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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
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. Observational-Dx 50 patients To compare accuracy and time efficiency of volume rendering compared to transverse images on MDCT to identify thoracic cage fractures. Patients with acute blunt chest trauma. 30/50 patients had 178 rib fractures. Mean sensitivity, specificity and accuracy for their detection were similar for transverse (96%, 100% and 99%) and volume rendering (98%, 100% and 100%) images. The time to read volume rendering images (106 seconds) was significantly reduced compared to the time needed for transverse image reading (167 seconds). 2
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. Review/Other-Dx 552 patients To identify the incidence of clinical and radiographically documented rib fractures, their impact on patient recovery. To assess the need for follow-up outpatient radiography for evaluation and treatment of clinical rib fractures. Patients with blunt thoracic trauma and clinical or objective evidence of a rib fracture examined over a 3-year period. 552 patients (28%) had rib fractures. 60% had fractures involving ribs four through ten. Associated pulmonary contusion (31.1%), pneumothorax (19.6%) and flail chest (5.3%) and 16.3% required a chest tube. 93% of patients with clinical rib fractures resumed daily activities without disability. Follow-up radiographs effected a change in treatment in only 2 cases. 4
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. Observational-Dx 233 patients To evaluate the accuracy of emergency physicians in interpreting rib radiographs and to determine if that interpretation resulted in any variance in treatment patterns. The overall chi2 calculation showed no differences between the fractured group and the no fracture group (P=.072). From this, it can be concluded that there were no between group differences in drugs prescribed based on whether a fracture was diagnosed by the ED physician. Indicating that the interpretation of the rib series does not influence the physicians treatment plan. 3
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. Review/Other-Dx 548 cases with rib fractures To explore the morbidity and mortality rates and the management following rib fractures. The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31). 4
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. Review/Other-Dx 27,855 trauma patients To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers. Mortality for elderly patients (aged>/=65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P<.001). Mortality rates increased with increasing numbers of RIBFs for both age groups and were always significantly higher in elderly trauma patients. The effect of PECs on patient mortality was inversely related to number of RIBFs and was most pronounced for patients with four or more RIBFs. Seven of 10 complications were more common in elderly patients despite lower mean+/-standard deviation Injury Severity Score (19.4+/-13.4 vs 23.2+/-14.2, P<.001). 4
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. Review/Other-Dx 105,683 patients Three or more rib fractures on initial CXR indicate a subset of patients with severe injury requiring trauma center care. 3 or more rib fractures compared to 2 or less rib fractures in patients 14 years of age and older had significant association with splenic and liver injury. With increased morbidity and mortality, 2.4% of these patients had 3 or more rib fractures. 4
7. American College of Radiology. ACR Appropriateness Criteria®: Blunt Chest Trauma. Available at: https://acsearch.acr.org/docs/3082590/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
8. Bencardino JT, Stone TJ, Roberts CC, et al. ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol 2017;14:S293-S306. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. No results stated in abstract. 4
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. Observational-Dx 39 patients with 204 rib fractures and 24 subjects with no fractures To assess the sensitivity and image quality of CXR with or without dual-energy subtracted bone images in the detection of rib fractures. The sensitivity for fracture detection using both methods was very similar (34.3% with standard CXR and 33.5% with energy subtracted-CXR, P=0.92). At the patient level, both sensitivity (71.8%) and specificity (92.9%) with or without energy subtracted were identical. Diagnostic confidence was not significantly different (2.61 with CXR and 2.75 with energy subtracted-CXR, P=0.063). Image quality with energy subtracted was rated higher than that on standard CXR (4.08 vs 3.74, P<0.001). 2
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. Observational-Dx 422 patients To investigate the utility of rib X-rays using turnaround time (TAT), radiation exposure, and cost-efficiency as the key parameters. Our investigation consisted of 422 patients, 208 females aged (57?±?20.8) and 214 males aged (48?±?17.3). A total of 74(17.5 %) abnormal findings were noted, out of which only 1(0.23 %) underwent management change. The mean turnaround time for patients undergoing rib series had a value of 133.5 (±129.8)?min as opposed to a single chest PA of 61.8(± 64)?min. Average effective radiation dose for a rib series was 0.105 (±0.04)?mSv, whereas average effective radiation dose of a single chest PA was 0.02 mSv. Dedicated rib series has a low-yield diagnostic value as it pertains to management change. The overall impact on patient care based on our findings is small when compared to the risks associated with prolonged TAT, repeated exposure to radiation, and extensive medical costs. 2
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. Observational-Dx 669 patients To asses the clinical relevance of rib fractures diagnosed by RS in minor thoracic trauma. We included 669 patients (61.4?% men, 38.6?% women, median age: 51 years, range: 13?-?92 years). Analyzing the reports of 669 patients who received RS, 157 (23.5?%) patients were diagnosed with at least one fractured rib while no fracture was found in 512 (76.5?%) patients. Considering the 157 patients with fractured ribs, 73 (46.8?%) had a single fracture, 38 (24.4?%) and two fractures and 45 (28.8?%) had more than two fractures. When assessing the 405 CRs, we detected 69 (17?%) fractures while the corresponding RS of the same patients revealed 87 (21.5?%) fractures (p?<?0.05). Concerning all patients with rib fractures, 63.1?% received medical therapy, while 64.5?% of those patients without a radiologically documented fracture also received therapy (p?=?0.25). 3
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. Observational-Dx 110 patients To assess whether inverted grayscale rib series, used alone or as an additional imaging modality, improves diagnostic accuracy of rib fractures of emergency medicine (EM) residents in minor chest trauma. For senior EM residents, there was no difference in sensitivity (P = .283) and accuracy (P = .888) between conventional rib series and the double-modality method. For junior EM residents and medical students, the double modality offered higher diagnostic sensitivity (P < .001, P = .001) and accuracy (P = .006, P = .002) than did conventional radiography. In cases with more than 3 rib fractures, who required specialist trauma care, the double modality provided greater sensitivity and accuracy among junior EM residents (P = .035 and P = .035, respectively) and medical students (P = .010, P = .010) than did conventional radiography. 1
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. Observational-Dx 36,39 participants To determine the proportion of patients with normal CXR result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. Of 3,639 participants, 2,848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% CI, 78.7–84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%–21.3%]) had CTs diagnosing injuries-primarily rib fractures, pulmonary contusion, and incidental pneumothorax. 12 patients had injuries classified as clinically major (2.0% [95% CI, 1.2%–3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%–16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%–4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%–91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%–17.6%]) had no injury on CT. 3
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. Observational-Dx 245 patients To determine whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. 2
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. Review/Other-Dx 288 patients The authors hypothesized CT evaluation of rib fracture number and patterns would provide a better prediction of respiratory failure and mortality after chest injury than the data derived from the initial CXR. 388 patients had >/=1 rib fracture. The mean (+/-standard deviation) age was 44 +/- 18. injury severity score was 21 +/- 11. Mortality was 6% (22 of 388). Sixty-three (16%) patients developed respiratory failure. The mean number of rib fractures per patient was four (range, 1-23); 21% of patients had one rib fracture and 17% had six or more fractures. 208 (54%) of the initial CXRs were read as having no rib fractures. The mean number of rib fractures per patient in this group was 3.1 (CI95 2.9-3.2). In 43% (179 of 388) of patients, the CT radiology report incorrectly identified the number and location of the fractured ribs. Of these reports, 72% (129 of 179) differed from the prospective review by more than one fracture. The number of fractures was higher in patients who died (7 +/- 5 vs. 4 +/- 3; p = 0.02) and in those developing respiratory failure (6 +/- 4 vs. 3 +/- 3; p = 0.02). Any rib fracture or pulmonary contusion visible on the initial plain CXR significantly increased the incidence of pulmonary morbidity or mortality. CT determination of fracture location had no effect on respiratory failure, pneumonia, or mortality when fractures were confined to one anatomic location. The presence of rib fracture in more than anatomic region doubled the incidence of respiratory failure (24% vs. 12%; p = 0.002) but had no effect on mortality. Logistic regression identified only injury severity score and presence of a parenchymal injury on plain CXR as independent predictors of subsequent respiratory failure. 4
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. Observational-Dx 385 patients To develop and validate a radiographic rib fracture scoring system based on computed tomographic chest findings. A total of 385 patients with one or more rib fractures were identified; 274 (71.2%) were males, median age was 48 years, and median Injury Severity Score (ISS) was 17. Of these patients, 156 had six or more rib fractures, 120 had bilateral fractures, 46 had flail chest, 32 had three or more severely displaced fractures, 91 had a first rib fracture, and 58 had fractures in all three anatomic areas. Each RibScore component variable was associated with the three pulmonary outcomes by univariate analysis (p < 0.05). The median RibScore was 1 (range, 0-6). The distribution of the RibScore was as follows: score of 0, 41.9%); score of 1, 23.9%; score of 2, 15.4%; score of 3, 9.9%; score of 4, 7.6%; and score of five, 1.3%. RibScore was linearly associated with pneumonia (p < 0.01), acute respiratory failure (p < 0.01), and tracheostomy (p < 0.01). The receiver operating characteristic areas under the curve for the outcomes were 0.71, 0.71, and 0.75, respectively. 2
17. Dubinsky I, Low A. Non-life-threatening blunt chest trauma: appropriate investigation and treatment. Am J Emerg Med. 1997;15(3):240-243. Review/Other-Dx 85 patients To investigate the usefulness of clinical criteria as indicators of rib or lung injury and to evaluate usefulness of CXR and rib radiographs in patients with non-life-threatening chest trauma. 12/45 patients who had radiographic studies had rib fractures but none of the 85 patients had significant organ injury and no difference in outcome between those with and those without fractures. 4
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. Observational-Dx 204 patients To evaluate first steps in trauma care to discover subgroups with greater chance of significant injury. In patients with low-energy impact and lower rib fractures: NPV for intra-abdominal organ injury was 100%. In patients with trauma and rib fractures: NPV of a negative reliable physical examination was 97%. 3
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. Observational-Dx 110 patients Compare patients to clarify whether injuries that are likely to be revealed by initial clinical and conventional radiological examination at the trauma bay meaningfully contribute to the prior probability of accompanying hepatic lesions in multiple injured patients. Prevalence of hepatic injury was 25.2%. Neither injury mechanism nor some accompanying injuries predicted the presence of hepatic injury. There are no index injuries that will reliably indicate the presence of liver involvement in multiple trauma cases. The absence of these injuries cannot rule out liver damage. 4
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. Observational-Dx 274 blunt aortic injury cases Prospectively conducted multi-center trial to obtain a large sample size over a short time span to dileneate present day management of blunt aortic injury in North American Trauma centers. There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. 3
21. Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Value of chest radiography in excluding traumatic aortic rupture. Radiology. 1987;163(2):487-493. Observational-Dx 205 patients To retrospectively review chest radiographs from patients with blunt chest trauma who also underwent aortography. 41 of the 205 had aortographically proved aortic rupture. Discriminant analysis of 16 radiographic signs indicated that the most discriminating signs were loss of the aorticopulmonary window, abnormality of the aortic arch, rightward tracheal shift, and widening of the left paraspinal line without associated fracture. No single or combination of radiographic signs demonstrated sufficient sensitivity to indicate all cases of traumatic aortic rupture on plain chest radiographs without the performance of a large number of aortographically negative studies. The bedside anteroposterior "erect" view of the chest proved far more valuable than the supine view in detecting true-negative studies. Despite significant reader variability in the interpretation of the various radiographic signs, in general the analysis confirmed the role of chest radiography in this clinical situation, but suggests that its most beneficial use is in excluding the diagnosis and eliminating unwarranted aortography rather than in predicting aortic rupture. 2
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. Observational-Dx 548 patients To determine whether significant correlation exists between thoracic skeletal injuries and traumatic aortic tear. No relevant correlation between thoracic fractures (ribs, clavicle, sternum, scapula, spine) and aortic injury. Need for aortography should be based on mechanism of injury and presence or absence of radiographic evidence of mediastinal hematoma. 3
23. Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg. 1994;57(3):726-730. Review/Other-Dx 530 motor vehicle fatalities revealed 105 aortic injuries in 90 victims. Five-year retrospective study of 530 motor vehicle fatalities to determine the injury patterns, circumstances, and mechanisms involved. In addition, the survival time, the driver's age and sex, the time of day of the accident, and the blood alcohol level were considered. The aortic injuries consisted of 61 transections and 44 tears (13% were multiple). Sixty-five percent of the injuries were located in the proximal descending aorta (66% of these were transections), 14% were in the ascending aorta and arch (33% of these were transections), 12% were in the distal descending aorta (more than 1 cm distal to the subclavian artery) (46% of these were transections), and 9% were in the abdominal aorta (56% of these were transections). Associated injuries consisted of multiple rib fractures (78%), liver lacerations (61%), head injuries (42%), first rib fractures (42%), splenic lacerations (36%), heart lacerations (34%), sternal fractures (28%), cervical spine fractures (26%), and thoracic spine fractures (20%). Death occurred within 1 hour in 94% and within 24 hours in 99%. The impact was head-on in 62% of the accidents. The victim was the driver 74% of the time and male in 77% of the cases, and the blood alcohol level exceeded 0.1 mg/dL in 43%. 4
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. Review/Other-Dx 185 patients To determine whether first- and second-rib fractures diagnosed on CT, which is of greater sensitivity than CXR for rib fractures, are associated with traumatic vascular injury. Incidence of major vessel injury was similar between patients with and without first- and/or second-rib fractures (7% vs 9%, respectively; P=0.59). No subset of type of rib fracture was associated with greater incidence of AI. First- and second-fractures are not associated with greater incidence of AI. Thus, the previous axiom that first- and second-rib fractures should result in increased examination for AI may not hold true. 4
25. Poole GV. Fracture of the upper ribs and injury to the great vessels. Surg Gynecol Obstet. 1989;169(3):275-282. Review/Other-Dx 1,347 patients Is there a greater incidence of aortic transection in patients with fractures of the first two ribs and should all of these patients have angiography? Risk of aortic transaction is not greater in patients with fractures of the first two ribs compared with patients with fractures of other ribs or with no rib fractures. 4
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. Observational-Dx 37 patients with minor blunt chest trauma and no evidence of fracture on radiography To assess the use of US in the evaluation of rib fractures in patients with minor blunt chest trauma. 15 patients (40.5%) had rib lesions; most commonly rib fracture with associated subperiosteal hematoma (66.7%), fracture of rib alone (26.7%), subperiosteal hematoma alone (6.7%). 53.3% had bony rib fractures and 46.7% had chondral rib fractures. 4
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. Review/Other-Dx 8 patients To describe the CT and sonographic appearance of 15 costal cartilage fractures observed in eight patients. On CT, fracture was seen as a low-density area through the costal cartilage, with surrounding calcifications present near old fractures, and gas density within the cleft in some cases. On sonography, cartilage fracture appeared as an interruption of the smooth anterior aspect of the cartilage. 4
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. Observational-Dx 50 patients To compare the sensitivities of sonography and radiography for revealing acute rib fracture. At presentation, radiographs revealed eight rib fractures in six (12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all reexamined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture. 3
29. Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures? Injury. 2004;35(6):562-566. Observational-Dx 14 patients Prospective study to determine the usefulness of US in the detection of rib fractures. US does not significantly increase the detection rate of rib fractures, may be uncomfortable for the patient and is too time-consuming to justify its routine use to detect rib fractures. 3
30. Harbert JC, George FH, Kerner ML. Differentiation of rib fractures from metastases by bone scanning. Clin Nucl Med. 1981;6(8):359-361. Review/Other-Dx 471 patients The intensity and appearance of rib lesions in serial bone scans were analyzed and reported. By analyzing the intensity and appearance of rib lesions in serial bone scans, it was concluded that there is a high probability that rib lesions detected by bone scanning are fractures if 1) they are focal as opposed to linear, and 2) they decrease in intensity within three to six months or they are aligned so as to involve two or more ribs in the same location. 4
31. Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med. 1979;20(12):1227-1231. Review/Other-Dx 204 patients To examine the use of bone scans in determining how the pattern of radioactive uptake changes with time, and how soon the scan of a fracture site returns to normal. The minimum time for a bone scan to become abnormal following fracture was age-dependent; however, 80% of all fractures were abnormal by 24 hr, and 95% by 72 hr, after injury. Three distinct temporally related phases were noted on bone scans as sequential studies showed a gradual return to normal. The minimum time for a fracture to return to normal on a bone scan was 5 mo. Approximately 90% of the fractures returned to normal by 2 yr after injury. 4
32. Shon IH, Fogelman I. F-18 FDG positron emission tomography and benign fractures. Clin Nucl Med. 2003;28(3):171-175. Review/Other-Dx 4 case reports To provide additional information regarding the appearance of benign fractures on FDG-PET images. In 3 of these cases, FDG uptake was noted in fractures when images were obtained 17 days to 8 weeks after injury, with the most avid uptake observed when FDG-PET imaging was performed 17 days after fracture. In the patient in whom imaging was performed 8 weeks after fracture, no uptake of FDG was seen in a benign fracture. 4
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. Observational-Dx 40 patients To evaluate the MDCT findings of chest injuries secondary to CPR, by comparing with the findings of radiography. MDCT revealed that 26 patients (65%) had rib fractures and 12 patients (30%) had sternal fractures. However, radiography detected only 10 patients who had rib fractures. In 25/26 cases, multiple ribs were fractured (ranging up to 13 rib fractures), and the rib fractures were bilateral in 18 of these cases. The majority of rib fractures were located in the anterior part of the thoracic cage. 6 of the patients had fracture-related complications (pneumothorax=1, subclavian vein injury=1, chest wall hematoma=4). The sternal fractures predominantly occurred in the middle and lower third of the sternal body (5 each for the middle and lower third of the sternal body). 2
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. Review/Other-Dx 19 patients Do findings of rib fracture on CXR correlate with post-mortem findings on patients who underwent CPR after out-of-hospital cardiac arrest? Patients with post-CPR radiography and post-mortem evaluation. Rib fractures diagnosed in 6/19 patients on radiography and in 17/19 patients at autopsy. A total of 12 rib fractures diagnosed at radiography vs 83 rib fractures diagnosed at autopsy. Most fractures were in the anterior part of the thoracic cage. 4
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. Meta-analysis 27 references To review relevant published pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries. The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression-decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries. Good
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. Observational-Dx 69 patients To describe pre-treatment imaging features of pathologic fractures caused by primary bone tumors (PBTs) and metastatic bone tumors (MBTs) and determine if radiographic or cross-sectional features can differentiate the underlying pathologies associated with the fractures. Compared to pathologic fractures caused by MBTs, the fractures caused by PBTs demonstrated a higher incidence of lytic bone cortex, mineralization and a soft-tissue mass on radiographs, mineralization and a soft-tissue mass on CT scans, and periosteal abnormality on MRI scans (P<0.01). These features also exhibited a high negative predictive value in supporting the diagnosis of an underlying PBT over MBT. 3
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. Observational-Dx 56 patients To compare conventional bone scintigraphy as an established skeletal staging procedure with PET using FDG in the detection of osseous involvement in malignant lymphoma. Of the 56 patients studied, 12 were found to have skeletal involvement on both studies (PET, 30 regions; bone scintigraphy, 20 regions). Findings were confirmed in all 12 patients. FDG PET detected an additional 12 involved regions in 5 patients. This was subsequently verified in 3 patients, although the other 2 cases remained unresolved. Conversely, bone scintigraphy revealed five abnormalities compatible with lymphoma in 5 patients. Three of these lesions were found to be erroneous; final evaluation of the remaining two findings was not possible. 2
38. Harris SR.. Differentiating the Causes of Spontaneous Rib Fracture After Breast Cancer. Clin Breast Cancer. 16(6):431-436, 2016 12. Review/Other-Dx N/A To provide an update on recent developments in understanding how to differentiate the possible reasons for non-traumatic rib fracture in women treated for breast cancer. Not results stated in abstract. 4
39. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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