Imaging of Rib Fractures


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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Stephen R. -

Great piece, thanks! You mentioned the risk of intra-abdominal trauma with lower rib fractures but didn't really elaborate on it. I find myself talking myself into abdominal CTs with lower rib fractures, especially in setting of anticoagulation. Am I going overboard as usual? Is a FAST enough?

Matthew O. -

Hi Folks,

Great segment thank you. I'm the trauma director for our hospital and have put together our chest injury protocol. I find it really hard to work out when to get CT imaging, so this talk was useful. A few comments/questions:

1. I find the hardest part of the NEXUS chest CT decision aid is the "chest wall tenderness". Wouldn't anyone with rib fractures have chest wall tenderness and therefore meet the criteria to get scanned?
Obviously, this then comes to clinician judgement. But my protocol is for everyone to use esp. more junior staff, and so I haven't incorporated the decision instrument into our protocol for that reason. Otherwise, everyone would be scanned.

2. You mention the low mechanism group of ground-level falls not needing imaging. But in our experience, this accounts for a significant proportion of our trauma population, the elderly!!
I think 'all bets are off' for this group as they can have some serious injuries from low energy trauma, especially the more frail patients. For this reason, I advocate scanning most elderly/frail patients with blunt chest trauma. The M+M in this patient group is incredibly high. This is a great paper on the topic (
(FYI serratus anterior block is great for these patients.. we think... hopefully, some evidence coming soon!)

3. The use of FAST to rule out solid organ injury is fairly controversial here. Whilst I understand the point, the FAST scan was never intended for clinically 'stable' patients. But we do them all the time anyway (for practice and for triage of the CT scan). But with the true use of FAST, you are looking for free fluid and not intraparenchymal injury to the liver and spleen. Therefore, it may be worth having a lower threshold for CT esp if the patient has LUQ or RUQ tenderness, anticoagulated, elderly or slightly abnormal vitals/labs. (again clinician judgement)

Thanks again for the talk, a great topic of discussion.

p.s. looking forward to seeing you guys in LA in April!!


Matt Oliver
Sydney, Australia

Josiah H. -

Your #1 point is exactly my thoughts. Both of the NEXUS Chest decision tools mentioned seem to be designed for use starting with ONLY a history of blunt chest trauma. However, if we're already suspecting a rib fracture, that kind of assumes we've got the blunt force Hx + chest wall pain + tenderness. These findings flip both calculators ("consider CT" and "CT indicated"). Also, neither tool provides a risk stratification based on number of positive factors. Am I missing something or are these tools useless for suspected rib fracture?
I'm all for using adjuncts and tools when appropriate, I'm just confused as to the appropriateness here.

Matthew C. -

I also had questions about the NEXUS criteria for the elderly specifically. My understanding is that there is a significantly higher mortality in this population if a rib fracture is present; if only a CXR is done which we know will miss a significant portion of these fractures, is there any data suggesting that it is safe to manage this specific population as an outpatient if no rib fracture is seen on CXR? Wouldn't a CT scan showing the rib fracture that you suspect but can't see on CXR change management/dispo for these patients? I'm curious as to your thoughts.

Dallas H. -

Hard disagree with comments about US for rib fracture. There's very little utility in imaging every single rib the entire length, that's a radiology take, not a POCUS take. POCUS for rib fracture is much simpler and is very easy to learn. Don't scan the entire chest, instead, have the patient point to the maximal area of tenderness. Perform a forcised scan in that region. It's highly unlikely the patient will have painless rib fractures (and if they did, who would really care since the main problem is pain). One could argue if they had significant other distracting injuries they might not be able to localize but in that scenario, CT is likely to be involved.

Jess Mason -

These are good thoughts. If I were to attempt ultrasound I would put the probe right where the patient points. But I would not rely on my ultrasound for the diagnosis! I know in some parts of the world ultrasound is the go-to modality, so including the pros and cons of ultrasound and full technique in the segment was important to me.

jeff g. -

Love EMRAP for advocating evidence based medicine but a little disappointed in the conclusion that rib views can be ordered if it makes the physician more comfortable. Increased radiation to the pt, increased cost, increased repositioning and time for a patient that is already uncomfortable, and increased technician time to complete (as if their time is not in demand for other things) make the physician more comfortable? pfft.

Ali Raja, MD -

Jeff, this is a great comment. I'm right there with you in terms of not ordering rib views, and I hope my preference and the evidence came through in the piece. But the fact is that some of the physicians I've spoken to who are reading films on their own in the middle of the night aren't comfortable discharging patients without the rib views and would - otherwise - order a chest CT (which would lead to even more cost/time than the rib series you note above).

Thanks for the comment though - I appreciate the time you took to write it.

Jess Mason -

I think it’s important to recognize the context of the study. If it’s done in an academic center with radiologists interpreting plain films 24/7 this is not the same environment that a lot of us work in, so it’s not necessarily applicable. It’s cool to see so many people engaged with this piece and having their own opinions and practice. Good topic!

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