From the Guidelines
For a patient with a normal chest X-ray but persistent focal point tenderness in the left ribs, the next step in management should be to obtain a CT scan of the thoracic cage, as suggested by the initial impression, to further evaluate for potential rib fractures or other pathology not visible on plain radiographs. This recommendation is based on the increased sensitivity of CT scans for detecting rib fractures, as noted in the study by Kea et al 1, which found that CT detected rib fractures in 11% of patients with initial chest radiographs interpreted as normal. Although the study by Livingston et al 1 suggested that the presence of rib fractures on radiography was associated with increased pulmonary morbidity, the detection of rib fractures by CT may still be indicated, especially if severe injury is suspected.
The patient's clinical presentation and the potential for underlying injuries should guide the decision to proceed with further imaging. While waiting for the CT scan, appropriate pain management should be initiated, typically with NSAIDs such as ibuprofen or naproxen, combined with acetaminophen as needed. For more severe pain, a short course of an opioid medication might be considered. The patient should be advised to avoid strenuous activities, apply ice to the affected area, and perform deep breathing exercises to prevent atelectasis.
If the CT scan is also negative but symptoms persist, consideration should be given to other potential causes such as costochondritis, intercostal neuralgia, or referred pain from underlying visceral structures, which may require further specialized evaluation. The study by Dubinsky and Low 1 found that clinical evidence of a complicated injury may warrant further evaluation, and the study by Schurink et al 1 suggested that contrast-enhanced CT might be indicated in patients with multiple injuries and lower rib fractures. However, the most recent and highest quality study, 1, prioritizes the use of CT scans for detecting rib fractures and guiding management.
In terms of specific management, the study by Bugaev et al 1 found that the number of rib fractures and the degree of fracture fragment displacement accurately predicted subsequent opioid requirements, highlighting the importance of accurate diagnosis and management. Overall, the use of CT scans in this context is supported by the most recent and highest quality evidence, and a CT scan of the thoracic cage is the recommended next step in management for this patient.
From the Research
Next Steps in Management
The patient has a normal chest X-ray but persistent clinical concerns for focal point tenderness in the left ribs. The next steps in management are:
- Correlation with CT scan of the thoracic cage can be considered if clinical concerns persist 2, 3, 4
- CT scan may help identify additional findings that are therapeutically relevant, such as fractures or other injuries 4
- The use of CT scan in addition to chest X-ray may lead to changes in diagnosis and management, including the initiation or discontinuation of antibiotics and hospitalization 3
Considerations for CT Scan
The decision to perform a CT scan should be based on the patient's clinical presentation and the presence of focal point tenderness in the left ribs. Considerations include:
- The patient's haemodynamic stability, as CT scan is more useful in stable patients 4
- The potential for CT scan to detect additional findings that are not visible on chest X-ray, such as fractures or other injuries 4, 5
- The potential for CT scan to influence decision-making and guide treatment decisions 3, 5
Potential Findings on CT Scan
The CT scan may reveal additional findings that are therapeutically relevant, including: