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Three Part Question

In [patients with unilateral first rib fractures] is [a CT thorax] required [to rule out associated injuries]?

Clinical Scenario

An 74 year old lady presents to the emergency department following a fall at home. She complains of pain in her right shoulder. An x-ray confirms an isolated first rib fracture. I wonder if I need to investigate further to exclude associated injuries.

Search Strategy

[(1 OR first) ti.ab] AND[ rib fracture ti. ab. OR fracture* rib ti.ab. OR exp RIB FRACTURES] AND [CT OR CAT OR Computer Tomography ti.ab OR exp TOMOGRAPHY, X-RAY COMPUTED]

EMBASE
Limit to English, Human

Search Outcome

68 papers of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Woodring et al 1981 US	105 patients with blunt chest trauma. Of which 50 had first/second rib fractures on plain CXR	Group one consisted of patients with (other) abnormalities on a plain CXR(n=29). Group twon consisted of patients with no other abnormalities on CXR. All patients undertook aortography	Group One had 13.8% arterial injuries. Group 2 had 0% arterral injuries	They do not recommend routine use of aortography in all first/second rib fractures	p < 0.07 and was reported as 'marginal significance. The paper pre-dated regular use of CT and uses aortography as its gold standard. It also only looks at vascular injury.
Albers et al 1982 US	75 patients with first rib fractures	Group one had isolated rib fractures. Group two had first rib fractures associated with mulitple rib fractures	Group one showed no serious other injuries. Group two had a 58% mortality rate. Most were due to vascular injuries	Isolated first rib fractures are relatively benign	Group two data was significantly skewed by patients that were dead on arrival and were post-mortem diagnoses. There were no statistical analysis undertaken. The paper pre-dates regular of CT
Galen et al 1989 US	Collective Review of 27 papers that looked at blunt trauma patients with first and second rib fractures. Total of 1,393 patients	Compared rate of injuries to patients with rib fractures to thoses without rib fractures	Overall incidence of 3% associated vascular injury. Comparable or less when compared to patients without rib fracture	No difference between patients with/without rib fractures	No methods. No detailed anlaysis of 27 papers used.
Traub et al 2007 Australia	141 patients who attended a level one trauma centre with blunt chest trauma and had a Chest CT and a chest x-ray	Compared the incidence of pathology on the CT and chest x-ray and looked at whether the CT scan changed management	Incidence of Pathology	CT Scan - 90% Chest X-ray - 58%. CT scan altered mangement in 19% of cases	No specific relevance to first rib fractures as a predictive feature

Comment(s)

There is no single study that answers the question. The available evidence is relatively out-of-date (pre-1982) and pre-dates the regular use of Computer Tomography. First rib fractures have very little predictive value. Isolated fractures of the first rib appear relatively benign but poly-trauma that involves the first rib seems much more serious. Similarly, absence of first rib fracture cannot be considered reassuring Previously, it was concluded that in the absence of clinical signs and with an unremarkable Chest x-ray; further imaging (aortography) was not required. Whether this can be transferred to CT is unclear. CT does appear to find more pathology but it is unclear if this effects management

Clinical Bottom Line

Fracture of the first rib is not a accuarte predictor of associated injuries. As with all patients – each case needs to be considered individually and further investigations tailored to the patient’s individual needs.

References

1. Woodring et al Fractures of First and Second Ribs: Predictive value for arterial and bronchial injury American Journal of Roentgenology 1982 Feb; 138 (2): 211-215
2. Albers et al Severity of Intrathoracic Injuries Associated with First Rib Fractures The Annals of Thoracic Surgery 1982 June; 33 (6); 614-18
3. Galen et al Collective Review: Fracture of the upper ribs and injury to the great vessels Surgery, Gynecology & Obstetrics Sept 1989: Vol 60: 275 - 282
4. Traub et al The use of chest computed tomography versus chest X-ray in patients with major blunt trauma Injury 2007; 38: 43-47