A man slipped on the ice and hurt his right chest wall. The radiologist says there are no fractures. I’m still suspicious. Is there a better a way?

We could do a CT scan, but that feels like overkill given the “normal” rib X-rays.

How about an ultrasound?

We clearly see a rib fracture here.

It is unreasonable to think that you might trace the entire length of every rib from the spine all the way around the chest wall to look for rib fractures. It would take forever and some portions of the ribs are hidden by the scapula and clavicle. So, a “comprehensive” ultrasound to definitively rule out rib fractures probably is not a realistic use of time.

However, the beauty of the ultrasound is that you can ask the patient to point with one finger to where they hurt the most. If they can find a pinpoint location, that’s where the fracture is going to be. It can be used in a very focused manner: localize the pain, then trace the rib in long axis with a linear transducer in that area. It would be wise to also look at a rib or two above and below the one they point at.

Is ultrasound the best test in every situation to look for rib fractures? Of course not. But, in the right patient, it is very easy to see a broken rib on ultrasound.

Could one argue the point that as long as there is no pneumothorax, flail segment, or grossly displaced fractures that it does not really matter if there is a subtle, non-displaced rib fracture? Sure. But, we all know that the patients like to know if their bones are broken. You look like a hero if you can show them fractures on the ultrasound screen that the X-ray missed. It provides some diagnostic closure for them as well, and the extra face time with a thorough provider is always a crowd-pleaser. The patient described above was actually a bounce back. He got the X-ray at the initial visit, but a few days later couldn’t understand why he was still hurting so badly if his bones weren’t broken. It just took a minute to find that the rib actually was broken – two in fact. He was relieved at the diagnostic closure and prognostication, even if the rib still hurt.

Finding rib fractures on ultrasound also opens the door to a costal nerve block, if you were so inclined. Again, there are arguments to limitations of the procedure, but if you’ve ever seen the total relief a patient gets from numbing up a single rib fracture you’d consider it.

Pitfalls?

1. Assuming the fracture you see is the only one, which could lead you to miss multiple fractures or even a flail segment. You have to be thorough – especially if there was not an x-ray done.
2. Seeing the junction where rib meets costal cartilage and mistakenly thinking you are seeing a fracture
3. Not looking for lung sliding at the apex to make sure there is no associated pneumothorax

Scan happy, my friends