A patient presents with chest discomfort after a fall from height. You suspected fractured ribs but the chest radiograph was negative. Traditionally radiographs are considered to have poor sensitivity for rib fractures. But how helpful is physical examination?
First, localize the tenderness. One can gently palpate the individual ribs through their arc. Crepitus essentially confirms a fracture, but is not expected in most patients. If the tenderness is anterior over the costal cartilage, a fracture there is not expected to be visible, as the bone in this area is “invisible” on x-ray.
The spring test argues for a fracture. Squeeze the chest cage perpendicularly from the area of interest. For example, if there is anterior tenderness then squeeze laterally. If there is lateral tenderness then squeeze the anterior-posterior dimensions.
Have the patient take a deep breath. Although not specific, exacerbation of pain with breathing increases the probability of a fracture.
In the past, with negative x-rays we diagnosed rib contusion in patients with negative x-rays, but then told the patient that recuperation typically is the same duration. But how many of these patients had subclinical fractures?
One study of ultrasound looked at 20 patients with a clinical diagnosis of rib fractures and negative x-rays. Ultrasound confirmed fractures in 18 of the 20.(Turk EMJ 2010)
Take Home Points
-Use the AP or lateral spring test to raise clinical suspicion of rib fracture
-Use deep inspiration to increase suspicion of a rib fracture
-Consider bedside ultrasound