Do All Patients With Left Costal Margin Injuries Require Radiographic Evaluation for Intraabdominal Injury?

• Published in: Annals of emergency medicine Vol. 46; no. 3; pp. 232 - 236
• Main Authors: Holmes, James F., Ngyuen, Hien, Jacoby, Robert C., McGahan, John P., Bozorgchami, Hormozd, Wisner, David H.
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01-09-2005; Elsevier
• Subjects: Abdominal Injuries - complications; Abdominal Injuries - diagnostic imaging; Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Child; Clinical death. Palliative care. Organ gift and preservation; Cohort Studies; Emergency Medicine - methods; Flank Pain - etiology; Humans; Injuries of the abdomen. Foreign bodies of the digestive system; Intensive care medicine; Medical sciences; Middle Aged; Outcome and Process Assessment (Health Care); Prospective Studies; Radiography; Rib Fractures - complications; Rib Fractures - diagnostic imaging; Spleen - diagnostic imaging; Spleen - injuries; Thoracic Injuries - complications; Thoracic Injuries - diagnostic imaging; Traumas. Diseases due to physical agents; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - diagnostic imaging; Human; Radiography; Intensive care; Rib(bone); Resuscitation
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2005.03.001

We determine whether all patients with pain or tenderness to the left lower ribs after blunt traumatic injury require abdominal computed tomography (CT) scanning for the detection of splenic injury.
This was a prospective, observational cohort of all blunt-trauma patients who had pain or tenderness to the left lower ribs and presented to the emergency department (ED) of a Level I trauma center. Patients were enrolled if they had a Glasgow Coma Scale (GCS) score greater than 13 and pain or tenderness to the left lower ribs (ribs 7 to 12). Patients with pain or tenderness to the left lower ribs were considered to have pleuritic pain if the pain increased with inspiration or cough. All hemodynamically stable patients underwent abdominal CT scanning for detection of intraabdominal injuries. Data forms collecting information on the medical history and physical examination of all patients were completed before radiographic imaging. Patients with left lower rib pain or tenderness were considered to have “isolated” left lower rib injury if they were without all of the following: ED or out-of-hospital systolic blood pressure less than 90 mm Hg, abdominal or flank tenderness, pelvic or femur fractures, and gross hematuria.
Eight hundred seventy-five patients had left lower rib pain or tenderness, 63 (7.2%; 95% confidence interval [CI] 5.6% to 9.1%) patients had splenic injuries, and 20 (2.3%; 95% CI 1.4% to 3.5%) patients had left renal injuries. Five hundred seventy-four patients had additional indications for abdominal imaging, leaving 301 patients with “isolated” left lower rib injury. Of the 301 patients, 9 (3.0%; 95% CI 1.4% to 5.6%) had splenic injuries. All 9 patients had a pleuritic component to their rib tenderness, and 3 (33%) patients underwent splenectomy.
A small but important percentage of patients with pain or tenderness to the left lower ribs has splenic injuries. All patients with splenic injury had pleuritic pain.