American College of Radiology
ACR Appropriateness Criteria®

Rib Fractures

Variant 1: Suspected rib fractures from minor blunt trauma (injury confined to ribs). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
2 (12013289) 4
1 (15100544) 2
9 (20171819) 2
Radiography rib views May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
10 (24297110) 2
11 (24648235) 3
12 (25690384) 1
CT chest without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
25 (2672391) 4
24 (20549285) 4
23 (8147647) 4
22 (9314299) 3
21 (3562831) 2
20 (9095103) 3
19 (16261391) 4
18 (9282178) 3
17 (9148976) 4
16 (26683395) 2
15 (18404055) 4
14 (27389132) 2
13 (23796979) 3
Tc-99m bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (12592121) 4
31 (536788) 4
30 (7261514) 4
CT chest with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
13 (23796979) 3
15 (18404055) 4
2 (12013289) 4
4 (12853057) 4
18 (9282178) 3
19 (16261391) 4
20 (9095103) 3
21 (3562831) 2
22 (9314299) 3
23 (8147647) 4
24 (20549285) 4
25 (2672391) 4
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
25 (2672391) 4
24 (20549285) 4
23 (8147647) 4
22 (9314299) 3
21 (3562831) 2
20 (9095103) 3
19 (16261391) 4
18 (9282178) 3
17 (9148976) 4
16 (26683395) 2
15 (18404055) 4
14 (27389132) 2
13 (23796979) 3
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
28 (10584808) 3
26 (14500082) 4
27 (11159088) 4
29 (15135274) 3
Variant 2: Suspected rib fractures after cardiopulmonary resuscitation (CPR). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
35 (24525116) Good
33 (21705131) 2
34 (15036733) 4
Radiography rib views May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 2 2 5 3 0 0 0 0
References Study Quality
33 (21705131) 2
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
33 (21705131) 2
Tc-99m bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
28 (10584808) 3
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
33 (21705131) 2
Variant 3: Suspected pathologic rib fracture. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
36 (23017193) 3
37 (10492357) 2
38 (27498118) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
36 (23017193) 3
Tc-99m bone scan whole body Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
30 (7261514) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
36 (23017193) 3
37 (10492357) 2
Radiography rib views May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
36 (23017193) 3
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
36 (23017193) 3
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.