Rib Fractures

Variant: 1 Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
Radiography rib views	May Be Appropriate	☢☢☢
US chest	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
Radiography rib views	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
US chest	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Suspected pathologic rib fracture. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
Bone scan whole body	Usually Appropriate	☢☢☢
CT chest without IV contrast	Usually Appropriate	☢☢☢
Radiography rib views	May Be Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
US chest	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
A. Radiography Chest

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
B. Radiography Rib Views

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
C. CT Chest

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
D. US Chest

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
E. Bone Scan Whole Body

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
A. Radiography Chest

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
B. Radiography Rib Views

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
C. US Chest

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
D. Bone Scan Whole Body

Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
E. CT Chest

Variant 3: Suspected pathologic rib fracture. Initial imaging.

Variant 3: Suspected pathologic rib fracture. Initial imaging.
A. Radiography Chest

Variant 3: Suspected pathologic rib fracture. Initial imaging.
B. Radiography Rib Views

Variant 3: Suspected pathologic rib fracture. Initial imaging.
C. US Chest

Variant 3: Suspected pathologic rib fracture. Initial imaging.
D. CT Chest

Variant 3: Suspected pathologic rib fracture. Initial imaging.
E. Bone Scan Whole Body

Variant 3: Suspected pathologic rib fracture. Initial imaging.
F. FDG-PET/CT Skull Base to Mid-Thigh

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Alkadhi H, Wildermuth S, Marincek B, Boehm T. Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images. J Comput Assist Tomogr. 2004;28(3):378-385.
2.	Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources? Am Surg. 2002;68(5):449-453.
3.	Davis S, Affatato A. Blunt chest trauma: utility of radiological evaluation and effect on treatment patterns. Am J Emerg Med. 2006; 24(4):482-486.
4.	Sirmali M, Turut H, Topcu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133-138.
5.	Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF, 3rd. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004;52(5):805-808.
6.	Lee RB, Bass SM, Morris JA, Jr., MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. 1990;30(6):689-694.
7.	American College of Radiology. ACR Appropriateness Criteria®: Blunt Chest Trauma. Available at: https://acsearch.acr.org/docs/3082590/Narrative/.
8.	Bencardino JT, Stone TJ, et al. ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol. 2017 May;14(5S):S1546-1440(17)30218-1.
9.	Szucs-Farkas Z, Lautenschlager K, Flach PM, et al. Bone images from dual-energy subtraction chest radiography in the detection of rib fractures. Eur J Radiol. 2011;79(2):e28-32.
10.	Shuaib W, Vijayasarathi A, Tiwana MH, Johnson JO, Maddu KK, Khosa F. The diagnostic utility of rib series in assessing rib fractures. EMERG. RADIOL.. 21(2):159-64, 2014 Apr.
11.	Hoffstetter P, Dornia C, Wagner M, et al. Clinical significance of conventional rib series in patients with minor thoracic trauma. Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 186(9):876-80, 2014 Sep.ROFO Fortschr Geb Rontgenstr Nuklearmed. 186(9):876-80, 2014 Sep.
12.	Park JB, Cho YS, Choi HJ. Diagnostic accuracy of the inverted grayscale rib series for detection of rib fracture in minor chest trauma. American Journal of Emergency Medicine. 33(4):548-52, 2015 Apr.
13.	Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?. American Journal of Emergency Medicine. 31(8):1268-73, 2013 Aug.
14.	Bugaev N, Breeze JL, Alhazmi M, et al. Magnitude of rib fracture displacement predicts opioid requirements. J Trauma Acute Care Surg. 81(4):699-704, 2016 Oct.
15.	Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of Rib fractures and the prediction of acute respiratory failure. J Trauma. 2008;64(4):905-911.
16.	Chapman BC, Herbert B, Rodil M, et al. RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. The Journal of Trauma and Acute Care Surgery. 80(1):95-101, 2016 Jan.
17.	Dubinsky I, Low A. Non-life-threatening blunt chest trauma: appropriate investigation and treatment. Am J Emerg Med. 1997;15(3):240-243.
18.	Schurink GW, Bode PJ, van Luijt PA, van Vugt AB. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury. 1997;28(4):261-265.
19.	Matthes G, Stengel D, Bauwens K, et al. Predictive factors of liver injury in blunt multiple trauma. Langenbecks Arch Surg. 391(4):350-4, 2006 Aug.
20.	Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma. 1997;42(3):374-380; discussion 380-373.
21.	Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Value of chest radiography in excluding traumatic aortic rupture. Radiology. 1987;163(2):487-493.
22.	Lee J, Harris JH Jr, Duke JH Jr, Williams JS. Noncorrelation between thoracic skeletal injuries and acute traumatic aortic tear. J Trauma. 43(3):400-4, 1997 Sep.
23.	Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg. 1994;57(3):726-730.
24.	Khosla A, Ocel J, Rad AE, Kallmes DF. Correlating first- and second-rib fractures noted on spine computed tomography with major vessel injury. Emerg Radiol. 2010;17(6):461-464.
25.	Poole GV. Fracture of the upper ribs and injury to the great vessels. Surg Gynecol Obstet. 1989;169(3):275-282.
26.	Kara M, Dikmen E, Erdal HH, Simsir I, Kara SA. Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma. Eur J Cardiothorac Surg. 2003;24(4):608-613.
27.	Malghem J, Vande Berg B, Lecouvet F, Maldague B. Costal cartilage fractures as revealed on CT and sonography. AJR Am J Roentgenol. 2001;176(2):429-432.
28.	Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. AJR Am J Roentgenol. 2001;176(2):429-432.
29.	Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures? Injury. 2004;35(6):562-566.
30.	Harbert JC, George FH, Kerner ML. Differentiation of rib fractures from metastases by bone scanning. Clin Nucl Med. 1981;6(8):359-361.
31.	Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med. 1979;20(12):1227-1231.
32.	Shon IH, Fogelman I. F-18 FDG positron emission tomography and benign fractures. Clin Nucl Med. 2003;28(3):171-175.
33.	Kim EY, Yang HJ, Sung YM, et al. Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2011;82(10):1285-1288.
34.	Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray. Resuscitation. 2004;60(2):157-162.
35.	Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. [Review]. Resuscitation. 85(6):724-31, 2014 Jun.
36.	Soldatos T, Chalian M, Attar S, McCarthy EF, Carrino JA, Fayad LM. Imaging differentiation of pathologic fractures caused by primary and secondary bone tumors. Eur J Radiol. 82(1):e36-42, 2013 Jan.
37.	Moog F, Kotzerke J, Reske SN. FDG PET can replace bone scintigraphy in primary staging of malignant lymphoma. J Nucl Med. 1999;40(9):1407-1413.
38.	Harris SR.. Differentiating the Causes of Spontaneous Rib Fracture After Breast Cancer. Clin Breast Cancer. 16(6):431-436, 2016 12.
39.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.