Images in Emergency Medicine
Article Outline
A 19-year-old unrestrained male driver was being pursued by police and struck a telephone pole at a high rate of speed. A 20-minute foot chase ensued. Once apprehended, he complained of back pain, was pale, was diaphoretic, and had 1 episode of bloody emesis.
On physical examination, he had a respiratory rate of 16 breaths/min, pulse rate of 86 beats/min, blood pressure of 134/76, and oxygen saturation of 98% on a nonrebreather facemask. He was uncooperative and agitated and complained only of back pain. On auscultation of his chest, his breath sounds were clear bilaterally. He had midthoracic spine tenderness and diffuse abdominal tenderness to palpation. A supine chest radiograph (Figure 1) was performed.
Figure 1.
Supine chest radiograph.
Diagnosis
Deep sulcus sign
First described by Gordon,1 the deep sulcus sign may be the only evidence of a pneumothorax on a supine chest radiograph. A deepening of the costophrenic angle occurs when air tracks anteriorly and caudally along the pleural space2 when the patient is lying supine. The arrows in Figure 2 highlight the hyperlucent area that is shown as an anterior pneumothorax, which is revealed in Figure 3, the computed tomography scan of the chest obtained immediately after the chest radiograph. Figure 4 shows that the findings resolved after placement of the chest tube. False-positive examples of the deep sulcus sign have been described in patients with chronic obstructive pulmonary disease1 and those receiving mechanical ventilation with high tidal volumes.3
Figure 2.
Supine chest radiograph.
Figure 3.
Computed tomographic scan.
Figure 4.
Chest radiograph. Used with permission of Alan J. Smally, University of Connecticut, Division of Emergency Medicine, Hartford, CT.
References
For the diagnosis and teaching points, see page 725.
PII: S0196-0644(06)02145-7
doi:10.1016/j.annemergmed.2006.08.025
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
