A 40-year-old female presented to our ED with chest pain after a motor vehicle collision. She was the restrained driver in head-on collision going about 30-40 mph. Her airbag deployed and struck her in her chest. She had immediate onset of chest pain over her sternum after the accident.
Initial VS were normal.
Physical exam revealed tenderness over the mid-sternum without obvious deformity.
CXR was obtained and is seen below:
This CXR is negative for pneumothorax. The mediastinum appears normal in size. There was no obvious abnormality of the sternum.
Given the high clinical suspicion for sternal fracture, a BSUS was performed to look for fracture. The patient was asked to point at the spot where she was having the most pain, and the transducer was placed there. A linear transducer was used. This is what was seen:
In this clip you can see that the normal cortex of the bone is interrupted. Seen below is a picture with the cortical interruption highlighted.
The patient went on to get a CT of the chest to look for any other underlying injuries. The CT scan showed buckling of the sternum consistent with what the ultrasound showed. No other injuries were found. See the CT below:
Bottom Line: Ultrasound can pick up small fractures that might otherwise be missed on x-rays.
This is a great case and I am generally a lover of ultrasound, but doesn’t this case hightlight the biggest potential problem with POCUS? We know how to deal with injuries found on X-ray. However, our standard work up revealed nothing on this patient, but because of an ultrasound finding we went further. When tests are used without knowing their benefits, they may actually have harms. In this case, a well patient was exposed to a CT scan apparently needlessly. Similarly, we are now seeing chest tubes placed on pneumothoraces seen on US but not on CXR. As all of us start running around with probes in hand, I think we are going to need to dedicate a lot of science to figuring out the specific impacts ultrasound is having on our patients.