Wednesday Image Review

Rib Fractures Part 1: Dr. DeMarzo

Rib fractures can be an incredibly painful condition for patients that is not only painful but also can make breathing difficult and lead to atelectasis and pneumonia. Correct diagnosis of a rib fracture as well as the exact location can help narrow down a differential as well as guide targeted treatments. Diagnosis of fractures can be clinical, but most providers will order imaging. According to the American College of Radiology, in minor blunt trauma that results in only an injury to the ribs, a chest X-ray is rated as “Usually Appropriate” while a rib view radiography is designated a step lower at “May Be Appropriate”. Of note, a rib view radiography is rated as “Usually Appropriate” for any pathologic fractures (i.e Underlying malignancy, metabolic disorders). While useful in identifying secondary injuries such as pneumothorax or flail chest, a chest x-ray can have sensitivities as low as 50% [1]. In the ED CT scans is the standard method through which rib fractures are identified.

A lesser known and utilized diagnostic method is the use of ultrasound, which is becoming more commonly employed in Emergency Departments. While skill level varies and heavily affects results, ultrasound is an effective tool to not only diagnose rib fractures, but also can help deliver a nerve block which provides much needed relief. In fact, in the hands of an experienced provider, ultrasound can be more effective than radiographs; a 2022 meta-analysis of 7 studies with 660 patients demonstrated chest ultrasonography achieving a pooled sensitivity of 89.3% and specificity of 98.4%. [2]

What are we looking for on Ultrasound?

  • A rib fracture is best visualized in a long view of the rib which would be best classified as a transverse view.
  • A fracture is best visualized by tracing the outer edge of the rib to visualize any breaks, bulges, or mismatched ends.
  • The best way to find the fracture: Ask the Patient! Ask them to point to the spot of their worst pain and begin probing there.
  • Some compression given to the probe may identify buckle fractures as seen in Figure 2 below:

Figure 1: Transverse fracture

(Source: https://doi.org/10.1002/sono.12176)

Figure 2: Buckle fracture (visualized w/ compression)

(https://radiopaedia.org/cases/buckle-rib-fracture-on-ultrasound)

Resources:

  1. Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources?. Am Surg. 2002;68(5):449-453.
  2. Gilbertson J, Pageau P, Ritcey B, et al. Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis. Ann Emerg Med. 2022;79(6):529-539. doi:10.1016/j.annemergmed.2022.02.006

 

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