Workup for Rib Fracture
Start with a standard posteroanterior (PA) chest radiograph as the initial diagnostic test for all patients with suspected rib fracture, regardless of mechanism, as this detects life-threatening complications that directly impact mortality and morbidity. 1, 2
Initial Imaging Strategy
Order a PA chest X-ray first in every case because it identifies critical complications including pneumothorax, hemothorax, pulmonary contusion, and flail chest—complications that carry greater clinical significance than the fractures themselves. 1, 2
Accept that chest radiography misses approximately 50% of rib fractures, but this limitation does not alter patient management or outcomes in uncomplicated cases. 1, 2
Do not order dedicated rib series radiographs as they provide no additional clinical benefit, prolong report turnaround time, and negatively impact patient care. 1
Risk Stratification for CT Imaging
Order contrast-enhanced chest CT when:
High-energy mechanism (motor vehicle collision >35 mph, significant fall height) with clinical suspicion for intrathoracic or intra-abdominal injury. 1, 2
Lower rib fractures (ribs 7-12) with multiple injuries, as 67% of these patients have associated abdominal organ injury even with normal physical examination. 1, 2
Clinical evidence of complicated injury including hemodynamic instability, ongoing blood loss, widened mediastinum, or signs of vascular injury. 2
First rib fracture, which warrants heightened suspicion for major vascular injury. 1, 2
Order non-contrast chest CT when:
Multiple rib fractures require precise anatomic definition for management decisions (≥6 fractures, bilateral fractures, ≥3 severely displaced fractures). 1, 2
Abnormal chest radiograph in trauma setting with need for fracture quantification. 2
Do not order CT when:
Low-energy injury with normal physical examination and stable vital signs. 1, 2
Isolated rib fracture without complications on chest X-ray in hemodynamically stable patient. 2
High-Risk Features Requiring ICU Admission
Transfer to ICU or tertiary care center when: 1, 2
Age ≥65 years with multiple rib fractures (dramatically increased morbidity and mortality due to poor cardiopulmonary reserve). 1
Flail chest. 1
Pain Management Considerations
For patients with normal renal function:
Implement multimodal analgesia with scheduled acetaminophen as first-line therapy, not as-needed dosing. 3
Add NSAIDs (ketorolac or ibuprofen) as second-line for severe pain. 3
Reserve opioids exclusively for severe breakthrough pain at lowest effective dose for shortest duration. 3, 4
For patients with impaired renal function:
Early NSAID administration is not associated with worsened renal outcomes or increased AKI progression in critically ill trauma patients, though this remains controversial. 5
Consider regional anesthesia techniques (thoracic epidural, paravertebral block, erector spinae block) for severe pain in patients with contraindications to systemic analgesics. 4
Critical Pitfalls to Avoid
Never assume absence of rib fractures rules out hepatic injury in right-sided trauma—right lower rib fractures show no strong association with liver injury, and hepatic laceration can occur without fractures. 1, 2
Do not dismiss a normal chest X-ray as excluding significant injury—fractures visible on radiography are associated with 3.8-fold increased pulmonary morbidity compared to CT-only detected fractures. 1
Lower your threshold for ICU admission in elderly patients, as mortality and morbidity increase dramatically with age and number of fractures. 1, 2
Do not order ultrasound as initial imaging despite its ability to detect fractures missed on X-ray, as it is time-consuming, causes patient discomfort, and rarely impacts clinical management. 2, 6
Avoid bone scintigraphy for acute trauma, as it cannot distinguish acute from chronic fractures and remains positive for up to 3 years after injury. 2, 7