Workup for Rib Fractures
Standard chest radiography is the appropriate initial imaging modality for suspected rib fractures, with CT scanning reserved for cases where underlying organ injury is suspected or surgical fixation is being considered. 1
Initial Evaluation
Clinical Assessment
- Evaluate for:
- Mechanism of injury (blunt trauma, direct force, violent muscle contraction)
- Pain with deep breathing or movement
- Point tenderness over ribs
- Paradoxical chest wall movement (indicating flail chest)
- Signs of respiratory distress (tachypnea, hypoxemia)
- Signs of underlying organ injury (abdominal tenderness, hemodynamic instability)
Initial Imaging
- Chest radiograph (posteroanterior view) is the first-line imaging test 1
- Despite low sensitivity (may miss up to 50% of rib fractures), studies suggest that undetected fractures rarely alter management in uncomplicated cases
- More important for detecting complications like pneumothorax, hemothorax, or pulmonary contusion
Advanced Imaging Considerations
CT Scanning
Indications for chest CT:
- Suspected underlying organ injury
- High clinical suspicion with negative chest X-ray
- Planning for surgical stabilization of rib fractures (SSRF) 1
- Suspected pathologic fractures
- Suspected first rib fracture (associated with vascular injury)
- Multiple rib fractures or flail chest
CT is more sensitive than chest radiography, detecting approximately 40% more fractures than plain films 1
3D CT reconstruction is recommended for surgical planning if SSRF is being considered 1
Ultrasound
- May be used as an adjunct in select cases
- Has approximately 80% diagnostic accuracy with 91.2% sensitivity and 72.7% specificity 2
- Particularly useful for:
- Pregnant patients
- Pediatric patients
- Bedside evaluation in unstable patients
- Intraoperative localization during SSRF
Risk Stratification
High-Risk Features Requiring ICU Monitoring 3
- 6 or more rib fractures
- Bilateral fractures
- Unstable chest wall (flail chest)
- 3 or more fractures with significant displacement
- First rib fracture
- Fractures in all three anatomical areas (anterior, lateral, posterior)
- Age >65 years with ≥6 rib fractures
Concerning Anatomical Locations
- Fractures of ribs 1-4: Risk of vascular or airway injury
- Fractures of ribs 7-12: Associated with abdominal organ injury in 67% of polytrauma cases 3
- Posterior rib fractures in children: Highly specific for non-accidental trauma 1
Common Pitfalls to Avoid
- Relying solely on chest X-ray: Remember that up to 50% of rib fractures may be missed on plain radiographs
- Overlooking associated injuries: Always evaluate for pneumothorax, hemothorax, pulmonary contusion, and abdominal organ injury
- Failing to recognize worsening displacement: Rib fractures tend to become more displaced over time, which may affect treatment decisions 4
- Missing non-accidental trauma in children: Posterior rib fractures in children should raise suspicion for abuse
- Inadequate pain control: Poor pain management leads to splinting, atelectasis, and pneumonia
Follow-up Considerations
- Serial clinical examinations to monitor for developing complications
- Consider repeat imaging if clinical deterioration occurs
- Implement a structured rib fracture management pathway for improved outcomes 5