75 Year Old With Rib Pain

Differential Diagnosis

• Left-sided rib fractures
• Rightward tracheal deviation
• Left-sided pneumothorax
• Left sided hemothorax

Diagnosis

The imaging reveals multiple left-sided rib fractures and rightward tracheal deviation. The tracheal deviation is concerning for underlying mass of the upper mediastinum. Common causes for tracheal deviation include aberrant right subclavian artery, bronchogenic cyst, double aortic arch, duplication cyst, esophageal carcinoma, lymphadenopathy, middle mediastinal lesion, neurenteric cyst, right aortic arch, thyroid mass, and tracheal cyst.  Complications from rib fractures include pneumothorax and hemothorax, neither of which are present in this image.

What to Look For

• Normal tracheal alignment should occur directly in front of the cervical spine on the PA view of a chest x-ray
• Rib fractures appears as “jumps” along the smooth edge borders of the rib bone

Pearls for Urgent Care Management

• Tracheal deviation requires further evaluation to understand the underlying etiology, including advanced imaging such as a CT scan
• Rib fractures heal with time and pain management
• Patients with rib fractures should be encouraged to do deep breathing or incentive spirometry to minimize risk of complications