Plotse toename van thoracale pijn 2 weken na een thoraxtrauma: meer dan een ribfractuur

Abstract

Sudden increase in thoracic pain 2 weeks after blunt thoracic trauma: more than just a rib fracture Two weeks after a blunt thoracic trauma caused by falling off her bike, a 42-year-old woman presented to the emergency department due to increasing, severe, stabbing thoracic pain that started around 2 am. She mentioned vomiting the evening before, around 8 pm. The chest X-ray showed a rib fracture, which was, however, not consistent with the clinical findings. For this reason, an additional ultrasound was ordered and because of the suspicion of a displaced cartilaginous low anterior rib fracture complemented with a CT scan. This confirmed the displaced fracture and showed a fixated overriding of the cartilage fragments. Surgical resection of the anterior cartilage fragment resulted in an immediate and significant improvement of the pain. Literature on this type of injury is limited and mainly includes case-reports and small retrospective studies showing that it is an often missed diagnosis. Several difficulties are encountered in establishing and elaborating this diagnosis. Additional imaging is needed, as rib cartilage cannot be evaluated on a standard X ray of the thorax. The American College of Radiology (ACR) appropriateness criteria do not mention this feature. Important to keep in mind in this case, are the non-fitting clinical characteristics to the rib fracture found on the X ray. In addition, there is a lack of guidelines and qualitative studies on whether or not to apply a surgical treatment. By presenting this case, the authors hope to highlight the clinical thought process that led to this often missed diagnosis, given its clinical importance. This is a very painful experience for the patient, that might require a surgical approach.