From the Guidelines
When ordering a chest x-ray for a patient with a history of traumatic rib injury, it is essential to request both posteroanterior (PA) and lateral views, along with dedicated rib views of the affected area, as this approach ensures proper evaluation of both the ribs and potential complications affecting underlying structures. The most recent and highest quality study, 1, highlights the importance of a comprehensive imaging approach in patients with suspected chest trauma. According to this study, a portable AP chest radiograph can help screen for immediate life-threatening findings, but it is not an adequate test for evaluating thoracic injuries due to its lower sensitivity in detecting pneumothorax, hemothorax, lung contusions, rib fractures, and cardiac and vascular injury.
Key considerations when ordering a chest x-ray for a patient with a history of traumatic rib injury include:
- Specifying the suspected location of injury in the order (e.g., "right lateral ribs 6-8")
- Including clinical information such as "trauma" or "fall" and symptoms like "chest pain with breathing"
- Noting the mechanism of injury, timing, and any concerning symptoms like shortness of breath that might indicate complications such as pneumothorax or hemothorax
- Instructing the patient to take a deep breath and hold it during the x-ray when possible, though this may be limited by pain
If the standard x-ray is negative but clinical suspicion remains high, consider ordering a CT scan, which offers greater sensitivity for detecting rib fractures, particularly in areas difficult to visualize on plain films such as the first ribs or costochondral junctions, as suggested by 1 and 1. This comprehensive approach is supported by the American College of Radiology's appropriateness criteria for rib fractures and major blunt trauma, which emphasize the importance of a thorough imaging evaluation in patients with suspected chest trauma 1.
From the Research
Ordering a Chest X-ray for a Patient with a History of Traumatic Rib Injury
When ordering a chest x-ray for a patient with a history of traumatic rib injury, several factors should be considered:
- The patient's medical history and current symptoms should be taken into account 2, 3
- A chest x-ray (CXR) may not be sufficient to identify all occult thoracic injuries, such as rib fractures, pneumothoraces, or hemothoraces 2, 4
- An abdominal computed tomography (CT) scan may be useful in identifying some of these occult injuries, particularly in patients with a high-risk mechanism of injury 2
- However, the clinical significance of these occult injuries is uncertain, and their management may not require immediate intervention 3
Specific Considerations for Rib Fractures
- Rib fractures are a common injury in patients with blunt chest trauma, and their diagnosis can be missed on initial chest x-ray 4, 5
- The presence of subcutaneous emphysema may be a risk factor for the development of delayed pneumothorax in patients with minor rib fractures 6
- Chest CT may be more sensitive than chest x-ray in diagnosing rib fractures, but the clinical significance of these fractures remains unclear 5
Implications for Clinical Practice
- A thorough evaluation of the patient's chest x-ray and medical history is necessary to identify potential thoracic injuries 4
- The use of abdominal CT scans and chest CT scans should be considered on a case-by-case basis, taking into account the patient's risk factors and clinical presentation 2, 5
- Close observation and monitoring of patients with minor rib fractures may be necessary to detect potential complications, such as delayed pneumothorax 6