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Andrea Magnacavallo - Piacenza -
Sospette fratture costali: quale imaging?
Rib fracture is the most common thoracic injury: 10%
of all traumatic injuries
ACR, Appropriateness Criteria - 2014
Almost 40% of patients who sustain severe non penetrating
chest trauma
Bansidhar BJ, Am Surg. 2002 Alkadhi H, J Comput Assist Tomogr. 2004
Isolated rib fractures have a low morbidity and mortality
Bansidhar BJ, Am Surg. 2002 Alkadhi H, J Comput Assist Tomogr. 2004
The diagnosis of associated complications may have a more
significant clinical impact
Bansidhar BJ, Am Surg. 2002 Alkadhi H, J Comput Assist Tomogr. 2004
Sospette fratture costali: quale imaging?
quale paziente?
QUALE PAZIENTE ?
Giovane sportiva: dolore acuto dopo “gomitata”
PAs 110, Fc 70 r SO2 98%, FR 14
Giovane operaio: grave trauma toracico chiuso
Pas 90, Fc 120 r SO2 85%, FR 30
PAs 110, Fc 70 r SO2 98%, FR 14
Giovane sportiva: dolore acuto dopo “gomitata”
Giovane operaio: grave trauma toracico chiuso
Pas 90, Fc 120 r SO2 85%, FR 30
PAs 110, Fc 70 r SO2 98%, FR 14
Frattura costale ?
Giovane sportiva: dolore acuto dopo “gomitata”
Giovane operaio: grave trauma toracico chiuso
Pas 90, Fc 120 r SO2 85%, FR 30
PAs 110, Fc 70 r SO2 98%, FR 14
Frattura costale ?
Lesioni life threatening?
Giovane sportiva: dolore acuto dopo “gomitata”
• Primary “ABCDE” assessment• Resuscitation
• Secondary assessment
• Continuing follow-up
• Invasive Procedures
US & CHEST TRAUMA
Towards an ultrasound curriculum in critical care medicine Critical Care Medicine, May 2007
CT chest with contrast
TRAUMA TORACICO MINORE
sospette fratture costali: quale imaging?
(asse corto costale)
CHEST WALL ULTRASOUND
(asse corto costale)
CHEST WALL ULTRASOUND
(asse corto costale)
CHEST WALL ULTRASOUND
(asse corto costale)
CHEST WALL ULTRASOUND
(asse lungo costale)
CHEST WALL ULTRASOUND
(asse lungo costale)
CHEST WALL ULTRASOUND
TRAUMA TORACICO MINORE
diagnosi ecografica delle fratture costali ?
LA LETTERATURA …
Several studies have investigated the role of US in the detection of rib fractures
CHEST ULTRASOUND
Battistelli JM, J Radiol 1993 Bitschnau R, Ultraschall Med 1997
Griffith JF, Am J Roentgenol 1990 Wischhofer E, Unfallchirurg 1995
The ultrasound imaging is not complicated and can also be
performed by trained clinicians
F. Turk. Emerg Radiol 2010
Li near
Pr o be
CHEST WALL ULTRASOUND
The site of maximum pain must be investigated
FRATTURA COSTALE
(asse corto costale)
FRATTURA COSTALE
(asse lungo costale)
FRATTURA COSTALE
(asse lungo costale)
Controllo a 2 settimane
FRATTURA COSTALE
FRATTURA COSTALE
Direct signs Concomitant indirect signs
At the site of pain Hematoma
Cortical gap Reverberation echoes “chimney phenomenon”
Step in cortical bone Pleural effusion
Dislocation Pneumothorax
Lung contusion
Sonography criteria for fractures of the ribs
Chest Sonography G. Mathis
Ultrasound is more sensitive than chest radiography (78% against 12%) in detecting rib fractures
AJR, December 1999
J. F. Griffith
Prospective study: 50 patients with clinical suspicion of rib fracture
Prospective study: 88 patients Isolated Mild-to-moderate blunt chest injury.
Detection of chest wall fractures: sensitivities of US (80.3%), clinical acumen (26.0%), chest radiography (23.7%)
Rainer, J Trauma. 2004
Radiography may miss 50% of rib fractures, especially those occurring in
costal cartilages and non dislocated fract.
M. E. Hurley. Injury 2004
Ultrasound also detects costal cartilage fractures and costo-chondral junction fractures
better than radiography
Griffith JF, AJR 1999
Malghem J, AJR 2001
FRATTURA COSTO-CONDRALE
(asse corto costale)
enfisema s.c.
Emerg Med J 2014;31:169–170.
further studies with a well-established gold standard should be completed before ultrasonography is used routinely
Nella diagnosi delle fratture costali gli US hanno un ruolo di rilievo,
specie nei bambini e nelle gravide
La diagnosi è di scarso impatto ai fini della gestione clinica e del trattamento
E’ più importante diagnosticare tempestivamente le complicanze
P ATO LO GI A S ENS I B I LI T
A’
S P ECI F I CI T
A’
VERS AMENTI
PLEURI CI 94% 97%*
PNX 95% - 100% 94% - 100%**
CONS OLI D.
POLMONARI 90% 97%***
S DR. ALVEOLO
I NTERS TI ZI AL
E 93% 93%****
*Intensive Care Medicine 1999; 25:955 – 958
**Chest 1995; 108:1345 – 1348
**Intensive Care Medicine 2000; 26 :1434 – 1440
*** Intensive Care Medicine 2004;30:276 – 281
**** Am J. Resp Crit Care Med 1997,156:1640 - 1646
CHEST ULTRASOUND
Grazie !
Injury, Int. J. Care Injured (2004)
A prospective study. Patients presenting with a high clinical suspicion of rib fracture(s) to the Accident and Emergency Department were referred for radiological work-up with a PA chest radiograph, an oblique rib view and a chest ultrasound
US is marginally superior to plain film and especially oblique rib views for rib fracture detection and may be helpful in diagnosing rib fractures not visualized on conventional radiography, if clinically indicated.
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