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Chest computed tomography imaging utility for radiographically occult rib fractures in elderly fall-injured patients

Singleton, Jennifer M., MD; Bilello, Leslie A., MD; Canham, Louisa S., MD; Levenson, Robin B., MD; Lopez, Gregory J., BS; Tadiri, Sarah P., BS; Shapiro, Nathan I., MD, MPH; Rosen, Carlo L., MD

Journal of Trauma and Acute Care Surgery: May 2019 - Volume 86 - Issue 5 - p 838–843
doi: 10.1097/TA.0000000000002208

BACKGROUND Previous studies demonstrate an association between rib fractures and morbidity and mortality in trauma. This relationship in low-mechanism injuries, such as ground-level fall, is less clearly defined. Furthermore, computed tomography (CT) has increased sensitivity for rib fractures compared with chest x-ray (CXR); its utility in elderly fall patients is unknown. We sought to determine whether CT-diagnosed rib fractures in elderly fall patients with a normal CXR were associated with increased in-hospital resource utilization or mortality.

METHODS Retrospective analysis of emergency department patients presenting over a 3-year period. Inclusion criteria: age, 65 years or older; chief complaint, including mechanical fall; and both CXR and CT obtained. We quantified rib fractures on CXR and CT and reported operating characteristics for both. Outcomes of interest included hospital admission/length of stay (LOS), intensive care unit (ICU) admission/LOS, endotracheal intubation, tube thoracostomy, locoregional anesthesia, pneumonia, in-hospital mortality.

RESULTS We identified 330 patients, mean age was 84 years (±SD, 9.4 years); 269 (82%) of 330 were admitted. There were 96 (29%) patients with CT-diagnosed rib fracture, 56 (17%) by CT only. Compared with CT, CXR had a sensitivity of 40% (95% confidence interval, 30–50%) and specificity of 99% (95% confidence interval, 97–100%) for rib fracture. A median of two additional radiographically occult rib fractures were identified on CT. Despite an increased hospital admission rate (91% vs. 78%) p = 0.02, there was no difference between patients with and without radiographically occult (CT+ CXR−) rib fracture(s) for: median LOS (4; interquartile range (IQR) 2–7 vs 4, IQR 2–8); p = 0.92), ICU admission (28% vs. 27%) p = 0.62, median ICU LOS (2, IQR 1–8 vs 3, IQR 1–5) p = 0.54, or in-hospital mortality (10.3% vs. 7.3%) p = 0.45.

CONCLUSION Among elderly fall patients, CT-identified rib fractures were associated with increased hospital admissions. However, there was no difference in procedural interventions, ICU admission, hospital/ICU LOS or mortality for patients with and without radiographically occult fractures.

LEVEL OF EVIDENCE Diagnostic, level III.

From the Department of Emergency Medicine (J.M.S., L.A.B., L.S.C., G.J.L., S.P.T., N.I.S., C.L.R.), and Department of Radiology (R.B.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Submitted: March 18, 2018, Revised: December 11, 2018, Accepted: December 27, 2018, Published online: January 23, 2019.

This research was initially presented as an oral presentation at the Annual Meeting of the Society of Academic Emergency Medicine, May 18, 2017 in Orlando, Florida.

Address for reprints: Jennifer M. Singleton, MD, Beth Israel Deaconess Medical Center, Rosenberg Clinical Center, 1 Deaconess Rd., Boston, MA 02215; e-mail:

© 2019 Lippincott Williams & Wilkins, Inc.