Holmes et al evaluated patients with isolated blunt trauma to the left lower ribs for their risk for splenic injury. This can help identify patients who may benefit from additional imaging studies and closer monitoring. The authors are from the University of California at Davis, the University of California at San Francisco, and the New York College in Valhalla.


Patient selection: blunt trauma


Left lower ribs are ribs 7 through 12.


Clinical findings - one or more of the following:

(1) left lower rib pain

(2) left lower rib tenderness to palpation

(3) left lower rib pleuritic pain (increased pain on respiration or with cough)


Exclusion criteria (reasons not to classify as "isolated"):

(1) minimum systolic blood pressure < 90 mm Hg (prehospital or in ED)

(2) abdominal tenderness

(3) flank tenderness

(4) pelvic fracture

(5) femoral fracture

(6) gross hematuria

(7) Glasgow coma scale (GCS) <= 13

(8) < 8 years of age


A patient with "isolated" left lower rib injury can have other injuries, including upper extremity fractures, flail chest, fracture of mandible, pneumothorax, lower extremity fracture, etc.


Approximately 3% of patients with "isolated" left lower rib injury had a splenic injury. A third of these (1% of total) had a Grade IV splenic injury that required splenectomy. All of the patients with splenic injury had pleuritic pain, but pleuritic pain was present in 83% of patients with isolated left rib injury (so splenic injury was seen in 3.6% of patients with isolated left rib injury and pleuritic pain)..


About 1% of patients who met criteria for isolated left lower rib injury had left renal injury. These patients all had left pleuritic pain.


Imaging studies were considered warranted at the outset of the study if the risk of splenic injury was > 5%. The 3% risk would be below this threshold. Looking at the patients with splenic injuries, patients might be selected for additional studies if the patient had:

(1) a motorcycle accident

(2) a motor vehicle accident, or

(3) additional rib fractures.


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