What are the management options for rib fractures?

From the Guidelines

Management of rib fractures should prioritize pain control, respiratory support, and preventing complications, with surgical fixation considered for flail chest, severely displaced fractures, or persistent pain, as supported by recent guidelines and studies 1.

Initial Treatment

Initial treatment includes analgesics such as acetaminophen (1000 mg every 6 hours) and NSAIDs like ibuprofen (400-600 mg every 6-8 hours), with opioids like oxycodone (5-10 mg every 4-6 hours) or hydrocodone (5-10 mg every 4-6 hours) used in more severe cases. Regional anesthesia techniques like intercostal nerve blocks, thoracic epidural analgesia, or paravertebral blocks may be used for severe pain 1.

Respiratory Support

Adequate pain control is crucial as it allows for deep breathing and effective coughing, which helps prevent atelectasis and pneumonia. Patients should perform deep breathing exercises (10 deep breaths every hour while awake) and use incentive spirometry to maintain lung expansion.

Surgical Fixation

Surgical fixation (rib plating) may be considered for flail chest, severely displaced fractures, or persistent pain, with recent studies and guidelines supporting its use in these cases 1. The decision to proceed with surgical fixation should be made on a case-by-case basis, taking into account the individual patient's condition and the presence of any underlying pulmonary disease.

Hospitalization

For multiple or displaced fractures, especially in elderly patients or those with underlying pulmonary disease, hospitalization may be necessary for more intensive pain management and respiratory monitoring.

Recovery

Most uncomplicated rib fractures heal within 6-8 weeks, during which time patients should gradually increase activity as tolerated while avoiding heavy lifting or contact sports. Recent studies have shown that surgical fixation can improve outcomes in patients with flail chest or severely displaced fractures, with reduced rates of pneumonia, tracheostomy, and mortality 1.

From the Research

Management Options for Rib Fractures

The management of rib fractures involves a multidisciplinary approach to reduce morbidity and mortality. Some of the management options include:

• Risk stratification to identify patients at high risk of complications 2, 3
• Multimodal analgesia, including pharmacologic and regional analgesia techniques, such as thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block 2, 4, 3
• Surgical stabilization of rib fractures (SSRF) for patients with severe chest trauma or those at high risk of pulmonary complications 5
• Intercostal nerve cryoablation as an additional therapeutic modality for rib fractures 5
• Regional anesthesia techniques, such as thoracic epidural analgesia (TEA) and paravertebral block (PVB), which have been shown to be effective in alleviating pain related to rib fractures 4
• Peripheral nerve blocks, such as serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB), which have impressive potential in the future and may surpass neuraxial techniques 4

Analgesic Techniques

Analgesic techniques play a crucial role in the management of rib fractures. Some of the analgesic techniques used include:

• Systemic opioids and non-opioid analgesics, which have been traditionally used to treat rib fractures 4
• Regional anesthesia techniques, such as TEA and PVB, which have been shown to be effective in alleviating pain related to rib fractures 4
• Peripheral nerve blocks, such as SAPB and ESPB, which have impressive potential in the future and may surpass neuraxial techniques 4
• Intercostal nerve block (ICNB), which has less analgesic impact and requires concurrent intravenous medication to achieve comparable outcomes to other blocks 4

Practical Guidelines for Clinicians

Practical guidelines for clinicians managing patients with rib fractures include:

• Calculating a rib fracture score to aid management decisions 3
• Starting multimodal analgesia promptly and proactively on hospital admission 3
• Using regional anaesthetic techniques, such as thoracic epidurals and erector spinae blocks, for patients with significant chest trauma or those at high risk of pulmonary complications 3
• Considering surgical stabilization of rib fractures (SSRF) for patients with severe chest trauma or those at high risk of pulmonary complications 5