Ultrasound detection of an occult Rib fracture: A Differential in Left Upper Quadrant Pain

INTERESTING CASE

Submitted by : Mr Stephen Moore, Sonographer, Princes Royal University Hospital: King’s College NHS Foundation Trust; Ms Anna Baker, Clinical Specialist Sonographer, King’s College Hospital NHS Foundation Trust; Dr Gibran Yusuf, Consultant Radiologist, Princes Royal University Hospital, King’s College NHS Foundation Trust;  Dr Shweta Gupta, Princes Royal University Hospital, King’s College NHS Foundation Trust

Clinical History:

A 76 year old male presented for an outpatient scan of the abdomen with a recent history of blunt force trauma to the LUQ.  Initial clinical examination demonstrated focal tenderness in the LUQ and loin. There were no other clinical findings of note. Biochemistry was unremarkable. Urine dip analysis came back negative for haematuria. An ultrasound of the abdomen was undertaken to check for any evidence of intraabdominal pathology with emphasis on ruling out splenic or renal abnormalities.

Imaging Findings:

Ultrasound of the abdomen demonstrated normal appearances of the liver, pancreas, kidneys and spleen and no free fluid.  The patient was focally tender in the left lower thoracic region/flank. Targeted ultrasound was undertaken at the site of maximal tenderness.

Figure 1

What is the probable diagnosis based on the imaging findings?