The patient presented by ambulance to the Emergency Department following a motor vehicle accident.

There are a number of findings demonstrated on this image.

Answer

There are multiple rib fractures on the left (white arrows). There is associated subcutaneous emphysema. Importantly, there is a fracture of the first rib on the left. There is an abnormally wide clavicle companion shadow on the left of unknown significance (not marked). There is subcutaneous emphysema on the right (grey arrow). There appears to be an adjacent rib fracture (black arrow). The left hemidiaphragm appears to be sharply marginated (it appears abnormally contrasty). This is known as "etched diaphragm" and is a result of air in the pleural space sited anteriorly adjacent to the diaphragm. Summary Bilateral subcutaneous emphysema Bilateral rib fractures Etched Diaphragm on the left.

Other Imaging
The patient proceeded to CT.

	There are bilateral pneumothoraces (not arrowed). Blood in both pleural spaces (grey arrow) seen posteriorly suggests that they there are actually bilateral haemopneumothoraces. There is subcutaneous air on the right (white arrow). There is a rib fracture on the left with a bone fragment extending into the pleural space. There is associated subcutaneous emphysema (black arrow).

CT 3D Reconstructions

Anterior View	Posterior View
Multiple rib fractures demonstrated on the left (red arrows). A fracture of the right 4th rib is noted. . ? old fracture right 10th rib (white arrow)

Left Lateral View	Right Lateral View
Multiple rib fractures (white arrows)	Fractured right 4th and 5th ribs

Comment

Chest radiography in the resuscitation room is usually a case of obtaining some important timely information about the patient's condition- gross pathology will be enough to act upon. CT is the "gold standard" for chest trauma and will usually help to confirm the plain film findings and frequently adds additional insight into suspected pathology and often new findings.