Rib Fracture Diagnosis in the Panscan Era
Rib Fracture Diagnosis in the Panscan Era. Murphy et al. (2017) Annals of Emergency Medicine. 70:1-6.
To determine if rib fractures missed on x-ray but picked up on CT have the same clinical significance as those diagnosed by x-ray.
A planned secondary analysis of data from 2 prospective observational studies of blunt trauma patients over age 14 who had both chest x-ray (CXR) and chest CT in the ED as part of their trauma work-up. Primary outcomes were the frequency of rib fracture observed on CT only compared to those observed on both CXR and CT, the frequency of 1st and 2nd rib fracture-associated great vessel injury, and admission and mortality rates for three groups of patients: patients with rib fractures diagnosed on CT only, patients with isolated rib fractures, and patients with 1st or 2nd rib fractures.
Of the 21,382 patients enrolled in the NEXUS chest studies, 8.661 (40.5%) had both CXR and chest CT performed. Of the 2,071 (9.7%) who had a rib fracture diagnosed on ED imaging, 1,368 (66.1%) were observed on CT only. Patients with rib fractures had higher admission rates (88.7% vs 45.8%), hospital mortality (5.6% vs 2.7%), and associated great vessel injury (1.8% vs 0.1%).
The mortality of patients with rib fracture observed on CT only was not statistically significantly different from patients with fractures observed on CXR (4.8% vs 5.7%). Four-hundred-fifty patients had isolated rib fractures and the admission rate was higher in this population than in patients without a rib fracture at all (84.2% vs 45.8%).
First or second rib fractures were diagnosed in 284 patients (2.5%). Compared to patients with fractures of ribs 3-12 rib fractures, this cohort had higher rates of admission (93.7% vs 84.1%), hospital mortality (7.4% vs 4.1%), and prevalence of great vessel injury (3.9% vs 0.6%, OR 4.4). Of the 284 patients with 1st or 2nd rib fractures, 165 (58.1%) were observed on CT only and 119 observed on CXR. There were similar hospital mortality rates (7.3% vs 7.6%) & great vessel injury rate (3.6% vs 4.2%) in both groups.
Rib fractures are more often observed on CT imaging than on CXR alone. Isolated rib fractures and fractures of ribs 3-12 had low mortality overall. First and second rib fractures had increased mortality and increased risk of great vessel injury regardless of the imaging modality used for diagnosis. Rib fractures should be managed the same way regardless of the imaging modality used for diagnosis.