CTICasesSubtle Pneumothorax on Supine Chest X-ray
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Imaging findings
Multiple examples of supine chest radiographs in trauma patients demonstrated subtle signs of pneumothorax. These signs included an unusually sharp or well-defined interface between the hemidiaphragm and adjacent air, particularly in the posterior or posteromedial basal pleural spaces, often where the hemidiaphragm meets the aorta or adjacent lung. These findings differed from a classic deep sulcus sign. Corresponding CT images consistently confirmed the presence of pleural air in these posterior or posteromedial locations, sometimes tracking in relation to the pulmonary ligament. In some cases, the air was medial to an atelectatic lower lobe.
Key takeaways
In recumbent trauma patients, pneumothorax can manifest subtly on chest radiographs, often without a prominent deep sulcus sign or clear visualization of visceral pleura. Key indicators for these occult pneumothoraces include an abnormally sharp interface of the hemidiaphragm, especially posteriorly or posteromedially, reflecting air in the basal and medial pleural spaces. CT correlation is invaluable for confirming these subtle findings, which represent air collecting in the most dependent portions of the chest (posterior/medial) in a supine patient. Radiologists should be vigilant for these atypical signs to avoid missing a pneumothorax in the trauma setting.
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