What is the role of chest radiography in the workup of hemothorax?

Updated: Jul 13, 2020
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Jeffrey C Milliken, MD  more...
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Plain radiography of the upright chest may be adequate to establish diagnosis by showing blunting at the costophrenic angle or an air-fluid interface if a hemopneumothorax is present. (See the image below.) If the patient cannot be positioned upright, a supine chest radiograph may reveal apical capping of fluid surrounding the superior pole of the lung. A lateral extrapulmonary density may suggest fluid in the pleural space.

Upright posteroanterior chest radiograph of patien Upright posteroanterior chest radiograph of patient with right hemothorax.

In the normal unscarred pleural space, a hemothorax is noted as a meniscus of fluid blunting the costophrenic angle or diaphragmatic surface and tracking up the pleural margins of the chest wall when viewed on the upright chest x-ray film. This is essentially the same chest radiographic appearance found with any pleural effusion.

In cases in which pleural scarring or symphysis is present, the collection may not be free to occupy the most dependent position within the thorax, but will fill whatever free pleural space is available. This situation may not create the classic appearance of a fluid layer on a chest radiograph.

In the acute trauma setting, the portable supine chest radiograph may be the first and only view available from which to make definitive decisions regarding therapy. The presence and size of a hemothorax is much more difficult to evaluate on supine films. Although as much as 400-500 mL of blood is required to obliterate the costophrenic angle on an upright chest radiograph, as much as 1000 mL of blood may be missed when viewing a portable supine chest x-ray film. Only a general haziness of the affected hemithorax may be noted.

In blunt trauma cases, hemothorax is frequently associated with other chest injuries visible on the chest radiograph, such as rib fractures (see the image below), pneumothorax, or a widening of the superior mediastinum.

Left hemothorax in patient with rib fractures. Left hemothorax in patient with rib fractures.

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