of the head (a) demonstrating the depressed right squamous temporal bone fracture (black arrow) detected on initial interpretation. An oblique reconstruction of the right temporal bone (b) shows that the fracture (white arrow) extends into the facial nerve canal (highlighted here by the white dots). Specifically, it involves the tympanic segment of the canal. The fracture line extending into the mastoid part of the temporal bone is pointed out by the black arrowhead in the axial image (c) - note the fluid in the mastoid air cells and compare it to the well-aerated left mastoid air cell; a secondary sign of temporal bone fracture. The fracture line (white arrowhead) is much more conspicuous on the axial cut of the bone reconstruction algorithm (d) than the soft tissue algorithm (e), despite both being set to a standard 'bone window'.
case_images: SAJR-26-2516-g005.jpg
case_images: PMC9724140_04_SAJR-26-2516-g005.jpg
case_images: F0005
case_images: Initial interpretation by a junior registrar noted the depressed squamous temporal fracture (Figure 5a) but failed to notice that it extended into the petrous and mastoid regions to involve the facial nerve canal within the otic capsule, known as an 'otic capsule-violating' fracture (Figure 5b-e).
case_images: PMC9724140_05
case_images: A CT pan-scan showing extensive subcutaneous emphysema of both the head (a) and chest (b). When viewed without straightening the scan using multiplanar reconstruction (c), the right temporal bone otic capsule-sparing fracture is not easy to detect even utilising the bone reconstruction algorithm (black arrow) and nearly invisible (white arrow) on the soft tissue reconstruction algorithm (d). The bone window (e) demonstrates an initially overlooked nondisplaced right 9th rib fracture (black arrowhead). Note the right haemothorax (black star) and pneumothorax (white star) seen on the lung window of the chest CT (f). Also note that the patient was 'scanned skew'.
case_images: SAJR-26-2516-g006.jpg
case_images: PMC9724140_05_SAJR-26-2516-g006.jpg
case_images: F0006
case_images: A CT pan-scan (Figure 6a-f) was performed at 12:48 on the Tuesday of presentation and was initially reported as normal by a junior registrar. However, on secondary analysis by a consultant, several missed fractures were detected, including an otic capsule-sparing right temporal fracture (Figure 6c-d) and multiple nondisplaced right rib fractures (Figure 6e-f).
case_images: Axial bone reconstruction of a CT (a and b) of the chest demonstrating subtle buckle-type fractures of the 10th and 11th ribs (black arrows) associated with a small lung contusion (white arrow).
case_images: SAJR-26-2516-g007.jpg
case_images: PMC9724140_05_SAJR-26-2516-g007.jpg
case_images: F0007
case_images: A CT pan-scan was performed at 12:42, and initial interpretation by a junior registrar failed to diagnose subtle fractures of the right 10th, 11th and 12th ribs with associated lung contusions (Figure 7a-b).
case_images: PMC9724140_06
case_images: Axial bone reconstruction CT of a the chest demonstrating a minimally displaced second rib fracture (black arrow) associated with a small lung laceration and contusion (white arrow). As with cases 5 and 6, lung injuries such as contusions or lacerations should prompt careful search for associated rib fractures in the trauma patient.
case_images: SAJR-26-2516-g008.jpg
case_images: PMC9724140_06_SAJR-26-2516-g008.jpg
case_images: F0008
case_images: Secondary analysis by a junior consultant, however, revealed a nondisplaced fracture of the right second rib and a buckle-type fracture of the right third rib (Figure 8). While small lung contusions and a laceration were associated with these fractures, there was no pneumothorax (Figure 8).