The elderly are more likely to fall. The elderly who fall are more likely to suffer rib fractures. The elderly who fall and suffer rib fractures are more likely to contract pneumonia and die. The chest x-ray is insensitive for rib fractures. So, we should always perform a CT in the elderly who fall and of whom we have suspicion for rib fractures?
This is a single-center retrospective study of 330 elderly patients, mean age 84, who presented after a fall. Each patient included in the study received a chest XR, followed by a CT of their chest. Overall, 96 patients had a rib fracture – 40 of which were seen on XR, the remainder only on CT. And, there are a number of interesting tidbits they describe in their population:
- Neither hospital length-of-stay, ICU length-of-stay, or hospital mortality (10.3% vs. 7.3%) were (statistically) increased in those with occult rib fractures compared to those without any rib fractures.
- These findings held true for the 63 patients with ≥2 occult rib fractures (both XR+ and XR-).
- In patients with rib fractures seen on XR, the median number of additional rib fractures seen on CT was 2 (range 0-11).
Rates of in-hospital complications were similar between those hospitalized with rib fractures visualized on XR and those visualized only on CT. Then, in their case review, most adverse events occurring in those with occult rib fractures occurred due to associated injuries, events, or iatrogenic causes – not primarily due to the thoracic trauma itself.
This is only a small case series, and it is biased towards higher acuity – considering clinician judgement obtained CT imaging in all cases, and admission rates were nearly 90%. However, it does generally further demonstrate the low value in obtaining CT imaging to ensure no occult rib fractures are missed. An XR has low sensitivity, but these data do not support a premise of increased harm due to missed occult fractures.
“Chest CT imaging utility for radiographically occult rib fractures in elderly fall-injured patients”