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Thoracic Ultrasound Images for the Identification of Pleural Effusion Cause After a Fall
      A 65-year-old man presented with a 3-week history of left-sided chest wall pain, cough, and progressive dyspnea after a significant fall. He was a current smoker with a 40 pack-year history but no relevant past medical history otherwise. Clinical examination revealed diffuse bruising on his left flank, with focal tenderness over his lateral left 10th to 12th ribs. Clinically, he had evidence of a left-sided pleural effusion. Chest radiography confirmed a large laminated left-sided effusion (Fig 1A). Blood tests showed raised inflammatory markers that included a C-reactive protein concentration of 275 mg/L, a total WBC count of 12.0 (10∗9/L), and a raised platelet count of 518 (10∗9/L).
      Figure thumbnail gr1
      Figure 1A, An anterior-posterior chest radiograph view shows a large left laminated effusion. B, A posterior-anterior chest radiograph view shows resolution of the left-sided effusion with raised left hemi-diaphragm after 28F chest drainage tube insertion. It is now possible to see a fracture/dislocation of the 9th rib after fluid drainage by a “step” in the cortex of the bone. Retrospectively, this is visible on Figure 1A, although it is hard to appreciate due to the volume of fluid.
      Question 1: What does Video 1 show and what are the next steps?Question 2: What does the initial video (Video 2) of the curvilinear low-frequency probe and subsequently the linear high-frequency probe show as the cause of the effusion?
      Answer 1: Bedside thoracic ultrasound scanning (TUS) revealed a large septated echogenic effusion spanning 6 rib spaces and a maximal depth of 13 cm. The diaphragm was flattened with paradoxical movement on inspiration. At the center of the image in Video 1, echogenic circular lattice-like septations are seen. On greater depth, we could see multiple circular septations with anechoic centers. Doppler examination revealed absent pulsation that indicated no blood flow. Further in-depth TUS examination suggested an abnormality that could explain the cause of the effusion. This was subsequently confirmed by focused assessment with the linear high-frequency probe.Answer 2: Assessment with the curvilinear probe showed a possible rib fracture with discontinuity of the bone cortex. There was no active pleural bleeding. The linear frequency probe revealed abnormal chest wall movement with a clear “step” in the cortex of the rib surrounded by a hypoechoic structure characteristic of a rib fracture and an adjacent organized hematoma. We suspected a hemothorax secondary to a traumatic rib fracture after his fall, as shown on TUS with organized hematoma formation at the site of the fracture.
      A diagnostic pleural aspiration under direct ultrasound guidance was performed in the left mid-axillary line above the suspected hematoma and rib fracture, which revealed very heavily blood-stained pleural fluid. A 28F surgical chest drain was inserted, and 1.5 L of heavily blood-stained pleural fluid was immediately drained, which improved ultrasonographic appearances, including diaphragmatic movement. Subsequently, 3 L of blood-stained pleural fluid were drained, with good symptomatic and radiologic outcome (Fig 1B). Postdrainage chest radiography revealed a clear fracture/dislocation of his 9th rib identified on TUS that had been obscured on initial chest radiography due to the volume of effusion. The drain was removed at day 2, and he was discharged the following day without the need for further investigations.

      Discussion

      Initial curvilinear probe assessment revealed a large echogenic effusion with intrapleural thrombus and paradoxical diaphragmatic movement (Video 3, Narration Video). We then identified abnormal chest wall movement and possible rib fracture above the intrapleural thrombus. Ongoing pleural bleeding was ruled out by scanning in Doppler mode. Linear probe assessment allowed clear identification of the rib fracture and bone fragment with organized hematoma as the underlying cause, which allowed us to proceed with our treatment plan without the need to investigate further.
      TUS is used widely for assessment of pleural effusion prior to intervention.
      • Havelock T.
      • Teoh R.
      • Laws D.
      • et al.
      Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010.
      In experienced hands and to ensure procedural safety, it can identify possible causes that include chest wall and rib abnormalities.
      • Hassan M.
      • Rahman N.M.
      Chest wall and parietal pleura.
      Each available US transducer carries different properties and can be used to evaluate the lung in a different way. A linear transducer emits a beam with a frequency of 6-12 MHz; a curvilinear probe has a range of 2-5 MHz. The higher frequencies allow high-resolution images of shallower structures such as ribs and pleura, whereas lower frequencies allow lower resolution images of deeper structures.
      • Alerhand S.
      • Graumann O.
      • Nelson B.P.
      Physics and basic principles.
      In this case, we demonstrated how the lower frequency curvilinear probe was used to assess for hematoma formation within the pleural effusion as seen in Video 1; the higher frequency linear probe was used subsequently to assess the chest wall and identify the rib fractures in Video 2.
      Most rib fractures are a result of direct trauma to the chest wall, such as blunt high-energy force or penetrating trauma. However, in elderly patients, relatively minor trauma can result in single rib fractures that result in disruption to the intercostal vessel. When conservative treatment fails, symptoms develop over time or worsen.
      • Turk F.
      • Kurt A.B.
      • Saglam S.
      Evaluation by ultrasound of traumatic rib fractures missed by radiography.
      In these patients with chest trauma, TUS can be key in identification of injuries to the chest wall, pleura, and lung with high sensitivity. In cases of blunt trauma, TUS has been shown to be more sensitive than chest radiographs at the detection of rib fractures, with an increase in diagnostic sensitivity from 50% to 90%.
      • Hwang E.G.
      • Lee Y.
      Simple X-ray versus ultrasonography examination in blunt chest trauma: effective tools of accurate diagnosis and considerations for rib fracture.
      ,
      • Lee W.S.
      • Kim Y.H.
      • Chee H.K.
      • Lee S.A.
      Ultrasonographic evaluation of costal cartilage fractures unnoticed by the conventional radiographic study and multidetector computed tomography.
      Fractures are identified by a gap or a discontinuity in the cortex or a “step” if the rib is dislocated.
      • Hassan M.
      • Rahman N.M.
      Chest wall and parietal pleura.
      TUS can be used to identify underlying hematomas adjacent to the rib fracture. They can have varying degrees of echogenicity depending on erythrocyte density and can form denser echoes due to organization from older lesions. TUS can also be used to assess for underlying disruption of vasculature.
      • Hassan M.
      • Rahman N.M.
      Chest wall and parietal pleura.
      As demonstrated in this case, TUS has a role in the identification of organized hematoma formation and rib fracture not otherwise visible on the plain chest radiograph. Linear TUS allows high resolution of the chest wall structures that allows for fracture identification. Recognizing the underlying cause in this way leads to the initiation of appropriate treatment without the need for further investigation, such as CT scans, and to a reduction in the number of bed days in the hospital.

      Reverberations

      • 1.
        TUS has high sensitivity for the detection of injuries to the chest wall, pleura, and lung after chest trauma.
      • 2.
        If there is a suspected rib fracture, linear TUS will help identify the discontinuity in the cortex and abnormal chest wall movement that can identify the fracture not initially identified on chest radiograph.
      • 3.
        TUS in chest trauma reduces the need for further imaging such as CT scanning.

      Acknowledgments

      Financial/nonfinancial disclosures: None declared.
      Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
      Additional information: To analyze this case with the videos, see the online version of this article.

      Supplementary Data

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      References

        • Havelock T.
        • Teoh R.
        • Laws D.
        • et al.
        Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010.
        Thorax. 2010; 65: ii61-ii76
        • Hassan M.
        • Rahman N.M.
        Chest wall and parietal pleura.
        in: Laursen C.B. Rahman N.M. Volpicelli G. Thoracic Ultrasound (ERS Monograph). European Respiratory Society, Sheffield, UK2018: 31-42
        • Alerhand S.
        • Graumann O.
        • Nelson B.P.
        Physics and basic principles.
        in: Laursen C.B. Rahman N.M. Volpicelli G. Thoracic Ultrasound (ERS Monograph). European Respiratory Society, Sheffield, UK2018: 1-13
        • Turk F.
        • Kurt A.B.
        • Saglam S.
        Evaluation by ultrasound of traumatic rib fractures missed by radiography.
        Emerg Radiol. 2010; 17: 473-477
        • Hwang E.G.
        • Lee Y.
        Simple X-ray versus ultrasonography examination in blunt chest trauma: effective tools of accurate diagnosis and considerations for rib fracture.
        J Exerc Rehabil. 2016; 12: 637-641
        • Lee W.S.
        • Kim Y.H.
        • Chee H.K.
        • Lee S.A.
        Ultrasonographic evaluation of costal cartilage fractures unnoticed by the conventional radiographic study and multidetector computed tomography.
        Eur J Trauma Emerg Surg. 2012; 38: 37-42