Rib Fracture Diagnosis in the Panscan Era

Murphy, Charles E.; Raja, Ali S.; Baumann, Brigitte M.; Medak, Anthony J.; Langdorf, Mark I.; Nishijima, Daniel K.; Hendey, Gregory W.; Mower, William R.; Rodriguez, Robert M.

doi:10.1016/j.annemergmed.2017.04.011

Cited by 49 publications

(28 citation statements)

References 23 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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This study aimed to evaluate rib fracture rate as well as rib fracture characteristics after thoracic trauma in patients with normal versus diminished bone mineral density (BMD). A retrospective cohort study of persons aged 50 years or older presenting to the Emergency Department after sustaining blunt thoracic trauma between July 1, 2014, and December 31, 2017, was performed. Patient and trauma characteristics and DXA scan results were collected. Rib fracture rate and characteristics were evaluated on a radiograph and/or CT scan of the thorax. In total, 119 patients were included for analysis. Fifty-eight of them (49%) had a diminished BMD. In the remaining 61, the BMD was normal. The diminished BMD group experienced rib fractures more often than the normal BMD group (n = 43 (74%) versus n = 31 (51%); p = 0.014). Patients with diminished BMD suffered low-energy trauma more frequently than the normal BMD group (21 (36%) versus 11 patients (15%), respectively (p = 0.011)). Rib fracture characteristics such as the median number of rib fractures, concomitant intrathoracic injury rate, and rib fracture type distribution were not different between the groups. The rate of rib fractures after blunt thoracic trauma was significantly higher in patients with diminished BMD than in patients with a normal BMD. Differences in number and location of rib fractures between groups could not be proven. When assessing patients aged 50 years or older presenting to the hospital after substantial blunt thoracic trauma, the presence of diminished BMD should be taken into account and the presence of rib fractures should be investigated with appropriate diagnostic procedures. Diminished bone mineral density (i.e., osteopenia or osteoporosis) is associated with increased fracture risk. This study evaluated if diminished BMD increases the rib fracture risk. Patients with diminished BMD have a higher risk of sustaining rib fractures after substantial blunt thoracic trauma, which implicates a lower threshold for CT imaging of the chest.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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“…The patient had sustained fractures to the anterior left two to three ribs, thus having a greater potential of associated vascular or neurological injury. According to the literature, a fracture of the first two ribs increases the overall mortality rate to 7.4% . This patient also possessed exactly six rib fractures—the number considered to be the breaking point for mortality and pulmonary morbidity in patients flowing blunt chest trauma .…”

Section: Discussionmentioning

confidence: 86%

Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Napier

2019

Sonography

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Rib fracture is reported to be the most commonly encountered aetiology following blunt chest trauma, 1,2 but despite this, it is frequently regarded as insignificant. Unfortunately, this ideology is compounded when the limitations of conventional imaging modalities are evaluated. In the acute setting, plain radiography can render rib fractures undetected in 50% of cases, 3 and although computer tomography (CT) is deemed to have a higher sensitivity than plain film, its limitations can include a lower specificity in the setting of higher radiation doses. 4,5 Regarded as being a sentinel injury, a rib fracture can act as an external marker to more serious pathologies 5-7 which can in turn compromise the normal breathing mechanism and/or the status of the thoraco-abdominal organs. As delayed diagnosis can result in increased patient morbidity and mortality, resulting from both primary and secondary complications, the detection of rib fracture is imperative in not only predicting patient outcomes but in the development of appropriate management pathways. 2,8 The aim of this case study is therefore twofold-it evaluates the sequelae that can result from rib fracture irrespective of how trivial the injury may seemand in doing so acknowledges the importance of correctly identifying this pathology in the acute setting. Secondly, it highlights a case where ultrasound detected rib fractures not seen on original plain radiographs, but suspected on magnetic resonance imaging (MRI) in a setting where CT of the chest was not performed. | CASE DESCRIPTIONA 37-year-old female presented to the emergency department following a high-speed motor vehicle accident (MVA) in which she was the front seat passenger. Suspicion was raised as to the presence of a retro-peritoneal bleed or hollow organ perforation upon sighting extensive thoraco-abdominal swelling and haematoma in conjunction with a tachycardic heart rhythm of 110 to 130 beats per minute. The initial chest radiograph was deemed unremarkable with normal cardio-mediastinal contours and clear lung fields. No evidence of pneumothorax or displaced rib injury was detected despite the patient complaining of slight chest discomfort on inspiration.As this woman was of child-bearing age and a radiation worker, doctors were hesitant to perform a CT scan initially, and as such intravenous fluids were hung and a period of observation undertaken in the hope that the tachycardia would subside. An ECG eight hours post MVA continued to demonstrate a tachycardic rhythm, and so it was decided to perform an abdominal ultrasound to exclude any intraperitoneal bleeding. No free fluid or solid organ lacerations were detected on the ultrasound scan. As mesenteric shearing could not be excluded by ultrasound, a CT was requested of the abdomen and pelvis. The results were again unremarkable, and the patient was observed overnight in case any pathology developed in the critical hours post trauma. Nine hours later, the patient's heart rate had dropped below 100 beats per minute, her chest sounds were cle...

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“…Some may argue that clinical importance is only if a procedure is performed or if an early discharge is accomplished. We found the length of stay of a patient receiving negative torso CT was 1 day less than similar patients that did not receive torso CT. Additionally, stratifying patients to level of care (floor versus intensive care unit) has been consistently shown to be important, especially with regard to the number of ribs fractured, even in patients as young as 45 [31,32]. There is also data that supports significant post-hospital morbidity exists for patients after relatively minor thoracic trauma [33,34].…”

Section: Discussionmentioning

confidence: 99%

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

et al. 2020

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Background: High morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient's survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort. Methods: A retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital's trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis. Results: There were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded. Conclusions: A negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.

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Rib Fracture Diagnosis in the Panscan Era

Cited by 49 publications

References 23 publications

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

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

Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

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