Rib Fracture Risk: Using RibScore + SCARF to Predict Decline

Written by Eric Steinberg DO, MEHP
REBEL EM
Medical Category: Thoracic and Respiratory, Trauma
CT chest, MDCalc, MDCalc Wars, pulmonary complications, rib fractures, rib trauma, RibScore, SCARF score

December 29, 2025

🗝️ Key Points

🧓 Rib fractures in older adults can decompensate late — early vitals and a “normal-ish” exam don’t rule out impending respiratory decline.
🖥️ RibScore = anatomy/CT risk — helps predict pulmonary complications and supports disposition decisions (floor vs stepdown/ICU).
🫁 SCARF = bedside physiology & function — repeatable and trendable; flags patients who need escalated monitoring and/or analgesia.
🤝 Together they’re stronger than either alone — pairing anatomic burden + physiologic reserve reduces false reassurance and catches high-risk patients early.
💊 High or rising scores should trigger action — multimodal pain control, early RT/incentive spirometry, and a lower threshold for higher-acuity care.

🤕 Case

75-year-old “Nana Eleanor” took her granddaughter ice skating for a birthday outing. Determined to prove she was still spry, she waved away the kiddie support walker, noting she had “been skating since Nixon.” During a mid-glide selfie attempt she drifted sideways, slipped on melted ice, and struck the boards.”EMS found her seated upright, mildly breathless but joking, “Next time I’ll stick to shuffleboard.” In the ED, vitals were notable for a respiratory rate of 25, SpO₂ 94% on room air, and normal blood pressure. No other injuries were identified. Chest CT showed multiple bilateral rib fractures without flail chest.

📌 Background:

Rib fractures are among the most common injuries in older trauma patients and can look deceptively “benign” early—until pain-limited ventilation, atelectasis, pneumonia, and respiratory failure develop hours to days later. Disposition decisions based on fracture count alone often miss the interaction between anatomic injury burden and physiologic reserve, especially in frail patients with limited pulmonary “margin.” RibScore offers an anatomy/CT-based estimate of pulmonary complication risk, while SCARF captures dynamic bedside physiology and functional respiratory performance that can worsen despite stable imaging. Using both together helps identify who needs earlier admission, aggressive multimodal analgesia, and closer respiratory monitoring—before decompensation declares itself.

🔗 Scoring Tools:

➡️ SCARF Score

➡️ Rib Score

🎯 Quick Hits

💬 Case Resolution

Mrs. Eleanor was admitted for close monitoring after a high RibScore and rising SCARF scores suggested she was at risk for respiratory decline. The team escalated multimodal pain control, including a serratus anterior plane block and a ketamine infusion, during which she cheerfully informed the resident that the ceiling tiles looked like “tiny skating judges holding up scorecards.” With effective analgesia and pulmonary hygiene, her oxygenation improved and she avoided ICU transfer. Upon discharge, she promised her granddaughter they would return to the rink, “but next time, no selfies and maybe a helmet.”

🚨 Clinical Bottom Line

RibScore:
- Anatomy-based.
- Best for predicting complications based on CT findings.
- Helpful for triaging and anticipating need for admission and respiratory decline.
SCARF Score: Physiology-based. Best for identifying patients with rib fractures who may warrant escalation of analgesia and/or level of care (e.g., stepdown, ICU).
*When used together, the sensitivity for detecting pulmonary complications is >95%!

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

🧭 Prep Sheets

Sequential Clinical Assessment of Respiratory Function (SCARF) Score

Rib Score

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

Meet The Team

🔎 Your Deep-Dive Starts Here

Cite this article as: Eric Steinberg DO, MEHP, "Rib Fracture Risk: Using RibScore + SCARF to Predict Decline", REBEL EM blog, December 29, 2025. Available at: https://rebelem.com/rib-fracture-risk-ribscore-scarf/.