How should a 72-year-old woman who fell and now has left lower rib pain for one day, with normal peripheral oxygen saturation, normal heart rate, and normal blood pressure, be evaluated and managed?

Approach to a 72-Year-Old Woman with Left Lower Rib Pain After Fall

Begin with a standard posteroanterior (PA) chest radiograph as the initial diagnostic test, combined with thorough physical examination to detect life-threatening complications rather than just confirming rib fractures 1.

Initial Assessment Priority

Your patient has multiple high-risk factors that place her at increased risk for complications despite stable vital signs 2:

• Age > 60 years (she is 72)
• Left lower rib location (ribs 7-12 carry risk of abdominal organ injury)
• Fall mechanism in elderly (associated with displaced fractures and pulmonary complications) 3

The key is not whether she has rib fractures, but whether she has complications that will kill her - pneumothorax, hemothorax, pulmonary contusion, flail chest, or abdominal organ injury 1.

Imaging Algorithm

Step 1: Chest X-Ray (PA view)

• Do this first - it will miss 50% of rib fractures, but that doesn't matter 1
• What you're actually looking for:
  • Pneumothorax
  • Hemothorax
  • Flail chest (displaced fragments)
  • Pulmonary contusion
  • Mediastinal widening

Skip dedicated rib series - they add nothing to management in 99.77% of cases and only delay care 1.

Step 2: Consider CT Chest (with contrast if indicated)

You need CT if:

• Multiple injuries suspected
• Lower rib fractures (ribs 7-12) with any abdominal tenderness - 67% have organ injury 1
• High-energy mechanism (though her fall is low-energy)
• Clinical deterioration
• Posterior rib fractures near the aorta (rare but potentially fatal complication) 4, 5

You can skip CT if:

• Normal physical exam
• Low-energy mechanism (her case)
• Stable vital signs
• No respiratory distress
• Chest X-ray shows no complications 1

Physical Examination Specifics

Look for these red flags:

• Respiratory: Tachypnea, decreased breath sounds, paradoxical chest wall movement (flail), inability to take deep breath
• Cardiovascular: Hypotension, tachycardia (may indicate hemothorax or aortic injury)
• Abdominal: Tenderness (especially with lower rib fractures - check for splenic/hepatic injury) 1
• Chest wall: Crepitus, severe tenderness, visible deformity
• Oxygen saturation: Her SpO2 is 98% now, but elderly patients with ≥2 rib fractures have significantly higher mortality 2, 6

Pain Management Strategy

This is where you prevent death - inadequate analgesia leads to hypoventilation, atelectasis, pneumonia, and respiratory failure in elderly patients 2, 7.

Multimodal Analgesia Approach:

First-line (start immediately):

• Oral or IV acetaminophen - equivalent efficacy, no difference in outcomes 2
• NSAIDs if no contraindications
• Avoid opioid monotherapy

Second-line (if pain uncontrolled or risk factors present):

She has risk factors (age >60, likely ≥2 rib fractures based on mechanism), so consider:

• Regional anesthesia blocks 2:

  • Serratus anterior plane block (SAPB) - safe, effective, reduces opioid needs
  • Erector spinae plane block (ESPB) - newer technique, good safety profile
  • Thoracic epidural or paravertebral blocks - gold standard but require monitoring for hypotension and motor block

• Low-dose ketamine (0.3 mg/kg IV over 15 min) - non-inferior to morphine, fewer cardiovascular events, but higher psycho-perceptual side effects in elderly 2

Critical caveat: Epidural analgesia carries risk of hypoventilation and pneumonia in elderly with rib fractures - requires close monitoring 2.

Disposition Decision

Admit if ANY of the following:

• Age >65 with ≥2 rib fractures (your patient qualifies) 2, 6
• Displaced fractures 3
• Any complication on imaging
• Inadequate pain control
• Lives alone or poor social support
• Chronic respiratory disease, anticoagulation, or other comorbidities 2

Can discharge home if:

• Single non-displaced fracture
• Adequate pain control with oral medications
• Normal imaging
• Good social support
• Reliable for follow-up

Monitoring During Admission

• Serial respiratory assessments (elderly develop complications over 24-72 hours)
• Incentive spirometry
• Early mobilization
• Pulmonary hygiene
• Pain reassessment every 4 hours
• Consider geriatrics, physical therapy, respiratory therapy consultation 6

Common Pitfalls to Avoid

1. Don't assume stable vitals = no serious injury - elderly patients can have aortic laceration from posterior rib fractures even after ground-level falls 5

2. Don't under-treat pain - this kills elderly patients through respiratory complications 2, 7

3. Don't order rib series - waste of time and radiation 1

4. Don't miss lower rib fractures with abdominal injury - examine the abdomen carefully 1

5. Don't discharge elderly patients with multiple rib fractures - mortality increases significantly with age and number of fractures 2, 1, 6