[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Radiology](https://durgical.com/en/radiology/) › [Chest](https://durgical.com/en/radiology/areas/chest/) › Chest trauma imaging: ribs, contusion, haemothorax and the aorta

# Chest trauma imaging: ribs, contusion, haemothorax and the aorta

- Finding

After a chest injury, a quick X-ray and bedside ultrasound look for problems that kill fast; a CT then finds the hidden injuries in stable patients.

Updated Nov 13, 2026

## Key points

- Supine X-ray plus eFAST first; tension and massive bleeding are treated before imaging.
- Stable significant trauma: contrast CT of the chest.
- First ribs, scapula or sternum broken = high energy; look for the aorta and great vessels.
- Contusion: non-segmental, appears in hours, clears in a week; worsening later = pneumonia or ARDS.
- Aortic injury: CT angiography; a normal X-ray does not exclude it.

## What it is

In chest trauma, imaging follows the primary survey. A supine chest X-ray and an eFAST at the bedside look for the immediate threats: pneumothorax, haemothorax, a widened mediastinum and the position of tubes. Tension pneumothorax and massive bleeding are treated on clinical grounds, not after a scan. In the stable patient with significant mechanism, CT of the chest with intravenous contrast is the reference study: it shows rib and spine fractures, pulmonary contusion and laceration, small pneumothoraces and haemothoraces missed on the supine film, and injuries of the aorta and great vessels. A normal chest X-ray does not exclude an aortic injury.

## What it looks like

- Supine film: pneumothorax gives a deep, dark costophrenic angle (deep sulcus); blood gives a hazy veil over the whole hemithorax with vessels still seen through it.
- Flail chest: three or more adjacent ribs each broken in two or more places; usually with underlying contusion.
- Fractures of the first to third ribs, the scapula or the sternum mean high-energy trauma; look for vessel and nerve injuries.
- Lower rib fractures (9 to 12) raise suspicion of liver, spleen or kidney injury.
- Contusion: patchy, non-segmental opacities that do not follow lobes, appear within hours and clear in about a week.
- Aortic injury signs: widened mediastinum, lost aortic knob, trachea or nasogastric tube pushed to the right, depressed left main bronchus, left apical cap.

## Why it looks that way

- Blunt force bruises the lung: blood and fluid leak into alveoli and interstitium, so the opacity crosses lobar boundaries.
- On a supine film, pleural fluid layers behind the lung instead of forming a meniscus, and air rises to the front and base of the chest.
- Sudden deceleration tears the aorta where it is fixed, most often at the isthmus just after the left subclavian artery; the mediastinal haematoma widens the mediastinum.

## Differential and pitfalls

- Many rib fractures, especially anterior and cartilage fractures, are invisible on the chest X-ray; the X-ray is mainly for their complications.
- A supine AP film magnifies the mediastinum; judge widening with care and compare with the clinical picture.
- Contusion that worsens after the first days suggests pneumonia or ARDS, not the bruise itself.
- A pneumothorax that persists despite a working drain, or a lung that falls away from the hilum, suggests a bronchial tear.
- Left diaphragmatic rupture is easily missed: an irregular or raised left hemidiaphragm or a nasogastric tube curling above it.
- On CT, fresh blood measures denser than simple fluid; contrast leaking into the pleural space means active bleeding.

## Next step

- Unstable patient: treat tension pneumothorax or massive haemothorax clinically; use supine chest X-ray and eFAST at the bedside, and call the trauma team.
- Stable with significant mechanism: CT of the chest (and abdomen as needed) with intravenous contrast.
- Widened mediastinum or high-energy deceleration: CT angiography of the aorta, even if the X-ray looks normal; involve vascular or thoracic surgery.
- Haemothorax: chest drain and record the output; ongoing bleeding or a contrast blush: call thoracic surgery.
- After a drain or in isolated rib fractures: repeat chest X-ray for lung re-expansion, drain position and delayed effusion or pneumothorax.

## Test yourself

Think of the answer, then tap the question to see it.

## What is a flail chest?

Three or more adjacent ribs each fractured in two or more places, so a segment of chest wall moves paradoxically; it usually comes with an underlying pulmonary contusion.

## How does a haemothorax look on a supine chest X-ray?

As a hazy veil over the whole hemithorax with lung vessels still visible through it, without a meniscus, because the blood layers behind the lung.

## How is a pulmonary contusion told apart from pneumonia on imaging?

Contusion appears within hours of injury, does not follow lobes or segments and clears in about a week; an opacity that appears or worsens after several days suggests pneumonia.

## Which chest X-ray signs suggest traumatic aortic injury?

A widened mediastinum, loss of the aortic knob contour, the trachea or nasogastric tube pushed right, a depressed left main bronchus and a left apical cap.

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## Elsewhere in DurgiPedia

- [Pneumothorax syndrome](https://durgical.com/en/clinical-exam/pneumothorax-syndrome/)
- [Shock: the clinical signs and the types](https://durgical.com/en/clinical-exam/shock-the-clinical-signs-and-the-types/)

## Connections

## Related 8

- [The FAST and eFAST exam in trauma](https://durgical.com/en/radiology/the-fast-and-efast-exam-in-trauma/)
- [Pneumothorax on the chest X-ray](https://durgical.com/en/radiology/pneumothorax-on-the-chest-x-ray/)
- [The widened mediastinum and the hila](https://durgical.com/en/radiology/the-widened-mediastinum-and-the-hila/)
- [Free air in the chest: pneumomediastinum and subcutaneous emphysema](https://durgical.com/en/radiology/free-air-in-the-chest-pneumomediastinum-and-subcutaneous-emphysema/)
- [Lines and tubes on the chest X-ray: where each tip should be](https://durgical.com/en/radiology/lines-and-tubes-on-the-chest-x-ray-where-each-tip-should-be/)
- [Abdominal and pelvic trauma on CT: liver, spleen, kidneys and shock bowel](https://durgical.com/en/radiology/abdominal-and-pelvic-trauma-on-ct-liver-spleen-kidneys-and-shock-bowel/)
- [Reading a chest CT step by step](https://durgical.com/en/radiology/reading-a-chest-ct-step-by-step/)
- [Which chest study to order: X-ray, CT, CT angiography or ultrasound](https://durgical.com/en/radiology/which-chest-study-to-order-x-ray-ct-ct-angiography-or-ultrasound/)

## Related conditions 6

- [Pneumothorax](https://durgical.com/en/conditions/pneumothorax/)
- [Aortic dissection](https://durgical.com/en/conditions/aortic-dissection/)
- [Blunt traumatic aortic injury](https://durgical.com/en/conditions/blunt-traumatic-aortic-injury/)
- [Pulmonary contusion](https://durgical.com/en/conditions/pulmonary-contusion/)
- [Rib fractures](https://durgical.com/en/conditions/rib-fractures/)
- [Haemothorax](https://durgical.com/en/conditions/haemothorax/)

[← All of radiology](https://durgical.com/en/radiology/)

Educational content; it does not replace a radiologist's report and is not a clinical instruction. Each study is ordered on the patient's assessment and your institution's protocols.

Sources: [Thoracic Trauma](https://www.ncbi.nlm.nih.gov/books/NBK482194/) (StatPearls (NCBI Bookshelf), 2026); [Rib Fracture](https://www.ncbi.nlm.nih.gov/books/NBK541020/) (StatPearls (NCBI Bookshelf), 2023); [Pulmonary Contusion](https://www.ncbi.nlm.nih.gov/books/NBK558914/) (StatPearls (NCBI Bookshelf), 2024); [Hemothorax](https://www.ncbi.nlm.nih.gov/books/NBK538219/) (StatPearls (NCBI Bookshelf), 2023); [Widened Mediastinum](https://www.ncbi.nlm.nih.gov/books/NBK539890/) (StatPearls (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/radiology/chest-trauma-imaging-ribs-contusion-haemothorax-and-the-aorta/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/radiology/chest-trauma-imaging-ribs-contusion-haemothorax-and-the-aorta/