Rib Fracture Guidelines

Updated: Jan 18, 2023
  • Author: Sarah L Melendez, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines Summary

The American College of Radiology (ACR) Appropriateness Criteria for rib fracture includes the following [75, 76] :

  • A radiograph of the chest is usually appropriate for the initial imaging of suspected rib fractures from minor blunt trauma (injury confined to ribs).
  • A radiograph of the chest is usually appropriate for the initial imaging of suspected rib fractures after cardiopulmonary resuscitation.
  • A radiograph of the chest is usually appropriate for suspected pathologic rib fracture with CT chest without IV contrast or Technetium-99m whole-body bone scan as complementary to the chest radiography.
  • It is usually unnecessary to perform dedicated radiography (in addition to chest radiography) for the diagnosis of adults after minor trauma.
  • Although the diagnosis of multiple fractures has prognostic implications, there is no evidence that performing dedicated studies, CT, or bone scintigraphy is beneficial, except in the setting where such evaluation is necessary for establishing further care or other investigations (eg, elder abuse, legal documentation).
  • CT, skeletal scintigraphy, and US may be helpful in evaluating selected patients with occult "stress" and in evaluating selected CPR survivors or in situations in which identifying a rib fracture is deemed to be clinically important.
  • Neither clinical examination nor radiography is ideal for the diagnosis of rib fractures. The standard posteroanterior (PA) chest radiograph is specific but not very sensitive for fractures (the supine anteroposterior [AP] radiograph is even less sensitive), and clinical examination is sensitive but not specific. Rib detail radiographs rarely add additional information to the PA film that would change treatment. Similarly, dual-energy chest radiography with bone subtraction imaging has failed to show improved detection when compared to standard radiographs.
  • Multidetector CT is increasingly used as the method of choice for the radiologic evaluation of the traumatized patient. It provides an accurate assessment of fractures and associated internal injuries. CT also provides an accurate means of assessing cartilage fractures, which are typically missed on radiography. However, CT is not usually performed to only identify rib fractures; rather, it is used to identify other complications of trauma. Ultrasound (US) may also be used for depiction of rib fractures or associated costal cartilage injury in the emergency setting.
  • Nuclear medicine bone scans are sensitive but not specific for detection of rib fracture. Bone scans are most commonly used for detection of osseous involvement in systemic processes (eg, metastatic disease) and may result in false-positive diagnosis of malignancy in a patient with rib fractures, although the pattern of tracer uptake can often help differentiate the 2 processes.