Page 74 - JSOM Fall 2023

Imaging an unnecessary evacuation. As this case demonstrates, Soldiers
with simple rib fractures that are managed by identifying the
Initial imaging can miss injuries. Specifically, in determinations injury with POCUS and controlling their pain can be kept on
of rib fractures, 74.5% of fractures identifiable on CT are location with a lighter workload until discomfort resolves
missed on initial chest xray. It is understood that ultrasound is with minimal care or the need for evacuation. In a time where
9
more sensitive than chest radiography in detection of rib frac- the military faces limited evacuation resources in many the-
ture. 10,11 Chest ultrasonography has a 89.3% sensitivity and aters and is looking to future wars where medical evacuation
a 98.4% specificity in detection of confirmed rib fractures. may be unavailable, it is important to train skills that alleviate
12
In this instance, the treatment team had extended training in evacuation burden. A training regimen that prioritizes thor-
bedside ultrasonography allowing for easy incorporation into ough history and physical exam, appropriate analgesia, and
their diagnostic process. If this extended training in POCUS adjunctive US exams can pay dividends. A simple low- velocity
was applied across a greater cross section of Operators, rib mechanism rib fracture, like the one demonstrated in this case,
fracture detection and treatment could be simplified in austere can very easily be managed by an Operator in the field once
environments. US is an established and still evolving imaging the diagnosis is confirmed with POCUS, life-threatening in-
modality and diagnostic tool in modern medicine that is grow- jury is ruled out, and complications are prevented using the
ing more deployable with advances such as smaller handheld approach shown here.
devices and incorporation of artificial intelligence.
Disclosure
Conclusion The views presented are those of the authors and do not nec-
essarily represent the views of the Department of Defense or
At the 30-day mark, the patient did not have any pain or other its components.
medical issues related to the rib fracture and did not require
follow-up imaging. He did not seek any follow-up care, as all References
pain and discomfort was resolved after 2 weeks of light duty. 1. Peek J, Beks RB, Hietbrink F, et al. Epidemiology and outcome
If this patient had presented in an austere environment, it is of rib fractures: a nationwide study in the Netherlands. Eur J
possible that a 47-year-old male with chest pain that was re- Trauma Emerg Surgery. 2022;48(3):265–271.
ported as atraumatic on initial evaluation could have led to 2. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: The
breakpoint for mortality. Surgery. 2005;138(4):717–725.
3. Richards JR, McGahan JP. Focused Assessment with Sonography
in Trauma (FAST) in 2017: What radiologists can learn. Radiol-
ogy. 2017;283(1):30–48.
4. Litwack K. Pain management in military trauma. Crit Care Nurs
Clin North Am. 2015;27(2):235–246.
5. Gracies J, Elovic E, McGuire J, Simpson D. Traditional pharmaco-
logical treatments for spasticity part I: Local treatments. Muscle
Nerve. 1997;20(S6):61–91.
6. Mandyam MC, Ahuja NK. Perineural injection therapy in the
management of complex regional pain syndrome: a sweet solu-
tion to pain. Pain Medicine. 2017;18:2041–2045.
7. Martin TJ, Eltorai AS, Dunn R, et al. Clinical management of
rib fractures and methods for prevention of pulmonary complica-
tions: a review. Injury. 2019;50(6):1159–1165.
8. May L, Hillermann C, Patil S. Rib fracture management. BJA
Educ. 2016;16(1):26–32.
9. Chapman BC, Overbey DM, Tesfalidet F, et al. Clinical utility
of chest computed tomography in patients with rib fractures CT
chest and rib fractures. Arch Trauma Res. 2016;5(4):37070.
10. Turk F, Bekir Kurt A, Saglam S. Evaluation by ultrasound of trau-
matic rib fractures missed by radiography. Emerg Radiol. 2010;
17(6):473–477.
11. Yousefifard M, Baikpour M, Ghelichkhani P, et al. Comparison
of ultrasonography and radiography in detection of thoracic bone
fractures; a systematic review and meta-analysis. Emergency.
2016;4(2):55–64. Published online 2016. Accessed February 15,
2023.
12. Gilbertson J, Pageau P, Ritcey B, et al. Test characteristics of chest
ultrasonography for rib fractures following blunt chest trauma: a
systematic review and meta-analysis. Ann Emerg Med. 2022;79
(6):529–539.

PMID: 37253154; DOI: 10.55460/5EY1-GPAM

72 | JSOM Volume 22, Edition 3 / Fall 2023