32 year old female with no past medical history presents with cough for two weeks, no fever, no sputum. Multiple sick contacts with same symptoms at work. She acutely presents with left rib pain for several days.  She reports no trauma, and noted the sharp, positional pain during a fit of coughing. Her vital signs are all within normal limits. She is breathing comfortably, with good air movement, no wheezes, rales, or ronchi. She displays point tenderness over her anterior left 8th rib at the anterior axillary line.  A chest x-ray was ordered; images are below.

 

Sonopalpation of the tender area revealed the following:

Untitled from Sinai EM Ultrasound on Vimeo.

 

The chest x-ray was read as negative for atypical pneumonia and the rib X-ray series reported as negative.   The ultrasound image reveals a bright white cortex (horizontal line halfway down screen) with an obvious discontinuity. This is a classic appearance of fracture (cortical break) on ultrasound. The patient was prescribed analgesia, given instructions for caring for a rib fracture, and did well.

Further reading:

  • Wuster et al. Ultraschall Med. 2005 (German)
    • N=100 patients with blunt thoracic trauma comparing ultrasound and chest x-ray
    • Rib fractures diagnosed in 65% by US vs. 36% by CXR
      • Hemothorax/pleural effusion: 37% US vs. 11% CXR
  • Bitschnau et al. Ultraschall Med 1997 (German)
    • N=103 patients: 101 rib fx Dx by US vs. 49 rib fx Dx by X-ray
  • Griffith et al. Am Jo Roentgenol. 1999
    • N=50 patients: 83 rib fx in 39 patients vs. 8 rib fx in 6 patients.
  • Kara et al. Eur J Cardiothroacic Surg. 2003
    • N=37 patients with CXR negative for rib fx: US detected 15/37 (40%)
  • Hurley et al. Injury. 2004
    • N=10 patients with 15 rib fractures: US detected 14/15, CXR 11/15, Oblique Rib Series 13/14.
  • Weinberg et al.  Injury 2010.
    • Subgroup N=10. Sensitivity 100%, Specificity 89%.  NB: Specificity was 89% because ultrasound was “false positive” in cases where x-ray (used as gold standard) missed rib fracture.