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## Complete Summary

#### GUIDELINE TITLE

Rib fractures.

#### BIBLIOGRAPHIC SOURCE(S)

Rosado de Christenson ML, Davis SD, Goodman PC, Haramati LB, Khan A,
Leung AN, McLoud TC, Rozenshtein A, White CS, Kaiser LR, Expert Panel on
Thoracic Imaging. Rib fractures. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2005. 5 p. \[30 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version:  Westcott J, Davis SD,
Fleishon H, Gefter WB, Henschke CI, McLoud TC, Pugatch RD, Sostman HD,
Tocino I, White CS, Yankelevitz D, Bode FR, Goodman N. Rib fractures.
American College of Radiology. ACR Appropriateness Criteria. Radiology.
2000 Jun;215 Suppl:637-9.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Rib fractures

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Pediatrics\
Pulmonary Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with possible rib fractures

#### TARGET POPULATION

Patients with possible rib fractures

#### INTERVENTIONS AND PRACTICES CONSIDERED

X-ray (chest or rib views)

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examination in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders with in a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Injury, Possible Rib Fracture**

**Variant 1: Adult: \<65 years old.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         8                    

  X-ray, rib views     2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

**Variant 2**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         8                    

  X-ray, rib views     5                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

**Variant 3: Children.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                    

  X-ray, rib views     8                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Rib fracture is the most common thoracic injury and is thought to be
present in 10% of all traumatic injuries and in almost 40% of patients
who sustain severe non-penetrating trauma. Rib fractures typically
affect the fifth through ninth ribs. This may be due to the fact that
the shoulder girdle affords relative protection to the upper ribs and
the lower ribs are relatively mobile and may deflect before fracturing.
Neither clinical examination nor radiography is ideal for the diagnosis
of rib fractures. While rib fractures can produce significant morbidity,
the diagnosis of associated complications (such as pneumothorax,
hemothorax, pulmonary contusion, atelectasis, flail chest,
cardiovascular injury, and injuries to solid and hollow abdominal
organs) may have a more significant clinical impact. Radiographs are
specific but not very sensitive (for undisplaced fractures), and
clinical examination is sensitive but not specific.

Multidetector computed tomography (MDCT) is increasingly used as the
method of choice for the radiologic evaluation of the traumatized
patient. It provides an accurate assessment of fractures and associated
internal injuries. Computed tomography (CT) also provides an accurate
means of assessing cartilage fractures, which are typically missed on
radiography. However, such studies result in a large number of images
that must be viewed at several window settings (lung, soft tissue,
bone).

Post-processing techniques such as volume rendered display may depict
rib fractures with high accuracy and may provide a more time-efficient
method of evaluation compared to the sequential evaluation of numerous
axial images. It should be noted that 3D image processing often requires
a second console or workstation. One study compared sonography and
radiography (chest radiography plus one oblique rib radiograph) in 50
patients and found that radiographs detected only 8 of 83 (10%) of
sonographically detected rib fractures and were positive in only 6 of
the 39 patients who had demonstrated fractures. In this study,
sonography allowed evaluation of the costochondral junction, the costal
cartilage, and the ribs and was able to show non-displaced fractures.
However, the procedure is time consuming, may be difficult to perform in
uncooperative patients and may be limited by body habitus and the fact
that retroscapular and infraclavicular portions of the rib are not
accessible. Another study found rib fractures in 40.5% of 37 patients
with minor blunt chest trauma and negative radiographs by using
ultrasound; osseous fractures were more common in the elderly, and
duration of pain was significantly longer in these patients compared to
those with chondral injuries. Sonography of cartilage fractures
typically demonstrates an interruption of the smooth anterior surface of
the cartilage. CT imaging of such fractures typically shows a
low-density line through the cartilage, and surrounding calcification
may be evident in old fractures. In a study of 552 patients who had
blunt chest trauma and resultant rib fracture (diagnosed on clinical or
radiographic grounds), 93% of affected patients ultimately resumed daily
activities without significant disability. The authors also evaluated
the use of routine radiographic follow-up for these patients and
concluded that it is not useful in the absence of clinical
deterioration.

Certain types of rib fractures are associated with an increased
incidence of various organ injuries. There is increased likelihood for
injury to the adjacent subclavian and innominate vessels with displaced
first and second rib fractures, but this injury can usually be suspected
on clinical grounds or from the chest radiographic abnormalities. Lower
rib fractures are frequently associated with upper abdominal organ
injury. Multiple fractures (three or more) are associated with an
increased incidence of pneumothorax, hemothorax, abdominal organ injury,
and mortality. However, there is no evidence that the presence, absence,
or number of fractures directly influences the diagnostic approach and
treatment. Suspicion based on the mechanism and severity of injury and
physical examination should lead to observation or abdominal CT for
verification. One study reported that the negative predictive value for
abdominal organ injury with lower rib fractures due to low energy impact
was 100%; with lower rib fractures in the setting of a reliable negative
physical examination, negative predictive value was 97%. Based on a
study of 69 patients with non-threatening trauma (stable vital signs
with no evidence of cardiac injury, solid or hollow viscus rupture, or
fractures associated with significant blood loss), the authors concluded
that neither rib studies nor even chest radiographs were of clinical
benefit.

Early literature stressed rib fractures (especially of the first and
second ribs) as predictors for aortic injury, but several studies have
demonstrated no increased likelihood of aortic injury with upper rib
fractures, nor with the presence of multiple fractures. In a recent
study of 548 patients who underwent aortography, the authors reported
that fractures of the clavicle, sternum, scapula, and thoracic spine had
no positive predictive value for aortic injury, and that rib fractures
had a very weak positive predictive value (thoracic spine fractures
actually had a negative predictive value for aortic injury).

A flail chest can usually be diagnosed at physical examination. It is
conceivable that in a heavy patient, a flail chest could be missed by
clinical examination. However, a chest radiograph almost always shows
the displaced fragments.

One study showed that rib fractures are underreported on radiography
performed following cardiopulmonary resuscitation (CPR). These fractures
are more common on the left side and are more numerous in the elderly.
The diagnosis of such fractures on CPR survivors is important.
Approximately half of CPR survivors with rib fractures experience
complications, and the presence of rib fractures in these patients may
impair ventilation and compromise recovery. It should be noted that many
of these patients are examined with portable supine radiography, which
may contribute to underdiagnosis.

The presence and number of rib fractures do carry prognostic
significance, and detection of rib fractures in children and adults may
be indicated under certain circumstances. Rib fractures are associated
with pulmonary dysfunction (atelectasis, shunting, impairment of
clearance of secretions, pneumonia, adult respiratory distress
syndrome). Treatment of rib fractures is aimed at pain control and
avoidance of respiratory distress and intubation. Mortality is increased
in patients with three or more fractures, particularly the elderly as
they may have additional comorbid conditions that contribute to poor
cardiopulmonary reserve (65 years or age or older). The diagnosis of
multiple fractures in an elderly patient may warrant his/her transfer
from a community hospital to a tertiary care center.

Children younger than 14 years of age have more compliant rib cages than
adults. The presence of rib fracture(s) therefore indicates that the
child\'s chest has sustained significant trauma. Such fractures
frequently occur at the costovertebral and costochondral junctions and
may be difficult to identify on standard chest and rib radiographs. One
study reported 14 deaths in 33 children with more than one rib fracture.
Although thoracic injury accounted for only 1.6% of 2,080 injuries in
their study, it led to 25% of the deaths.

Rib fractures may account for 5 to 27% of all skeletal injuries in
abused children. In this population, rib fractures may be diagnosed
during the evaluation of infants who present for a variety of complaints
unrelated to rib fractures such as respiratory problems, seizures, and
mental status changes. Although rib fractures are uncommon in infants,
they frequently indicate abuse and are thought to result from
anterior-posterior chest compression associated with shaking. Thus, the
majority are located in the posterior rib near the costovertebral
junction, although the mechanism of injury may also result in lateral
and anterior rib fractures. First rib fractures in infants are
considered virtually diagnostic of abuse. It should be noted that
posterior rib fractures may occur as a result of birth trauma and that
rib fractures unassociated with non-accidental trauma (NAT) may occur in
very low birth weight infants, premature infants and infants with
disease processes that cause increased bone fragility such as
osteogenesis imperfecta and rickets, but are extremely rare in the
setting of CPR. One study reported a strong association between rib
fractures and NAT in children under the three years of age with a high
positive predictive value of a rib fracture as an indication of NAT,
particularly when other causes of fracture are excluded based on history
and clinical exam. The study suffers from errors in statistical analysis
but highlights the importance of skeletal imaging in the diagnosis of
NAT in children under the age of three. In patients with suspected NAT,
bone scintigraphy may complement radiography in the recognition of
fractures undetected by radiography.

Radiographically occult nondisplaced (\"stress\") rib fractures may
result from severe coughing. Nuclear scintigraphy and chest CT may be
employed to diagnose these injuries. While scintigraphic findings are
nonspecific, CT may demonstrate the fracture, fracture-related
osteosclerosis or osteolysis, or callus formation. More importantly,
metastatic of primary neoplasia may be successfully excluded.

Nuclear medicine skeletal scintigraphy may result in false-positive
diagnosis of malignancy in patients with rib fractures. In addition,
patients with known malignancy and benign rib fractures may exhibit
false-positive findings on fluorodeoxyglucose-positron emission
tomography (FDG-PET) studies performed 17 days to 8 weeks after injury.

In summary, it is usually unnecessary to perform dedicated rib
radiography (in addition to chest radiography) for the diagnosis of
fractures in adults, because CT is almost always used to evaluate
potential organ injury in patients with significant chest and upper
abdominal trauma. Although the diagnosis of multiple fractures has
prognostic implications, there is no evidence that performing rib
studies is beneficial (as opposed to performing other diagnostic
procedures to evaluate the presence or absence of internal organ
injury). An exception is the evaluation of a child in whom abuse is
suspected; extended examination is warranted because of the high
association of certain rib fractures with abuse and the difficulty of
identifying such fractures with standard chest radiography. In these
cases, scintigraphy may be useful as a complementary imaging study for
diagnosing fractures not detected by radiography. Another possible
exception is to establish the diagnosis of multiple fractures in the
elderly if such information is to be used clinically to determine the
need for tertiary or intensive care. A recent study suggests that
sonography is much more sensitive than radiography for situations in
which identification of rib fractures is clinically important. CT,
skeletal scintigraphy and ultrasound may be helpful in evaluating
selected patients with occult \"stress\" fractures and in evaluating
selected CPR survivors.

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with possible rib fractures

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (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
radiologist, radiation oncologist, 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 exams 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
U.S. Food and Drug Administration (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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Rosado de Christenson ML, Davis SD, Goodman PC, Haramati LB, Khan A,
Leung AN, McLoud TC, Rozenshtein A, White CS, Kaiser LR, Expert Panel on
Thoracic Imaging. Rib fractures. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2005. 5 p. \[30 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Melissa L. Rosado de Christenson, MD (*Review Author*);
Sheila D. Davis, MD (*Panel Chair*); Philip C. Goodman, MD; Linda B.
Haramati, MD; Arfa Khan, MD; Ann N. Leung, MD; Theresa C. McLoud, MD;
Anna Rozenshtein, MD; Charles S. White, MD; Larry R. Kaiser, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version:  Westcott J, Davis SD,
Fleishon H, Gefter WB, Henschke CI, McLoud TC, Pugatch RD, Sostman HD,
Tocino I, White CS, Yankelevitz D, Bode FR, Goodman N. Rib fractures.
American College of Radiology. ACR Appropriateness Criteria. Radiology.
2000 Jun;215 Suppl:637-9.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/RibFracturesDoc5.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 6, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008