A 16-year-old boy was hit by a car. He complained of right-sided chest/abdominal pain and dyspnoea. His observations were stable. A chest radiograph showed a right haemothorax and an intercostal drain was inserted. The chest radiograph also showed rib fractures, and a CT scan confirmed multiple rib fractures and a displaced rib entering the liver with surrounding haematoma (fig 1). There was cardiovascular deterioration but, following resuscitation, it was decided to manage his liver injury conservatively. He remained under observation with repeat imaging assessing resolution. The drain was removed after 10 days and he was discharged home.

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Figure 1 CT scan showing a rib fragment entering the liver with surrounding haematoma.

Penetrating liver injury usually results from trauma breaching the skin and may be managed conservatively.1 In our case the penetration was “internal” and was managed without surgery. The chest radiograph gave no hint of the extent of internal displacement of the rib as shown by CT scanning.