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Case 3 - Rib Fractures

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This case is a 28-year-old, patient's status post MVC, complaining of chest pain.

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It's not infrequent that your requisitions may not specify laterality.

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So you obviously want to keep an open mind for what may be going on.

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So we have a PA and lateral views

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of the chest and we'll go through in our standard approach.

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So looking at the lung fields, they are normal-appearing. And window and level

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a little bit better to see the parenchyma, but the lung fields are clear.

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There's no pneumothorax that we see, no focal consolidation or pleural effusion.

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The heart and mediastinum are normal in appearance.

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Again, as we look at the bones and the ribs, the shoulders on the left,

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on the right. Again, we can window and level to be able to optimize

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their appearance. Nothing initially comes out.

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One thing I will do is just say, again,

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beware of satisfaction of search and that ability to say, 'Normal. Next case.'

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Just to blow this up a little

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bit and to show something that's pretty subtle here. If we follow the pleural along

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the right thorax, we see here that there is a very subtle

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bulging and opacity that's sitting along the periphery.

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And so, again, if we kind of zoom back

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out, it may not have been completely apparent, but we have PACS,

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we've got the ability to zoom in, to magnify, take advantage of those tools

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and look closely, particularly before you want to call someone or something normal.

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So, again, if we look at the ribs very closely in this area where there's

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a little bit of opacity, what we began to see

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is a very subtle rib fracture that's sitting here at this rib right here.

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And there's this continuity that's sitting right through here.

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And this is in the same area as this opacity.

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So this is a singular, minimally displaced, right rib fracture.

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And this is involving the lateral aspect of this rib.

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Will count the rib number in a second.

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And then there's associated hematoma here.

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When we zoom back out, we don't see any associated pneumothorax,

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we don't see an evidence of a large contusion.

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But this very subtle

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likely hematoma associated with the rib fracture is seen there.

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And so, again, if you want to count

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the ribs here, this is the first, the second, the third, the fourth,

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the fifth rib is coming around and through here.

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So this is a fifth lateral right rib

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fracture, associated with an MVC trauma and patient presenting with pain.

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So this is a very subtle case.

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And again, be aware of those subtle cases before you say, 'Normal. Next'

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Just kind of take a look at it one more time, look through things.

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We want to take a look at the lateral view just for completeness on this case.

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And again, the great look at the spine,

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the alignment, the heights of the vertebral bodies.

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And again, this is a trauma patient.

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So this is important to take a look at.

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We can take a look at the retrosternal clear space and that looks normal.

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Take a look at the sternum itself, and it's intact.

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We don't see any evidence, again,

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of a large pneumothorax, which would be better appreciated on the frontal view.

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And the hematoma is so small that we're not really seeing it on the lateral view.

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So again, this is a subtle case of a rib fracture with an associated hematoma.

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Not really something I would call a contusion, but I think it's just

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localized blood associated with this rib fracture.

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The rib fracture itself is subtle.

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Sometimes it can be helpful to, as you're

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looking at ribs, particularly on the frontal radiograph,

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to use the inversion tool, to see if this helps identify any issues of concern.

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This is also a tool I like to use for evaluating for pneumothorax.

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So we see lung markings all the way out.

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We're able to see this small hematoma

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that's right here and then the rib fracture that's in through here.

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I've got a couple of other cases to show

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you that are a little bit less subtle, but we'll go through those now.

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So the next case is a patient, also status post-trauma, and we've got frontal

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and lateral radiographs. In this case, is obviously a much more pronounced case

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and this is not something you would say, 'Normal. Next case.'

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But again, if you look through,

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again in a standard function, when we look through the left lung field,

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we see a large pneumothorax with basically atelectatic lung.

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So it's completely down.

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We've talked before around just kind

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of giving information around measuring the air gap.

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So the apical air gap here is about 12cm,

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so it's going to be considered large.

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And then we see lots of subcutaneous gas along the periphery of the left thorax.

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And so that should be an indication if you're seeing subcutaneous gas, that not

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only is there likely been a significant injury, but you should be looking

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for the rib fractures that are associated with getting the gas from the lung,

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from the pleura into the subcutaneous tissues themselves.

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So there needs to be a trajectory.

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So usually the ribs, or at least a rib, is going to be fractured.

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And so again,

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if we begin to look at the ribs for their continuity, we see here that this rib is

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discontinuous and it's fractured right here.

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Let's blow that up a little bit.

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You'll see nicely that this rib is fractured and it doesn't necessarily need

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to be tons of rib fractures to create subcutaneous emphysema.

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So just for complete mistake,

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we want to make sure that we are looking at everything.

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So let's not forget about the heart and the mediastinum.

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So again, we see a pneumothorax.

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So is there tension?

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We are a little bit pushed to the right, so there is rightward tension movement

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with this large pneumothorax.

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We take a look at the right lung. The right lung is clear.

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There's no large effusion.

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There is no pneumothorax over here, no consolidation.

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Take a look at the ribs here.

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Again, be aware of satisfaction of search.

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We don't see any other rib fractures.

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The clavicles, the scapula, shoulders look normal.

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Below the diaphragm looks normal as well.

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So this is a case where, again, we want to take a look at all of our images.

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So we take a look very quickly at our lateral view,

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and we can see that the spine nicely aligns.

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A lot of this opacity down here at the base is the collapsed lung.

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If we increase the level, we can see the area where the large pneumothorax

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is situated, but we see it much better on the frontal view.

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And then we'll see, again, how extensive some of the subcutaneous emphysema is,

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that it's really extending all the way to the back, which wasn't necessarily

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fully appreciated on just simply the frontal view.

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And so we see it along here laterally, but it also wraps posteriorly.

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So this is a less subtle rib fracture

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with a complication of a pneumothorax, with tension subcutaneous emphysema

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and a patient who also experienced trauma before they came into the ER.

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So we've got one other case to show. Similar conversation.

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And sometimes, it can be difficult on a single frontal view

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to identify where the injury may have occurred.

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But again, on this case we're looking

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at a cone-down view, and this is really part of a rib series, where it's hard

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to identify where the rib fracture may exist.

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But you can clearly see the subcutaneous

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emphysema extending into the neck, seen here along the flank.

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You can also appreciate the small

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pneumothorax and the atelectatic lung. When looking at the bones,

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even with some of the inversion,

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it can be hard to identify which ribs, one, many where are fractured.

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And again, you want to be able to identify flail chest, so those multiple, multi-part

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segments, because that has implications for management,

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it may just be one with a lot

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of subcutaneous emphysema, it could be multiple.

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And so we don't really see it here.

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It was very hard for us to identify it

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on this view, but we were able to have the patient come back for a rib series,

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and to be able to rotate the patient and to look at the multiple ribs to see if

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there was evidence of a fracture that we could identify.

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And obviously, we're less worried about the right side and very much worried about

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the left side because of the findings of subcutaneous emphysema.

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And it was here on this version of the rib

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series where you can see that the rib at this level is fractured.

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So it was a little hard to see on the other views.

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But as we went through on the rib series, we're able to identify this minimally

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displaced posterior rib fracture here at this level.

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So sometimes, in terms of problem-solving, the rib series can be helpful.

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Again, if a patient is in pain, if you're

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looking at reserving resources, this is a nice to have, not necessarily

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a need to have. The management for rib fracture like this is really...

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We've managed the pneumothorax and we're going to manage your pain.

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We're not necessarily going to do anything with this singular rib fracture.

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So sometimes it's not as important.

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And it is sort of an academic exercise

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to be able to find the rib fracture, to be able to report. When there is

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a satisfaction of patients knowing, 'Yes, your rib is fractured,

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it's going to hurt for a while,' versus not having a diagnosis.

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But you have to consider that in your

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clinical context, given what you have in terms of your

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resources, in terms of what the time urgency is.

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But this is a case of a posterior rib fracture with pneumothorax

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and subcutaneous emphysema after trauma and a rib series that was helpful

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for identifying find the actual location of the rib fracture.

Report

Faculty

Jamlik-Omari Johnson, MD, FASER

Chair, Department of Radiology

University of Southern California

Tags

X-Ray (Plain Films)

Trauma

Pleural

Emergency

Chest

Bone & Soft Tissues

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