Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures

Abstract

BackgroundChest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear.ObjectivesThe purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma.MethodsRetrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student’s t-test and chi-square analysis were used for comparison.ResultsWe identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest.ConclusionsThe chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study

“…However, in their study the diagnosis of rib fractures did not result in differences of the length of hospital stay, intensive care unit (ICU) admission rate or in-hospital mortality, which was remarkably higher-by 10.3%-in patients with CT-detected rib fractures [10]. Further studies on blunt trauma patients of every age have demonstrated that chest XR misses rib fractures and relevant intrathoracic injuries in blunt trauma patients of every age [27][28][29]. The proportion of undiagnosed rib fractures in chest XR ranges from 45% [29] to 74.5% (median three additional fractures in CT) [27].…”

“…Further studies on blunt trauma patients of every age have demonstrated that chest XR misses rib fractures and relevant intrathoracic injuries in blunt trauma patients of every age [27][28][29]. The proportion of undiagnosed rib fractures in chest XR ranges from 45% [29] to 74.5% (median three additional fractures in CT) [27]. Intrathoracic injuries have been CT-identified in 26% of the cases [28], leading to changes in clinical management in 8% [28], respectively 34.5% [27] of the cases.…”

“…The proportion of undiagnosed rib fractures in chest XR ranges from 45% [29] to 74.5% (median three additional fractures in CT) [27]. Intrathoracic injuries have been CT-identified in 26% of the cases [28], leading to changes in clinical management in 8% [28], respectively 34.5% [27] of the cases. Additionally, it has been demonstrated that mortality increases by 19% with each additional rib fracture in older patients with blunt trauma [30].…”

Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study

“…Thoracic CT imaging is superior to chest radiography. Approximately 75% of all rib fractures which are seen on chest CT are missed on radiography [36,37]. The low sensitivity is aggravated in the trauma setting because chest radiography is performed with the patient in the supine position.…”

Blunt chest trauma: is there a place for rib stabilization?

“…For example, Chapman et al (24) noted that plain films missed about 75% of fractures diagnosed by CT; this led to changes in clinical management in 35% of patients. Other studies have found similar results (25,26).…”