Six clinical scenarios that call for chest radiography
When a clinician suspects an isolated rib fracture, without additional injury, the protocol is often quite simple: treat the pain, not the break.1
But what if there’s more to the story — either because of a pathologic actor (e.g., a bone malignancy) or internal injury (e.g., organ damage)?
Those what ifs are why rib imaging has never been a black-and-white matter. Rather, it’s a spectrum of grays that may call for different diagnostic actions based on different factors, including a patient’s history, age, circumstances of injury, and presentation of symptoms.
The American College of Radiology (ACR) accounts for those factor-dependent variances in its ACR Appropriateness Criteria® for rib fractures. Notably, the imaging recommendation for minor blunt trauma differs from that of ribcage damage after cardiopulmonary resuscitation, which further differs from that of suspected stress fracture.2 Each of those wildly differs from blunt chest trauma, which has its own set of ACR protocols that often involve complementary exams pairing X-rays with computed tomography (CT) scans.3 With a ranging set of protocols, whether or not to perform an X-ray is a call that is dependent on the situation; these six clinical scenarios most often call for chest radiography in some form, either as X-ray alone or in tandem with other modalities like CT scans or ultrasounds.
1. When associated injuries and complications are unclear
The most common types of complications from broken ribs include pneumothorax (37.2 percent), hemothorax (26.8 percent), and pulmonary contusion (17.2 percent). Because rib fractures have been linked to a high rate of these types of associated injuries (as high as 94 percent, with up to 50 percent of them needing surgery)4, clinically confirming a rib fracture with a standard X-ray sequence can help properly diagnose patients so that they can get the correct interventions as early as possible.1
But prevention also plays a role. By confirming a rib fracture, clinicians can help prevent other complications like a collapsed lung — notably in cases of additional illness, like heart disease, chronic obstructive pulmonary disease, or chronic kidney disease.1
There’s an operational piece of that puzzle too. All told, complications and associated injuries linked with traumatic rib fractures can lead to lengthened hospital stays, more complex and costly procedures, and prolonged time spent in the intensive care unit.4 Quick diagnostic measures not only support the patient’s outcomes and progress, but also a hospital’s bottom line.
2. When there’s a legal component involved
As many as 60 percent of car crash victims who sustain several injuries have at least one broken rib. For legal reasons, a chest X-ray may be needed to confirm the severity of those injuries, inclusive of autopsies.5 Other traumatic circumstances may call for X-ray confirmation for legal reasons, including physical assault and abuse.1
3. When the fracture’s origin is unclear
Often, the types of associated injuries can depend on the location of the suspected rib fracture, which X-ray can identify if the patient’s symptoms alone can’t. The upper rib area (ribs 1-4) could indicate vascular or nerve damage, while the middle area (ribs 5-9) has been linked with contusions or lacerations of the lung, as well as hemothorax and pneumothorax. The lower area (ribs 10-12) has often shown correlations with abdominal organ damage.4
4. When the number of fractured ribs is unclear
Clinicians may be able to diagnose a single broken rib by presentation of localized chest pain.1 But in cases where there’s a suspected plurality (e.g., blunt trauma), X-ray can help practitioners diagnose with more accuracy. When more sensitivity is needed, CT scans can help too.6
That matters because the more fractured ribs a patient, adult or pediatric, has, the rate of mortality increases. For example, studies have shown that an adult’s risk of death increases significantly after six broken ribs, and in children, that risk climbs from nearly 6 percent for one rib fracture to more than 8 percent for seven rib fractures.7
5. When an underlying disease is known or suspected
For every three cases of a spontaneous rib fracture, one of them is due to metastatic disease, like breast cancer, spreading to the bones.8 Other conditions, like osteoporosis, can also weaken bones and lead to fractures.9
Whether the underlying disease is already known and diagnosed or simply suspected, X-ray can serve as a useful tool to spot rib fractures that could be linked to a pathologic cause.10 Occasionally, CT or ultrasonography can complement an X-ray in pathologic cases so that providers can get a clearer sense of the break’s characteristics.1
6. When a patient is elderly
A person’s risk of dying because of injuries sustained from a rib fracture goes up with old age, such as from falls, which are the most common reason for broken ribs in the elderly.11For example, one study showed that among those with major blunt trauma involving at least one broken rib, 17 percent of pediatric patients died, followed by 9 percent of adults, and 18 percent of elderly patients (i.e., patients over 65).4
To scan or not to scan?
Though chest radiographs have been considered controversial for broken ribs (due to a reported miss rate of 50 percent),11 the ACR's stance is clear: a physical exam plus a standard posterior anterior chest radiograph is the recommended frontline diagnostic measure for suspected rib fractures.2
Of course, the diagnostic insights gleaned from those scans may not drastically change the patient’s treatment plan; patients may still just be treated for their pain, after all.1 But if a simple, low-dose X-ray could spot underlying issues that could impact outcomes in a major way — it’s all the more worth it in the end.
1. When and how to image a suspected broken rib. Cleveland Clinic Journal of Medicine. https://www.mdedge.com/ccjm/article/95085/imaging/when-and-how-image-suspected-broken-rib. Accessed Dec. 21, 2018.
2. ACR Appropriateness Criteria® for Rib Fractures. American College of Radiology. https://acsearch.acr.org/docs/69450/Narrative/. Accessed Dec. 21, 2018.
3. ACR Appropriateness Criteria® for Blunt Chest Trauma. American College of Radiology. https://acsearch.acr.org/docs/3082590/Narrative/. Accessed Dec. 21, 2018.
4. Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment. RadioGraphics. https://pubs.rsna.org/doi/full/10.1148/rg.2017160100. Accessed Dec. 21, 2018.
5. Rib Fracture Imaging. Medscape. https://emedicine.medscape.com/article/395172-overview. Accessed Dec. 21, 2018.
6. Rib Fracture Workup. Medscape. https://emedicine.medscape.com/article/825981-workup#c7. Accessed Dec. 21, 2018.
7. No breakpoint for mortality in pediatric rib fractures. Journal of Trauma and Acute Care Surgery. https://www.ncbi.nlm.nih.gov/pubmed/26713973. Accessed Dec. 21, 2018.
8. Differentiating the Causes of Spontaneous Rib Fracture After Breast Cancer. Clinical Breast Cancer. https://www.ncbi.nlm.nih.gov/pubmed/27498118. Accessed Dec. 21, 2018.
9. Broken ribs. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/broken-ribs/symptoms-causes/syc-20350763. Accessed Dec. 21, 2018.
10. Finding Bone Metastases. American Cancer Society. https://www.cancer.org/treatment/understanding-your-diagnosis/advanced-cancer/finding-bone-metastases.html. Accessed Dec. 21, 2018.
11. Rib Fracture. Medscape. https://emedicine.medscape.com/article/825981-overview. Accessed Dec. 21, 2018.