MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic Value of Bone SPECT/CT Using 99mTc-Methylene Diphosphonate in Patients with Unspecified Chest Wall Pain

PURPOSE

We investigated the diagnostic performance of single photon emission computed tomography (SPECT)/computed tomography (CT) as a combination of functional and anatomic imaging, in patients with unspecified chest wall pain.

METHODS

Fifty-two patients with unspecified chest wall pain and no history of recent major traumatic events or cardiac disease were included. The number and location of radioactive chest wall lesions were evaluated on both planar images and SPECT/CT. The clinical diagnosis was made based on all of the clinical and imaging data and follow-up information.

RESULTS

Chest wall diseases were diagnosed in 42 patients (80.8 %). SPECT/CT showed abnormal findings in 35 (67.3 %) patients with positive predictive value (PPV) of 97.1 %. SPECT/CT revealed 56 % more lesions than planar bone scan (P = 0.002) and most of the abnormal radioactive lesions (94.6 %) showed combined morphological changes on the matched CT component. When comparing between age subgroups (< 60 y vs. ≥ 60 y), the prevalence of chest wall disease and diagnosis rate of fracture was significantly higher in the older age group. On SPECT/CT, the older age group showed higher frequency of having abnormal finding (95.8 % vs. 42.9 %, P < 0.001) and significantly more lesions were detected (a total of 189 vs. 32, P = 0.003).

CONCLUSION

SPECT/CT showed good diagnostic performance and proved to have higher sensitivity, detecting 56 % more lesions than planar bone scan. A negative result could be helpful for excluding pathologic chest wall disease. SPECT/CT might be recommended for integration in to the diagnostic workup in patients with unspecified chest wall pain, especially in patients ≥ 60 y of age, considering the high disease prevalence and the high frequency of positive results.

Rib soft fixation produces better analgesic effects and is associated with cytokine changes within the spinal cord in a rat rib fracture model

Traumatic rib fracture can cause severe pain and is usually associated with the depression of respiratory drive followed by severe respiratory complications. It is critical for patients with rib fracture to receive adequate analgesia. However, strong opioids and other analgesics often produces side effects and may even cause respiratory suppression. Meanwhile, rib fixation now has become a popular method for treating rib fracture patients. However, the actual molecular mechanism leading to its effectiveness as an analgesia has not been fully investigated, and the best analgesic method for its use in rib fracture patients has not yet been determined. We developed a new animal model for rib fracture and evaluated changes in pain severity after rib fixation. Our data indicated significantly better analgesic behavior if a soft string rib fixation is performed, which is associated with cytokine (interleukine-6 and interleukine-10) decreases in the spinal cord and co-localization with glia cells. Our results provided a treatment suggestion for rib fracture patients and the possible molecular mechanism for the analgesic effects. Further molecular mechanisms and the best therapeutic methods are still needed for this severe painful condition.

Low-trauma rib fracture in the elderly: Risk factors and mortality consequence

PURPOSE

Low trauma rib fracture (hereinafter, rib fracture) is common in the elderly, but its risk factors and mortality consequence are rarely studied. We sought to define the epidemiology of rib fracture and the association between rib fracture and postfracture mortality.

METHODS

The study was part of the Dubbo Osteoporosis Epidemiology Study, which was designed as a population-based prospective study, and consisted of 2041 women and men (aged ≥ 60). The incidence of rib fracture was ascertained from X-ray reports. Bone mineral density (BMD) was measured by DXA (GE-Lunar). The time-dependent Cox model was used to access the relationship between rib fracture and mortality.

RESULTS

During the median follow-up of 13 years, 59 men and 78 women had sustained a rib fracture, making the annual incidence of 4.8/1000 person-years. Each SD (0.15 g/cm²) lower in femoral neck BMD was associated with ~2-fold increase in the hazard of fracture (hazard ratio [HR] 1.9; 95% CI, 1.4 to 2.6 in men; and HR 2.1; 95% CI, 1.6 to 2.8 in women). Among those with a rib fracture, the incidence of subsequent fractures was 10.2/100 person-years. Compared with those without a fracture, the risk of mortality among those with a fracture was increased by ~7.8-fold (95% CI, 2.7 to 22.5) in men and 4.9-fold (95% CI 2.0 to 11.8) in women within the first year postfracture.

CONCLUSIONS

A rib fracture signifies an increased risk of subsequent fractures and mortality. The increased risk of mortality during the first 2.5 years postfracture suggests a window of opportunity for treatment.

Pleural effusion with rib fractures in infant

The causes of pleural effusions in children are various. This case demonstrates the importance of considering rib fractures associated with child abuse in the differential diagnosis of pleural effusion in infants.