Tag Archives: chest x-ray

Best Of: Finding Rib Fractures On Chest X-Ray

A lot of people have been viewing and requesting this post recently.

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. 

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Chest X-Ray After Chest Tube Insertion: Why Do We Do It?

More dogma, or is it actually useful? Any time a chest tube (tube thoracostomy) is inserted, we automatically order a chest x-ray. Even the ATLS course recommends obtaining an image after placement. But anything we do “automatically” is grounds for critical analysis to see if there is a valid reason for doing it.

A South African group looked at the utility of this practice retrospectively in 1004 of their patients. They place 1042 tubes. Here are the factoids:

  • Patients were included if they had at least one chest x-ray obtained after insertion
  • Patients were grouped as follows: Group A (10%) had the tube inserted on clinical grounds with no pre-insertion x-ray (e.g. tension pneumothorax). Group B (19%) had a chest x-ray before and had ongoing clinical concerns after insertion. Group C (71%) had a chest-xray before and no ongoing concerns.
  • 75% of injuries were penetrating (75% stab, 25% GSW), 25% were blunt
  • Group A (insertion with pre-x-ray): 9% had post-insertion findings that prompted a management change (kinked, not inserted far enough)
  • Group B (ongoing clinical concerns): 58% required a management change based on the post-x-ray. 33% were subcutaneous or not inserted far enough (!!)
  • Group C (no ongoing clinical concerns): 32 of 710 (5%) required a management change, usually because the tube was too deep

The authors concluded that if there are no clinical concerns (tube functioning, no clinical symptoms) after insertion, then a chest x-ray is not necessary.

Bottom line: But I disagree with the authors! Even with no obvious clinical concerns, the tube may not be functioning for a variety of reasons. Hopefully, this fact would then be discovered the next day when another x-ray is obtained. But this delays the usual progression toward removing the tube promptly by at least one day. It increases hospital stay, as well as the likelihood of infection or other hospital-associated complication. A chest x-ray is cheap compared to a day in the hospital, which would potentially happen in 5% of these patients. I recommend that we continue to obtain a simple one-view chest x-ray after tube insertion.

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Reference: What is the yield of routine chest radiography following tube thoracostomy for trauma?  Injury 46(1):45-48, 2015.

Quiz: Is This A Good Chest Tube?

A blunt trauma activation patient presents with a pneumothorax seen on the initial chest x-ray, obtained in your trauma bay. You professionally insert a large chest tube, and all appears to go well. You shoot a followup chest x-ray and this is what you get:

What do you think of the tube position? Looks great, right?

But if you look carefully, you can see the lung outline in the middle of the right side of the chest. Big-time pneumothorax despite what looks like a perfectly placed tube. There are several possible explanations, and many of you sent me your guesses:

  • The tube is in the lung. This rarely happens to normal lungs. Sure, you can probably do it to an ARDS lung, but otherwise it’s not very likely.
  • The tube is in the fissure. This does happen on occasion, but not often. And many times it works anyway.
  • The tube is occluded or kinked. A PA or AP chest x-ray will show the kink, although bent tubes frequently work anyway. If a hemothorax is present, it is possible that a clot is plugging the tube. Clearing a plugged tube will be the subject of another post.
  • It’s not really a chest tube. Hopefully, this would have been detected when it was placed, but it isn’t always. The chest x-ray above looks great, right? Unfortunately, it’s a 2 dimensional representation of a 3-D object. Where is that tube in the z-axis?

In this case the correct answer is the last one. This is one time when I would actually recommend a lateral chest x-ray. Have a look at the result. You can clearly see the tube snaking around into the soft tissues of the back.

Bottom line: Remember that a perfect x-ray doesn’t necessarily mean a perfect tube. Go through the various possibilities quickly, and make it work.

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Pop Quiz! Hint Hint!

Yesterday I hit you with a chest x-ray after chest tube insertion in a young man who presented with a pneumothorax. The lung was not yet expanded (chest x-ray taken less than 5 minutes after the procedure).

So what’s wrong? I had a lot of good guesses yesterday (@ResusReview, @uclamutt, and others in the comments to name a few), but nobody quite got it. Yes, the lung is not up yet. No, the tube is not in a fissure. The person inserting the tube worked up a sweat doing it, taking about 10 minutes to get it in. But some air came out initially, and the tube rotated freely on its axis.

Any ideas? Tweet or comment! Answer tomorrow.

Pop Quiz! What’s Wrong In This Picture?

Here’s another one to challenge your skills! A young male presents to your ED after minor chest trauma with pleuritic chest pain and slight shortness of breath. A chest x-ray is obtained which shows a large pneumothorax on the right. You insert a chest tube, and the procedure goes well.

Another x-ray taken immediately after insertion looks like this:

The lung is not yet fully expanded, but the patient already feels better. 

What is wrong in this picture? Tweet or leave comments. Hints tomorrow if I don’t receive the correct answer.