Imaging In Practice

When and how to image a suspected broken rib

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ABSTRACTRadiographic confirmation of rib fracture is often clinically irrelevant in patients who appear to have no complications or associated injuries. However, it is essential in a number of cases, especially when the clinical presentation and history raise suspicion of complications such as organ damage, or if the patient has other risk factors or conditions for which the precise information would help in management decisions. The authors discuss when to order imaging and which imaging test to order.

KEY POINTS

  • Knowing the number of ribs fractured may influence treatment decisions, such as whether to transfer a patient to a trauma center.
  • Classic clinical signs and symptoms of rib fracture include point tenderness, focally referred pain with general chest compression, splinting, bony crepitus, and ecchymosis.
  • In a patient with minor blunt trauma, when there is little suspicion of associated injury or complication, plain radiography is likely sufficient.
  • Computed tomography is the imaging study of choice in patients with penetrating or major chest or abdominal trauma.


 

References

A 70-year-old man falls in his bathroom and subsequently presents to an urgent care clinic. Among his complaints is right-sided chest pain. On physical examination he has point tenderness over the lateral right thorax with some superficial swelling and bruising. The chest is normal on auscultation.

Should this patient undergo imaging to determine if he has a rib fracture? And which imaging study would be appropriate?

This article outlines the use of various imaging tests in the evaluation of suspected rib fractures and recommends an approach to management. This article does not address fractures in children.

MANY CAUSES OF RIB FRACTURES

Trauma, the most common cause of rib fractures, includes penetrating injuries and blunt injury to the chest wall. Between 10% and 66% of traumatic injuries result in rib fractures. 1 Traumatic injury can result from motor vehicle accidents, assault, sports, cardiopulmonary resuscitation, physical abuse (“nonaccidental” trauma), and, rarely, severe paroxysms of coughing.2

Cancer can cause pathologic fractures of the rib.

Stress fractures of the ribs are more likely to occur in high-level athletes whose activity involves repetitive musculoskeletal loading, although they can also occur in people with repetitive coughing paroxysms.3 Sports and activities that result in stress fractures include rowing, pitching or throwing, basketball, weight-lifting, ballet, golf, gymnastics, and swimming.4

WHICH RIB IS BROKEN?

The fourth through 10th ribs are the most often fractured. Fractures of the first through the third ribs can be associated with underlying nerve and vascular injuries, and fractures of the 10th through 12th ribs are associated with damage to abdominal organs,5 most commonly the liver, spleen, kidneys, and diaphragm.3

Fractures of the costal cartilage can occur by any of the mechanisms described above. The true incidence of costal cartilage fractures is not known because plain radiography, the traditional method of evaluation, does not reliably detect them.

WHY CONFIRM A RIB FRACTURE?

For many rib fractures without associated injury, a radiographic diagnosis has little impact on patient management, which consists mainly of pain control. But knowing whether a patient has a broken rib can often be important.

To detect associated injury. The rate of associated injury in patients with rib fractures is high.6 Potentially severe complications include:

  • Pneumothorax
  • Hemothorax
  • Pulmonary contusion
  • Flail chest
  • Pneumonia
  • Vascular and nerve damage (especially with trauma to the upper chest or the first through third ribs)
  • Abdominal organ injury (particularly with trauma to the lower thorax or lower ribs).

The absence of a rib fracture does not preclude these conditions, however.

To prevent complications. Even in the absence of associated injuries, radiographic confirmation of a rib fracture can help prevent complications such as atelectasis and is particularly important in patients with comorbidities such as chronic obstructive pulmonary disease, cardiac disease, hepatic disease, renal disease, dementia, and coagulopathy.1

To document the injury. Radiographic documentation of a rib fracture may be required for medical-legal issues in cases of assault, motor vehicle accident, occupational injury, and abuse.

To help manage pain. Confirmation of rib fracture can facilitate pain management, particularly in patients with undiagnosed fractures with long-standing refractory pain. For example, conservative pain control with nonsteroidal anti-inflammatory drugs may be sufficient for a soft-tissue injury but may not be enough for a rib fracture. Intravenous narcotics or nerve blocks might be preferable.3,7 Controlling pain helps limit the incidence of associated complications.

Figure 1. Oblique radiographic view shows an acute rib fracture in a patient with multiple myeloma.

To detect pathologic fractures. Radiographic diagnosis can provide important information in cases of suspected pathologic fracture, as in multiple myeloma (Figure 1) or other malignancies.

To count how many ribs are broken. The more ribs broken, the greater the likelihood of illness and death in certain populations, such as the elderly. One study8 found that patients over age 45 with more than four broken ribs are at a significantly higher risk of prolonged stay in the intensive care unit, prolonged ventilator support, and prolonged overall hospital stay.

Knowing the number of ribs fractured may also influence other treatment decisions, such as whether to transfer the patient to a trauma center: a study showed that the more ribs broken, the greater the death rate, and that more than three rib fractures may indicate the need to transfer to a trauma center.6

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