0:01

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

0:06

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

0:12

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

0:15

So we have a PA and lateral views

0:17

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

0:20

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

0:26

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

0:28

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

0:34

The heart and mediastinum are normal in appearance.

0:38

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

0:43

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

0:48

their appearance. Nothing initially comes out.

0:53

One thing I will do is just say, again,

0:55

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

1:01

Just to blow this up a little

1:02

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

1:07

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

1:11

bulging and opacity that's sitting along the periphery.

1:15

And so, again, if we kind of zoom back

1:17

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

1:22

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

1:27

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

1:32

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

1:35

a little bit of opacity, what we began to see

1:40

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

1:46

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

1:49

And this is in the same area as this opacity.

1:52

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

1:56

And this is involving the lateral aspect of this rib.

1:59

Will count the rib number in a second.

2:01

And then there's associated hematoma here.

2:04

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

2:09

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

2:13

But this very subtle

2:15

likely hematoma associated with the rib fracture is seen there.

2:21

And so, again, if you want to count

2:22

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

2:27

the fifth rib is coming around and through here.

2:30

So this is a fifth lateral right rib

2:32

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

2:39

So this is a very subtle case.

2:41

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

2:46

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

2:49

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

2:53

And again, the great look at the spine,

2:57

the alignment, the heights of the vertebral bodies.

2:59

And again, this is a trauma patient.

3:00

So this is important to take a look at.

3:03

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

3:07

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

3:10

We don't see any evidence, again,

3:12

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

3:18

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

3:23

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

3:28

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

3:31

localized blood associated with this rib fracture.

3:33

The rib fracture itself is subtle.

3:35

Sometimes it can be helpful to, as you're

3:37

looking at ribs, particularly on the frontal radiograph,

3:41

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

3:47

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

3:51

So we see lung markings all the way out.

3:54

We're able to see this small hematoma

3:56

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

4:00

I've got a couple of other cases to show

4:02

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

4:06

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

4:12

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

4:17

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

4:19

But again, if you look through,

4:20

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

4:24

we see a large pneumothorax with basically atelectatic lung.

4:29

So it's completely down.

4:31

We've talked before around just kind

4:33

of giving information around measuring the air gap.

4:35

So the apical air gap here is about 12cm,

4:40

so it's going to be considered large.

4:42

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

4:49

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

4:52

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

4:55

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

5:00

from the pleura into the subcutaneous tissues themselves.

5:05

So there needs to be a trajectory.

5:06

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

5:10

And so again,

5:10

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

5:16

discontinuous and it's fractured right here.

5:18

Let's blow that up a little bit.

5:20

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

5:26

to be tons of rib fractures to create subcutaneous emphysema.

5:32

So just for complete mistake,

5:34

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

5:37

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

5:41

So again, we see a pneumothorax.

5:42

So is there tension?

5:44

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

5:49

with this large pneumothorax.

5:51

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

5:53

There's no large effusion.

5:54

There is no pneumothorax over here, no consolidation.

5:57

Take a look at the ribs here.

5:59

Again, be aware of satisfaction of search.

6:02

We don't see any other rib fractures.

6:04

The clavicles, the scapula, shoulders look normal.

6:08

Below the diaphragm looks normal as well.

6:12

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

6:16

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

6:20

and we can see that the spine nicely aligns.

6:22

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

6:28

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

6:34

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

6:39

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

6:42

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

6:46

fully appreciated on just simply the frontal view.

6:49

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

6:53

So this is a less subtle rib fracture

6:57

with a complication of a pneumothorax, with tension subcutaneous emphysema

7:03

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

7:08

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

7:12

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

7:17

to identify where the injury may have occurred.

7:21

But again, on this case we're looking

7:23

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

7:28

to identify where the rib fracture may exist.

7:31

But you can clearly see the subcutaneous

7:34

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

7:38

You can also appreciate the small

7:40

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

7:46

even with some of the inversion,

7:49

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

7:55

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

8:00

segments, because that has implications for management,

8:03

it may just be one with a lot

8:05

of subcutaneous emphysema, it could be multiple.

8:07

And so we don't really see it here.

8:09

It was very hard for us to identify it

8:10

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

8:15

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

8:21

there was evidence of a fracture that we could identify.

8:24

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

8:28

the left side because of the findings of subcutaneous emphysema.

8:33

And it was here on this version of the rib

8:36

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

8:40

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

8:42

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

8:46

displaced posterior rib fracture here at this level.

8:49

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

8:54

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

8:56

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

9:00

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

9:04

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

9:08

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

9:10

So sometimes it's not as important.

9:12

And it is sort of an academic exercise

9:14

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

9:18

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

9:20

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

9:24

But you have to consider that in your

9:26

clinical context, given what you have in terms of your

9:29

resources, in terms of what the time urgency is.

9:32

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

9:36

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

9:40

for identifying find the actual location of the rib fracture.