Trauma – fractured ribs undiagnosed on chest Xray

Images Roger Burrell, text Genevieve Carbonatto

A 54 year old man presents one week after a fall. He is complaining of severe left lower rib pain especially with respiration. His chest Xray looking for rib fractures does not show any fractures, nor is there a pneumothorax or a pleural effusion. On palpation he is tender over his lower ribs.

These are 3 clips of his 3 lower ribs

There are 3 clear fractures.

The following is a clip of his intercostal space. A  large haematoma is visible.


A  chest wall fracture on ultrasound has been defined as “a clear disruption of the anterior margin of the rib or sternum, the costochondral junction, or the costal cartilage.” There is some debate in the literature as to whether US is a better image modality than Xray for diagnosing rib fractures despite  several studies  showing it’s  superiority over  Xray  (1, 2)

As the debate rages on, clinically we have found ultrasound useful in the diagnosis of missed fractures on chest Xray. Here 3 fractures, undiagnosed on chest Xray were clearly visible using ultrasound.

Teaching point: If the patient has had an injury and is suffering from a possible rib fracture order a chest Xray.  If no fractures are visible use the linear ultrasound probe to interrogate the area of maximum tenderness. This can be done gently without causing pain.


  1. Emerg Radiol : 2010 Nov;17(6):473-7. doi: 10.1007/s10140-010-0892-9. Epub 2010 Jul 23. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Turk F1, Kurt AB, Saglam S.
  2. Emerg med J:  Vol 31 Issue 2, Best Evidence Topic ReportsBET 1: Ultrasound in the diagnosis of rib fractures

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