Imaging Rib Fractures

Introduction

The identification of rib fractures radiographically is a controversial subject. Rib radiography is considered unnecessary in many centres because it often has, at best, a marginal effect on patient management. It should also be considered that undisplaced rib fractures can be missed on plain film images. Irrespective of which viewpoint you subscribe to, if you are planning to undertake rib radiography you should be attempting to achieve the highest image quality at the lowest radiation dose. This page considers rib radiography techniques.

Mechanism of Injury

Trauma
Coughing
Pathological

Anatomy

source: unknown
There are normally 12 pairs of ribs. Additional ribs can be present in the form of cervical ribs and 13th ribs.
The ribs that are most obvious on a PA/AP chest image are the posterior ribs.

The Appropriateness of Rib Radiography

The ACR suggest that rib radiography is more appropriate in children than adults. They note the following.


	<a name="1292">"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."</a>
		[[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.\|National Guidelines Clearing House]]

Counterpoint- arguments in favour of Rib Radiography
Point
Comment
Fractures of the first rib are associated with mediastinal/vascular injury. This contention is not universally supported by research
Fractures of the lower ribs are associated with trauma to the abdominal viscera These patients should be considered for CT imaging
A flail chest may not be clinically evident in some patients, particularly obese patients
patients with ribs fractures identified radiographically are more likely to receive appropriate pain relief
identification of multiple rib fractures can have management implications
rib fractures in children have high association with NAI

Technique Notes

A PA chest image should be included with rib views to assess for pneumothorax (erect, expiration)
It is difficult to include all ribs in a single exposure- centre to include the symptomatic anatomy
specific below diaphragm exposure technique may be required
including the lung apices may demonstrate pneumothorax
roll the scapula away from the lungfield where possible
upper ribs are best demonstrated on deep inspiration and lower ribs on deep expiration
low kVp's should be employed; 60 - 65 kVp for upper ribs and 70 - 75 kVp for lower ribs (digital radiography kVps can be higher)
A long exposure time in a compliant patient can produce very high quality results.
Long exposure time rib views should not be attempted in the erect position (movement unsharpness)

Long Exposure Time technique

These images compare a short exposure time technique with a long exposure time technique. Note also the increased contrast demonstrated in the long exposure time image- this is associated with a lower kVp.

Old vs New Rib Fractures

$old rib fractures$ This image demonstrates an old rib fracture. The presence of callus new bone formation around the fracture indicates that it is a healing fracture.

Fractured Ribs on Other Views

$rib fracture$ It is good practice to examine the ribs and lungs whenever they are demonstrated. This AP cervical spine image demonstrates a right second rib fracture (black arrow) and a pneumothorax (white arrow). Rib fractures can also be demonstrated on shoulder images.

Film-Screen Technique

This is a LPO rib position image taken in the supine oblique position using a film-screen technique. A long exposure time technique has been employed. This type of technique is more commonly associated with radiography of the sternum but is equally effective when demonstrating the patient's ribs. It is important to note that this technique will fail if the patient is imaged in the erect position. Equally, the patient must be able to hold his/her breath and hold very still.

DR Imaging

DR imaging of ribs can produce images of very high quality. A manual exposure technique using a fixed mA and an exposure time of 1.6 seconds has been employed with the patient in a supine oblique position and arrested respiration. The motion of the heart and great vessels tend to blur the thoracic viscera resulting in demonstration of the bony anatomy in sharp relief. This enlarged image demonstrates the blurring effect associated with a long exposure technique- the soft tissue structures are blurred and the bony anatomy remains sharp. This technique requires a very compliant patient and a supine oblique position. (same image as left)

This DR LPO rib image was produced with a philips Digital Diagnost DR release 1. The image was laser printed then photographed before importing into Wikiradiography. This process has seen it lose much of its quality. Despite these limitations of reproduction, the quality of the image shines through.

A manual exposure using fixed mA over 1.6 seconds was employed. An arrested respiration technique was employed. The new release 2 model has fixed mA AEC exposures over a maximum of 1 second.

Sonography

Ultrasound diagnosis of rib fractures can be very effective. One study which compared rib radiography with ultrasound imaging of patients with acute rib injuries reported the following;

"At presentation, radiographs revealed eight rib fractures in six ( 12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all re-examined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture."

<a class="external" href="http://www.ajronline.org/cgi/reprint/173/6/1603" rel="nofollow" target="_blank">J. F. Griffith et al
Sonography Compared with Radiography in Revealing Acute Rib Fracture.
AJR:173, December 1999</a>

CT Imaging

$3d ct rib fractures$ $3d ct rib fractures$
This is a CT chest 3D reconstruction. This image is useful in providing the clinician with a quick impression of rib fractures. Multiple fractures of the left posterior ribs are demonstrated. This is a CT chest 3D reconstruction. Multiple pairs of adjacent posterior rib fractures are demonstrated on the right indicating a flail segment.

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Imaging Rib Fractures

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source: unknown	There are normally 12 pairs of ribs. Additional ribs can be present in the form of cervical ribs and 13th ribs.
	The ribs that are most obvious on a PA/AP chest image are the posterior ribs.

Point	Comment
Fractures of the first rib are associated with mediastinal/vascular injury.	This contention is not universally supported by research
Fractures of the lower ribs are associated with trauma to the abdominal viscera	These patients should be considered for CT imaging
A flail chest may not be clinically evident in some patients, particularly obese patients
patients with ribs fractures identified radiographically are more likely to receive appropriate pain relief
identification of multiple rib fractures can have management implications
rib fractures in children have high association with NAI


DR imaging of ribs can produce images of very high quality. A manual exposure technique using a fixed mA and an exposure time of 1.6 seconds has been employed with the patient in a supine oblique position and arrested respiration. The motion of the heart and great vessels tend to blur the thoracic viscera resulting in demonstration of the bony anatomy in sharp relief.	This enlarged image demonstrates the blurring effect associated with a long exposure technique- the soft tissue structures are blurred and the bony anatomy remains sharp. This technique requires a very compliant patient and a supine oblique position. (same image as left)

	"At presentation, radiographs revealed eight rib fractures in six ( 12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all re-examined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture."
		<a class="external" href="http://www.ajronline.org/cgi/reprint/173/6/1603" rel="nofollow" target="_blank">J. F. Griffith et al Sonography Compared with Radiography in Revealing Acute Rib Fracture. AJR:173, December 1999</a>

$3d ct rib fractures$	$3d ct rib fractures$
This is a CT chest 3D reconstruction. This image is useful in providing the clinician with a quick impression of rib fractures. Multiple fractures of the left posterior ribs are demonstrated.	This is a CT chest 3D reconstruction. Multiple pairs of adjacent posterior rib fractures are demonstrated on the right indicating a flail segment.