Case Presented by: Dr. Meredith Hill
CC: “My Stomach Hurts”
HPI: 18-year-old man presents to the emergency department complaining of abdominal pain. He states last night his older brother who weights 400 lbs jumped on his back driving his knee into his left upper chest. This took place around 11 pm. At that time he did not feel significant pain but since then he has had pain in his left upper quadrant of his abdomen. He feels there is a “bump” which is growing in size and is also painful to the touch.
Family History: CAD Allergies: none
Social history: +tobacco, denies alcohol and drug use
VS: Temp: 36.7 BP: 137/67 HR: 64 RR: 20
General: Patient is resting in bed. He appears to be in some pain.
Head: Normocephalic, atraumatic
Eyes: Pupils are equal, round and reactive to light and accomidation. Extraoccular movements are intact bilaterally, no conjunctiva pallor, no sclera icterus
Throat: Moist oral mucosa without intraoral lesions. No tonsilar exudate.
Neck: Supple, no lymphadenopathy. Trachea midline.
Lungs: Breath sounds clear to auscultation bilaterally without rhonchi, wheezes or rales.
Cardiovascular: Regular rate and rhythm, S1 and S2 auscultated. No murmur, rubs or gallops to auscultation. No peripheral edema, radial and dp pulses present and equal bilaterally
Abdomen: The abdomen is tender in the left upper quadrant just below the costal margin. Patient also has tenderness to palpation of the ribs on left anterior chest. Appears to be rib 8 or 9. There is a slight amount of swelling here. There is no rebound of the abdomen appreciated. Normal bowel sounds.
Extremity: Normal muscle strength and tone. Full range of motion of upper and lower extremities.
Neurologic: Awake, alert and oriented to person, place and time.
Let’s review the information: 18-year-old male with history of trauma complaining of abdominal pain. +LUQ tenderness and pain as well as point tenderness over left anterior ribs with some swelling. Although patient’s mechanism of injury was from behind, he may have sustained either a significant abdominal injury as well as possible a skeletal injury. With concern for a splenic injury a FAST exam was performed which was negative. A trauma panel was sent and chest x-ray was obtained. Patient was given pain medication.
It was read as normal by radiology. An abdominal series was also obtained which did not show evidence of free air. There was still concern for bony injury versus possible splenic injury. Surgery was consulted.
A musculoskeletal ultrasound was performed to evaluate for rib fracture and a FAST exam repeated which was still negative. The ultrasound of patient’s ribs on his left anterior lower chest is pictured below.
There is an obvious cortical disruption. This is rib 9 on the left anterior chest toward the auxiliary line. Because of this finding, a CT abdomen was ordered to rule out splenic injury as patient continued to complain of pain. There was, however, no change in his abdominal exam. He did not have peritoneal signs. The Surgical team was able to view the ultrasound in real time and agreed with the plan to CT. A member of the on call surgical team also placed a rib block, which significantly improved patient’s pain.
CT scan read as negative for splenic injury. No acute intra-abdominal process was noted.
In this case, ultrasound was key in identifying patient’s diagnosis. Ultrasound has long been known as a more sensitive modality for identifying rib fractures as compared to a standard chest X-ray. The exam is easy to learn and not painful for the patient. It can also be used in conjunction with the initial FAST exam.
Musculoskeletal Scan for Rib Fracture
This is a limited exam. You start by asking the patient where the point of maximal tenderness is located. Using the linear probe, place the transducer on the patient’s thorax with the indicator facing caudally. Locate the rib you want to scan and then turn the probe 90 degrees so the indicator is to the patients right or operators’ left. Keeping the prop perpendicular to the long axis of the rib (see below) scan the rib for signs of cortical disruption. Remember that the rib will curve along the back so you will want to pay attention that you stay on the same rib. It does take some practice but ultrasound was found to be 78-80% sensitive as compared with X-ray, which is only 12-23% sensitive. In the case above, both X-ray and CT scan were read as normal.
A Few Pearls You Want to Remember:
– The area will be tender, so use a copious amount of gel to avoid placing pressure over a painful area.
– Keep the probe perpendicular to the rib and remember the angle of the rib will require you to angle the probe as you move from anterior to posterior.
– Scan multiple ribs around the point of maximal tenderness to look for other fractures.
Below is a video showing how to scan for rib fractures using ultrasound. This video uses a slightly different technique. The initial scan over the point of maximal tenderness is done in the transverse plane then rotated 90 degrees when a cortical disruption is visualized.