What X-ray View Should I Request for Ribs
Order a standard posteroanterior (PA) chest radiograph—do not order dedicated rib series, as they provide no additional clinical benefit and negatively impact patient care by prolonging report turnaround time. 1
Primary Imaging Recommendation
A PA chest X-ray is the only initial imaging you need for suspected rib injury, as it detects the life-threatening complications (pneumothorax, hemothorax, flail chest, pulmonary contusion) that carry greater clinical significance than the fractures themselves. 1, 2
The PA view will miss approximately 50% of rib fractures, but this does not alter patient management or outcomes in uncomplicated cases—the goal is detecting organ injuries, not counting every fracture. 2, 3
Why Dedicated Rib Views Are Not Recommended
Dedicated rib series should never be ordered as they resulted in a change of management in only 0.23% of patients (1 out of 422) in emergency department studies. 1
Rib series prolong report turnaround time and negatively impact patient care compared to standard PA radiographs, while diagnosing more fractures that don't change treatment decisions. 1
Even when rib series detect higher numbers of fractures compared to PA radiographs alone, there is no statistically significant difference in the number of patients who receive medical treatment. 1
When to Add a Lateral View
- Consider adding a lateral chest X-ray if the PA view shows abnormalities requiring better anatomic localization, as lateral views can detect posterior pleural-based opacities and fluid collections not clearly visible on frontal views. 4
When to Escalate to CT Imaging
Order non-contrast chest CT when you need precise anatomic definition for management decisions: ≥6 fractures, bilateral fractures, ≥3 severely displaced fractures, or suspected flail chest. 2
Order contrast-enhanced chest CT for high-energy mechanisms (motor vehicle collision >35 mph, significant fall height) with clinical suspicion for intrathoracic vascular injury or intra-abdominal injury. 2
Order contrast-enhanced CT for lower rib fractures (ribs 7-12) with multiple injuries, as 67% have associated abdominal organ injury even with normal physical examination. 2
Critical Clinical Context
Any rib fracture or pulmonary contusion visible on the initial PA chest X-ray significantly increases pulmonary morbidity risk (odds ratio 3.8), making the screening chest X-ray a better predictor of subsequent complications than CT-detected fractures. 3
Patients ≥65 years with multiple rib fractures require ICU admission due to dramatically increased mortality and morbidity from poor cardiopulmonary reserve. 2
Common Pitfalls to Avoid
Do not assume a normal chest X-ray excludes significant injury—fractures visible on radiography are associated with 3.8-fold increased pulmonary morbidity compared to CT-only detected fractures. 2, 3
Do not order oblique rib views (45° or 30° projections) as routine imaging—while research suggests 45° oblique views on expiration may improve fracture detection, these are not recommended in current ACR guidelines and do not change management. 5
Do not rely on absence of rib fractures to rule 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. 2