A 35-year-old woman is referred for a chest X-ray following a high-speed road traffic accident. The radiograph shows widening of the superior mediastinum to more than 8 cm, obliteration of the aortic knuckle, tracheal deviation to the right, and depression of the left main bronchus below 40 degrees from the horizontal. Which diagnosis must be excluded first?

• A Anterior mediastinal haematoma from sternal fracture
• B Oesophageal rupture with mediastinitis
• C Superior vena cava laceration
• D Traumatic aortic injury at the isthmus ✓

Explanation

Traumatic aortic injury characteristically occurs at the aortic isthmus (just distal to the left subclavian artery origin) due to differential deceleration forces. The classical radiographic signs include mediastinal widening greater than 8 cm, obliteration of the aortopulmonary window, tracheal and nasogastric tube deviation to the right, and depression of the left main bronchus. These findings mandate urgent CT aortography. Oesophageal rupture and SVC injury are far less common and produce different clinical and radiographic patterns.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.