- Email: [email protected]
Is ultrasound really helpful in the detection of rib fractures?
Injury, Int. J. Care Injured (2004) 35, 562—566
Is ultrasound really helpful in the detection of rib fractures? Maja E. Hurleya,*, Geoff D. Keyeb, Samuel Hamiltona a
Department of Radiology, Adelaide & Meath Hospital and National Children’s Hospital, Dublin 24, Ireland Department of Accident and Emergency, Adelaide & Meath Hospital and National Children’s Hospital, Dublin 24, Ireland
b
Accepted 19 June 2003
KEYWORDS Rib fracture; Thorax injury; Chest trauma; Emergency imaging; Chest radiography; Chest ultrasound; Thorax scintigraphy; Pleural effusion; Pneumothorax; Splenic laceration
Summary Objective: To determine the usefulness of ultrasound in the detection of rib fractures. Patients and methods: A prospective study was performed over a 3-month period. Patients presenting with a high clinical suspicion of rib fracture(s) to the Accident and Emergency Department were referred for radiological work-up with a PA chest radiograph, an oblique rib view and a chest ultrasound. Associated lesions, e.g. pleural effusion, splenic laceration and pneumothorax were recorded. Results: Fourteen patients were radiologically assessed. The mean patient age was 31 years (range 16—55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Ten patients displayed a total of 15 broken ribs. Chest radiography detected 11, oblique rib views 13 and ultrasound 14 broken ribs. Ultrasound findings included discontinuity of cortical alignment in 12 fractures, an acoustic linear edge shadow in nine and a reverberation artifact in six. Concordance with plain film findings, and especially oblique rib views, was good, though better when the rib fractures fragments were markedly displaced. One splenic laceration was detected with an associated small pleural effusion. There were no pneumothoraces. The average time of ultrasound examination was 13 min. Conclusion: Ultrasound does not significantly increase the detection rate of rib fractures, may be uncomfortable for the patient and is too time-consuming to justify its routine use to detect rib fractures. ß 2003 Elsevier Ltd. All rights reserved.
Introduction Rib fractures represent the most frequent thorax injury (25%).3 They are simple or complicated (the latter when associated with soft tissue injuries, in particular, pneumothoraces and splenic lacerations).6 Clinically, rib fractures are usually suspected based on patients’ history and pain, which *Corresponding author. Present address: Department of Radiology, Our Lady’s Hospital for Sick Children, Crumlin, Dublin 12, Ireland. Tel.: þ353-1-834-6231; fax: þ353-1-409-6161. E-mail address: [email protected] (M.E. Hurley).
is accentuated at inspiration, cough and localized palpation. Nevertheless, fractures are present in only 32—42% of symptomatic patients.4 Radiologically, rib fractures are documented conventionally with a frontal chest radiograph (CXR) followed by an oblique rib view if clinically indicated. Recently, several authors have investigated the role of ultrasound (US) in the detection of rib fractures.1,2,5—8 All found that US was more sensitive than conventional radiography for rib fracture diagnosis, ranging from marginal superiority to twice as much fracture detection by US when compared with plain film findings.1,2,5—8
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00263-8
Is ultrasound really helpful in the detection of rib fractures?
The aim of this study was to test these findings and to evaluate their relevance to our practice.
Patients and methods We included in our study over a 3-month period all patients presenting to the Accident and Emergency Department with a history of chest trauma. At initial examination a clinical assessment was made as to the likelihood of rib fracture(s) and their suspected location. All patients with a clinical suspicion of rib fracture(s) were referred for radiological work-up, which included a CXR and an oblique view of the ribs, followed immediately by a limited chest US. The CXR was performed without grid at a distance of 180 cm in posteroanterior projection with a 80 kVp and 3.2 mAs. The oblique view of the ribs was performed with a grid at a distance of 100 cm with a 70 kVp and 22 mAs, centered over the area of trauma. All plain films were assessed in double blind fashion by a radiologist (SH) on a PACS workstation (Magic View 1000, Siemens, Erlangen, Germany). US (ATL HDI 5000, Bothell, Washington, USA) was performed with a linear array probe at 12.5 MHz by one radiologist (MH). The patient was sitting, turning away from the radiologist and abducting the arm of the injured side. The patient was then asked to indicate the site of maximum pain with his other hand and the transducer was applied over the area of tenderness, its surrounding soft tissues as well as the adjacent ribs, longitudinally and transversally. When performing the US examination we were looking for the following criteria: discontinuity of the
Table 1
563
Ultrasound criteria of rib fractures
Direct signs
Indirect signs
Discontinuity of cortical margin Linear acoustic edge shadow Localized pain Change of appearance with pressure
Reverberation artifact Local haematoma Pleural effusion Pneumothorax
cortical margin at the fracture site, a linear acoustic edge shadow arising from the margin of the broken rib, a reverberation artifact and a local haematoma (Table 1). Initially, we also performed the previously described signs of localized pain reproduction and change of appearance of the fracture site with pressure.2 However, these criteria were abandoned early in the study due to patient discomfort. In addition, each patient was also scanned for a possible pleural effusion and pneumothorax. This was followed by a US of the spleen if the trauma occurred to the left upper quadrant. Scanning duration was timed from the moment the transducer was applied until the US examination was completed. Results were recorded immediately after the US by the examining radiologist (MH) based on the sonographic real time findings.
Results Of the 35 patients who were examined by the Accident and Emergency team for a history of chest trauma 14 (40%) presented clinical symptoms and
Figure 1 Rib fracture with markedly displaced fracture fragments. Note a reverberation artifact posteriorly (straight arrow) and a small haematoma at the fracture site (curved arrow).
564
Table 2
M.E. Hurley et al.
Direct ultrasound signs of rib fractures
Discontinuity of cortical margin Linear acoustic edge shadow Localized pain at fracture site Change of appearance with pressure
Number of rib fractures
Percentage
14/15 9/15 5/5 Abandoned as too painful
93 60
signs suggestive of rib fracture(s) and were referred for radiological correlation. The mean patient age of these 14 patients was 31 years (range 16— 55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Radiographic work-up revealed a total of 15 broken ribs in 10 patients. One patient had three broken ribs, three patients two and four none. Plain radiography and US findings were compared. Of the 15 broken ribs only 11 were visualized on CXR (73%). All of these 11 fractures were also detected by the oblique rib views and US (Fig. 1).
Oblique rib views were better than frontal views for rib fracture visualization, displaying 13 of the 15 fractures (87%). Twelve of these fractures were also detected by US. One rib fracture was only revealed on the oblique rib view. Situated in the posterior segment of the third upper rib, it was inaccessible to the ultrasound transducer due to the overlying scapula (Fig. 2). Two patients had a rib fracture displayed only by US. These two fractures were only minimally displaced, but were detectable by a disruption of the cortical margin (Fig. 3). Longitudinal rib scanning was more informative than transverse scanning, which did not contribute to the outcome. Overall, US revealed 14 (93%) and oblique rib views 13 (87%) rib fractures.
Direct and indirect US signs of rib fractures The most frequent direct sign was a discontinuity of the cortical margin, which was present in 14 documented fractures (Table 2). An acoustic edge shadow was the second most frequent sign, observed in nine rib fractures. Indirect US signs of rib fractures included a reverberation artifact, which was present in six patients, a local hematoma in four and a pleural effusion in one patient (Table 3). None of the patients had a pneumothorax. US of the left upper quadrant discovered one small splenic laceration. The average time of US examination was 13 min (range 8—17 min). Most of the time was spent localizing the fracture site. Nine patients had difficulty indicating precisely the site of maximal tenderness.
Table 3
Figure 2 Minimally displaced rib fracture of the posterior segment of left third rib detected only on plain film (arrow), but not on ultrasound, where the fracture was obscured by the scapula.
Indirect ultrasound signs of rib fractures
Reverberation artifact Local hematoma Pleural effusion Pneumothorax
Number of rib fractures
Percentage
6/15 4/15 1/5 None
40 27 20 0
Is ultrasound really helpful in the detection of rib fractures?
565
Figure 3 Rib fracture (#) displayed a minimal (þ) discontinuity of the cortical margin (4 mm) and linear edge shadow behind rib fracture.
Discussion Our findings confirm that ultrasound is marginally more sensitive than plain radiography for rib fracture diagnosis. The slightly higher detection rate of rib fractures by US is mainly based on the visualization of a disruption in the cortical interface at the fracture site, best seen on longitudinal scanning. The cortex of the ribs, as of all bones, is highly echogenic on US and reflects and absorbs most of the US transmission. A fracture is visualized as a discontinuity of this echogenic margin. Other useful ultrasound signs of rib fractures are the presence of a linear acoustic edge shadow and a reverberation artifact arising behind the rib margin or a bone fragment at the fracture site. The previously described signs of localized pain reproduction and displacement of fracture fragments under pressure were not only of little value, but could increase patient discomfort. This is why we abandoned these criteria early during the study. Whereas our results confirm a marginal superiority of US for rib fracture detection, our results vary significantly in degree from previous papers. While Bitschnau et al. diagnosed nearly twice as many patients with rib fractures with ultrasound (58%) than by plain radiography (CXRs and oblique rib views) alone (30%), our study could not reproduce this discrepancy among conventional radiography and ultrasound findings, as most fractures were already revealed on CXR (73%) and especially oblique rib views (87%).2 Martino et al. also detected more rib fractures (n ¼ 4) with US than
with plain radiography (n ¼ 1) in their small series (n ¼ 5) and recommended US as routine investigation in all chest trauma patients.6 A third group of authors, Wischhofer et al. investigated a group of patients (n ¼ 21) with clinically suspected rib fractures, but normal CXR, with US and detected rib fractures in 16 patients.8 In their series correlation was performed with scintigraphy, when available. This was positive in 11 patients, though the focus of increased activity was allowed to be two ribs above or below the suspected fracture site when compared with US. In addition, seven patients displayed on average two further foci of increased activity without corresponding US findings.8 In view of these findings we feel that the validity of scintigraphy as gold standard for rib fracture detection is questionable. Contrary to these series our study reveals only a marginal superiority of US for rib fracture detection compared to conventional radiography, especially when compared with the findings of oblique rib views.2,6,8 While the discrepancy of results might be partially due to the fact that our study has a relatively small number of patients, we think that, based on our results, a larger series would not have significantly changed the outcome. During the course of the study we observed that US has its own limitations in rib assessment. These are essentially due to limited access of the transducer to certain thorax areas. While rib fractures were easily visualized by US in the lower hemithorax and in the lateral aspects of the ribs, the upper ribs were posteriorly inaccessible due to the overlying
566
scapula. In addition, rib segments adjacent to the costotransverse joints and the costochondral junctions were difficult to interpret due to the proximity of the adjacent vertebral structures, which limited transducer access and interfered with the US beam. In addition, US had the disadvantage of being time-consuming–—with an average scanning time of 13 min, excluding the time the patient needed to get positioned and afterwards for getting dressed. This meant a substantial additional workload for an already busy US department. However, the strongest argument against this technique was the fact that chest US for rib fracture detection could be uncomfortable for the patient, even when performed most gently without any pressure on the fracture site. The pain, especially of acute rib fractures, was increased by the required arm abduction on the side of trauma, necessary to give access to the transducer. However, US was felt to be most useful for excluding soft tissue injuries, in particular, splenic lacerations and pleural effusions. From a practical viewpoint the diagnosis of rib fractures is primarily based on clinical examination, complemented by a CXR to exclude significant associated lung and pleural injuries and an upper abdominal ultrasound if there is any concern about intra-abdominal injury. Rib fracture documentation with an oblique rib view and an US might be of psychological help to a patient anxious to understand the cause of his/her ongoing pain. Overall, rib fracture imaging is however only of limited clinical importance, apart from medico-legal issues, and unlikely to alter patient management.
M.E. Hurley et al.
In summary, US is marginally superior to plain film and especially oblique rib views for rib fracture detection and may be helpful in diagnosing rib fractures not visualized on conventional radiography, if clinically indicated. However, the routine use of US for rib fracture diagnosis is not indicated, as it may be painful for the patient and time-consuming as well as most likely irrelevant to patient management.
Acknowledgements Dr. B. Richmond for his advice.
References 1. Battistelli JM, Anselem B. Echography in injuries of costal cartilages. J Radiol 1993;74(8—9):409—12. 2. Bitschnau R, Gehmacher O, Kopf A, Scheier M, Mathis G. Ultrasonography in the diagnosis of rib and sternal fracture. Ultraschall Med 1997;18:158—61. 3. Canini R, De Florio L, Ghigi G, et al. I traumi del torace. Radiol Med 1992;4(2):188—201. 4. De Luca SA, Rhea JT, O’Malley T. Radiographic evaluation of rib fracture. Am J Roentgenol 1982;138:91—2. 5. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute fracture. Am J Roentgenol 1990;173(6):1603—9. 6. Martino F, Laforgia R, Rizzo A, et al. Sonographic detection of rib fractures. Radiol Med 1997;94:166—9. 7. Mathis G. Thoraxsonography. Part I. Chest wall and pleura. Ultrasound Med Biol 1997;23(8):1131—9. 8. Wischhofer E, Fenkl R, Blum R. Ultrasound evidence of rib fractures. A pilot study. Unfallchirurg 1995;98:296—300.
Is ultrasound really helpful in the detection of rib fractures? Maja E. Hurleya,*, Geoff D. Keyeb, Samuel Hamiltona a
Department of Radiology, Adelaide & Meath Hospital and National Children’s Hospital, Dublin 24, Ireland Department of Accident and Emergency, Adelaide & Meath Hospital and National Children’s Hospital, Dublin 24, Ireland
b
Accepted 19 June 2003
KEYWORDS Rib fracture; Thorax injury; Chest trauma; Emergency imaging; Chest radiography; Chest ultrasound; Thorax scintigraphy; Pleural effusion; Pneumothorax; Splenic laceration
Summary Objective: To determine the usefulness of ultrasound in the detection of rib fractures. Patients and methods: A prospective study was performed over a 3-month period. Patients presenting with a high clinical suspicion of rib fracture(s) to the Accident and Emergency Department were referred for radiological work-up with a PA chest radiograph, an oblique rib view and a chest ultrasound. Associated lesions, e.g. pleural effusion, splenic laceration and pneumothorax were recorded. Results: Fourteen patients were radiologically assessed. The mean patient age was 31 years (range 16—55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Ten patients displayed a total of 15 broken ribs. Chest radiography detected 11, oblique rib views 13 and ultrasound 14 broken ribs. Ultrasound findings included discontinuity of cortical alignment in 12 fractures, an acoustic linear edge shadow in nine and a reverberation artifact in six. Concordance with plain film findings, and especially oblique rib views, was good, though better when the rib fractures fragments were markedly displaced. One splenic laceration was detected with an associated small pleural effusion. There were no pneumothoraces. The average time of ultrasound examination was 13 min. Conclusion: Ultrasound does not significantly increase the detection rate of rib fractures, may be uncomfortable for the patient and is too time-consuming to justify its routine use to detect rib fractures. ß 2003 Elsevier Ltd. All rights reserved.
Introduction Rib fractures represent the most frequent thorax injury (25%).3 They are simple or complicated (the latter when associated with soft tissue injuries, in particular, pneumothoraces and splenic lacerations).6 Clinically, rib fractures are usually suspected based on patients’ history and pain, which *Corresponding author. Present address: Department of Radiology, Our Lady’s Hospital for Sick Children, Crumlin, Dublin 12, Ireland. Tel.: þ353-1-834-6231; fax: þ353-1-409-6161. E-mail address: [email protected] (M.E. Hurley).
is accentuated at inspiration, cough and localized palpation. Nevertheless, fractures are present in only 32—42% of symptomatic patients.4 Radiologically, rib fractures are documented conventionally with a frontal chest radiograph (CXR) followed by an oblique rib view if clinically indicated. Recently, several authors have investigated the role of ultrasound (US) in the detection of rib fractures.1,2,5—8 All found that US was more sensitive than conventional radiography for rib fracture diagnosis, ranging from marginal superiority to twice as much fracture detection by US when compared with plain film findings.1,2,5—8
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00263-8
Is ultrasound really helpful in the detection of rib fractures?
The aim of this study was to test these findings and to evaluate their relevance to our practice.
Patients and methods We included in our study over a 3-month period all patients presenting to the Accident and Emergency Department with a history of chest trauma. At initial examination a clinical assessment was made as to the likelihood of rib fracture(s) and their suspected location. All patients with a clinical suspicion of rib fracture(s) were referred for radiological work-up, which included a CXR and an oblique view of the ribs, followed immediately by a limited chest US. The CXR was performed without grid at a distance of 180 cm in posteroanterior projection with a 80 kVp and 3.2 mAs. The oblique view of the ribs was performed with a grid at a distance of 100 cm with a 70 kVp and 22 mAs, centered over the area of trauma. All plain films were assessed in double blind fashion by a radiologist (SH) on a PACS workstation (Magic View 1000, Siemens, Erlangen, Germany). US (ATL HDI 5000, Bothell, Washington, USA) was performed with a linear array probe at 12.5 MHz by one radiologist (MH). The patient was sitting, turning away from the radiologist and abducting the arm of the injured side. The patient was then asked to indicate the site of maximum pain with his other hand and the transducer was applied over the area of tenderness, its surrounding soft tissues as well as the adjacent ribs, longitudinally and transversally. When performing the US examination we were looking for the following criteria: discontinuity of the
Table 1
563
Ultrasound criteria of rib fractures
Direct signs
Indirect signs
Discontinuity of cortical margin Linear acoustic edge shadow Localized pain Change of appearance with pressure
Reverberation artifact Local haematoma Pleural effusion Pneumothorax
cortical margin at the fracture site, a linear acoustic edge shadow arising from the margin of the broken rib, a reverberation artifact and a local haematoma (Table 1). Initially, we also performed the previously described signs of localized pain reproduction and change of appearance of the fracture site with pressure.2 However, these criteria were abandoned early in the study due to patient discomfort. In addition, each patient was also scanned for a possible pleural effusion and pneumothorax. This was followed by a US of the spleen if the trauma occurred to the left upper quadrant. Scanning duration was timed from the moment the transducer was applied until the US examination was completed. Results were recorded immediately after the US by the examining radiologist (MH) based on the sonographic real time findings.
Results Of the 35 patients who were examined by the Accident and Emergency team for a history of chest trauma 14 (40%) presented clinical symptoms and
Figure 1 Rib fracture with markedly displaced fracture fragments. Note a reverberation artifact posteriorly (straight arrow) and a small haematoma at the fracture site (curved arrow).
564
Table 2
M.E. Hurley et al.
Direct ultrasound signs of rib fractures
Discontinuity of cortical margin Linear acoustic edge shadow Localized pain at fracture site Change of appearance with pressure
Number of rib fractures
Percentage
14/15 9/15 5/5 Abandoned as too painful
93 60
signs suggestive of rib fracture(s) and were referred for radiological correlation. The mean patient age of these 14 patients was 31 years (range 16— 55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Radiographic work-up revealed a total of 15 broken ribs in 10 patients. One patient had three broken ribs, three patients two and four none. Plain radiography and US findings were compared. Of the 15 broken ribs only 11 were visualized on CXR (73%). All of these 11 fractures were also detected by the oblique rib views and US (Fig. 1).
Oblique rib views were better than frontal views for rib fracture visualization, displaying 13 of the 15 fractures (87%). Twelve of these fractures were also detected by US. One rib fracture was only revealed on the oblique rib view. Situated in the posterior segment of the third upper rib, it was inaccessible to the ultrasound transducer due to the overlying scapula (Fig. 2). Two patients had a rib fracture displayed only by US. These two fractures were only minimally displaced, but were detectable by a disruption of the cortical margin (Fig. 3). Longitudinal rib scanning was more informative than transverse scanning, which did not contribute to the outcome. Overall, US revealed 14 (93%) and oblique rib views 13 (87%) rib fractures.
Direct and indirect US signs of rib fractures The most frequent direct sign was a discontinuity of the cortical margin, which was present in 14 documented fractures (Table 2). An acoustic edge shadow was the second most frequent sign, observed in nine rib fractures. Indirect US signs of rib fractures included a reverberation artifact, which was present in six patients, a local hematoma in four and a pleural effusion in one patient (Table 3). None of the patients had a pneumothorax. US of the left upper quadrant discovered one small splenic laceration. The average time of US examination was 13 min (range 8—17 min). Most of the time was spent localizing the fracture site. Nine patients had difficulty indicating precisely the site of maximal tenderness.
Table 3
Figure 2 Minimally displaced rib fracture of the posterior segment of left third rib detected only on plain film (arrow), but not on ultrasound, where the fracture was obscured by the scapula.
Indirect ultrasound signs of rib fractures
Reverberation artifact Local hematoma Pleural effusion Pneumothorax
Number of rib fractures
Percentage
6/15 4/15 1/5 None
40 27 20 0
Is ultrasound really helpful in the detection of rib fractures?
565
Figure 3 Rib fracture (#) displayed a minimal (þ) discontinuity of the cortical margin (4 mm) and linear edge shadow behind rib fracture.
Discussion Our findings confirm that ultrasound is marginally more sensitive than plain radiography for rib fracture diagnosis. The slightly higher detection rate of rib fractures by US is mainly based on the visualization of a disruption in the cortical interface at the fracture site, best seen on longitudinal scanning. The cortex of the ribs, as of all bones, is highly echogenic on US and reflects and absorbs most of the US transmission. A fracture is visualized as a discontinuity of this echogenic margin. Other useful ultrasound signs of rib fractures are the presence of a linear acoustic edge shadow and a reverberation artifact arising behind the rib margin or a bone fragment at the fracture site. The previously described signs of localized pain reproduction and displacement of fracture fragments under pressure were not only of little value, but could increase patient discomfort. This is why we abandoned these criteria early during the study. Whereas our results confirm a marginal superiority of US for rib fracture detection, our results vary significantly in degree from previous papers. While Bitschnau et al. diagnosed nearly twice as many patients with rib fractures with ultrasound (58%) than by plain radiography (CXRs and oblique rib views) alone (30%), our study could not reproduce this discrepancy among conventional radiography and ultrasound findings, as most fractures were already revealed on CXR (73%) and especially oblique rib views (87%).2 Martino et al. also detected more rib fractures (n ¼ 4) with US than
with plain radiography (n ¼ 1) in their small series (n ¼ 5) and recommended US as routine investigation in all chest trauma patients.6 A third group of authors, Wischhofer et al. investigated a group of patients (n ¼ 21) with clinically suspected rib fractures, but normal CXR, with US and detected rib fractures in 16 patients.8 In their series correlation was performed with scintigraphy, when available. This was positive in 11 patients, though the focus of increased activity was allowed to be two ribs above or below the suspected fracture site when compared with US. In addition, seven patients displayed on average two further foci of increased activity without corresponding US findings.8 In view of these findings we feel that the validity of scintigraphy as gold standard for rib fracture detection is questionable. Contrary to these series our study reveals only a marginal superiority of US for rib fracture detection compared to conventional radiography, especially when compared with the findings of oblique rib views.2,6,8 While the discrepancy of results might be partially due to the fact that our study has a relatively small number of patients, we think that, based on our results, a larger series would not have significantly changed the outcome. During the course of the study we observed that US has its own limitations in rib assessment. These are essentially due to limited access of the transducer to certain thorax areas. While rib fractures were easily visualized by US in the lower hemithorax and in the lateral aspects of the ribs, the upper ribs were posteriorly inaccessible due to the overlying
566
scapula. In addition, rib segments adjacent to the costotransverse joints and the costochondral junctions were difficult to interpret due to the proximity of the adjacent vertebral structures, which limited transducer access and interfered with the US beam. In addition, US had the disadvantage of being time-consuming–—with an average scanning time of 13 min, excluding the time the patient needed to get positioned and afterwards for getting dressed. This meant a substantial additional workload for an already busy US department. However, the strongest argument against this technique was the fact that chest US for rib fracture detection could be uncomfortable for the patient, even when performed most gently without any pressure on the fracture site. The pain, especially of acute rib fractures, was increased by the required arm abduction on the side of trauma, necessary to give access to the transducer. However, US was felt to be most useful for excluding soft tissue injuries, in particular, splenic lacerations and pleural effusions. From a practical viewpoint the diagnosis of rib fractures is primarily based on clinical examination, complemented by a CXR to exclude significant associated lung and pleural injuries and an upper abdominal ultrasound if there is any concern about intra-abdominal injury. Rib fracture documentation with an oblique rib view and an US might be of psychological help to a patient anxious to understand the cause of his/her ongoing pain. Overall, rib fracture imaging is however only of limited clinical importance, apart from medico-legal issues, and unlikely to alter patient management.
M.E. Hurley et al.
In summary, US is marginally superior to plain film and especially oblique rib views for rib fracture detection and may be helpful in diagnosing rib fractures not visualized on conventional radiography, if clinically indicated. However, the routine use of US for rib fracture diagnosis is not indicated, as it may be painful for the patient and time-consuming as well as most likely irrelevant to patient management.
Acknowledgements Dr. B. Richmond for his advice.
References 1. Battistelli JM, Anselem B. Echography in injuries of costal cartilages. J Radiol 1993;74(8—9):409—12. 2. Bitschnau R, Gehmacher O, Kopf A, Scheier M, Mathis G. Ultrasonography in the diagnosis of rib and sternal fracture. Ultraschall Med 1997;18:158—61. 3. Canini R, De Florio L, Ghigi G, et al. I traumi del torace. Radiol Med 1992;4(2):188—201. 4. De Luca SA, Rhea JT, O’Malley T. Radiographic evaluation of rib fracture. Am J Roentgenol 1982;138:91—2. 5. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute fracture. Am J Roentgenol 1990;173(6):1603—9. 6. Martino F, Laforgia R, Rizzo A, et al. Sonographic detection of rib fractures. Radiol Med 1997;94:166—9. 7. Mathis G. Thoraxsonography. Part I. Chest wall and pleura. Ultrasound Med Biol 1997;23(8):1131—9. 8. Wischhofer E, Fenkl R, Blum R. Ultrasound evidence of rib fractures. A pilot study. Unfallchirurg 1995;98:296—300.