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Case of the Month 3/08

This 45 year old female was brought to the ED by EMS after an assault by her boyfriend which involved her being kicked in her back several times. Q: What is wrong with this picture? (hint – it’s a very subtle finding that may make you want to order further imaging.)

Hint #2 You can see the problem a little bit more clearly on the scout film done before her chest/abdomen/pelvis CT.

Hint #3. (before reading the answer, look at the CXR and scout again after looking at the CT below.)

View answer

There is some subcutaneous emphysema (due to fractured ribs and a large pneumothorax) in the soft tissue of the right lower lateral chest wall. (See circles below.) While it is possible that the size of the pneumothorax increased in the time between the initial portable x-ray and the chest CT (about 3 hours), we can tell from the original findings that the pnemothorax was present when the patient arrived. The pneumothorax was most likely not visible on the original films due to body habitus, poor inspiration, overlying wires and the patient not being in an upright position for enough time before the x-ray was taken. A bedside lung ultrasound would have been an excellent way to diagnose the pneumothorax before the CT was done. Subcutaneous emphysema is a subtle x-ray finding (as well as physical exam finding!) which can be used to help diagnose pneumothorax before it is picked up on imaging.