Use of thoracic ultrasound to detect fractures in patients with chest injury

Abstract

Objectives: To compare ultrasound, clinical findings and radiography in the detection of rib and sternal fractures; to identify clinical features which may discriminate the presence or absence of fractures; to determine whether bony chest wall injury is associated with increased, prolonged pain, increased risk of chest infection and delayed return to work. Design: Prospective, observational study Setting: Emergency Department of a university hospital in the New Territories of Hong Kong Subjects: 115 patients with isolated blunt chest injury of mild to moderate force Main outcome measures: Primary outcome measure was the presence or absence of a rib or sternal fracture detected by ultrasound. Secondary outcomes were pain score, respiratory complications and days off work. Results: 87 of 115 (76%) patients had fractures and 88 (77%) returned for a second ultrasound assessment. Pain on coughing, age >40 years and general clinical suspicion were useful discriminators between the presence and absence of fractures. An early ultrasound was the most reliable with an odds ratio of 76.3 (95%CI 14.0-416.3), sensitivity 91.0%, specificity 88.2%, and positive and negative predictive values of 96.8% and 71.4% respectively (p<0.0001). Rate of reduction in pain score both at rest and with movement was lower in patients with fractures and the least in patients with major fractures especially in the first three weeks. Mean time off work was greater in patients with fractures and greatest in those patients with major fractures (p=0.0009). Conclusion: Early ultrasound is more accurate than clinical and radiological evaluation in detecting rib and sternal fractures. The presence and knowledge of a bony injury has a major bearing on duration of chest wall pain and time off work.