Case history

This 38 year old woman presented at her local accident and emergency department complaining of severe pain on the right side of her chest. The pain started earlier in the day after she had a dizzy spell and fell, hitting a piece of furniture on the way down. The pain was worse on inspiration and on movement. On examination the lower, anterior ribs on the right were tender to palpation, she was in obvious distress, and the nurse reported that her respiratory rate was18, with a SpO2 of 95% on room air. An x ray examination was taken of her chest and the result is shown here.

Questions

(1) What acute radiological abnormality do you see on this film? Pay attention to the enlarged image.
(2) What else would you be particularly careful to look for on a chest radiograph in this case? The patient complained of continuing severe pain despite receiving an initial dose of cyclimorph (morphine and cyclizine). The accident and emergency consultant decided to give additional analgesia via a series of intercostal nerve blocks.
(3) How is this procedure undertaken?
(4) What must you do after this procedure and why?
(5) What other longstanding abnormalities are visible on this film?

Answers

(1) There is a fracture of the anterior eighth rib on the right hand side of the chest.
(2) A pneumothorax. Fractured ribs (single or multiple) mean that potentially hard, sharp edges may puncture the nearby pleura, allowing air to enter the pleural space. You may see an absence of vascular lung markings at the periphery of the lung, along with the edge of the lung away from the chest wall. This patient does not have a pneumothorax.
(3) The patient must be suitably positioned and exposed to give access to the ribs between which the block is needed. A local anaesthetic and adrenaline preparation of 0.5% bupivacaine and 1 in 200 000 adrenaline is suitable. Wash your hands and clean the patient’s skin over the desired area and then palpate to check the correct rib is known. A needle is then passed through the skin and advanced, directing the needleobliquely at the rib below until you feel it come into contact with the rib. Manoeuvre the needle until it slips into the soft tissue beneath the rib where the intercostal nerve lies in the subcostal groove as part of the neurovascular bundle. Aspirate to check that you are not in an artery before injecting 3-5mls. The block may be repeated to several ribs, although where multiple fractures are present a thoracic epidural may be considered.
(4) One of the risks of this procedure is an iatrogenic pneumothorax. A postprocedural chest radiograph should be requested to ensure that this has not occurred. An expiratory radiograph improves visualisation of a small pneumothorax. There is relatively increased intrapleural pressure on expiration which "pushes" the lung away from the chest wall.
(5a) There is no breast shadow on the right side of the chest. This is most commonly caused by a previous mastectomy.
(5b) Pectus excavatum (funnel chest). The ribs have a characteristic "heart shaped" contour. There is also increased density adjacent to the right heart border. This is the result of mediastinal shift to the left, but these appearances may mimic rightmiddle lobe consolidation. The ribs rise steeply from the sternum at the midline anteriorly, curving to the lateral chest margin, and then descend medially towards the spine. The overall effect looks heart shaped on the anterior radiograph.