Case vignette
19yo M presents with R sided lower chest pain after being tackled during a football game. It hurts to breath in. His teammate is with him.
BP 120/80, HR 90, RR 14, SpO2 95%, T 37
Non toxic but uncomfortable appearing, equal breath sounds bilaterally, tender to palpation R lower chest wall, benign abdomen.
What do you see?
CXR: no pneumothorax or opacity. No rib fractures visualized.
What do you do next?
The patient's teammate says the patient clearly needs to toughen up. After all, the CXR doesn't show fractures. He doesn't even need pain meds.
You have high clinical suspicion for rib fracture and turn to US to prove it.
What do you see?
Image (followed by highlights): using the linear probe, you identify a bony irregularity consistent with rib fracture. You also note a small hypoechoic collection suggestive of hematoma.
Teaching points. CXR often misses rib fractures, especially in areas over solid organs (e.g., the liver). POCUS can visualize these while also evaluating for pneumothorax, pericardial effusion, or hemoperitoneum (e.g., an eFAST exam).
For that matter, you can use POCUS to visualize any fracture. Trace the bone in transverse and longitudinal planes to localize the fracture. In extremity fractures, you can use this technique to find the optimal location for hematoma blocks. You can even use it to evaluate reductions (try it next time before your XR or C-arm -- you might be surprised at how well it can predict reduction quality.)
Rib fracture