What is the management of fractured ribs?

From the Guidelines

Management of fractured ribs primarily focuses on pain control, respiratory support, and preventing complications, with surgical stabilization of rib fractures (SSRF) considered in patients with flail chest or multiple severely displaced rib fractures, as it has been shown to reduce mortality, improve pulmonary function, and decrease the duration of mechanical ventilation and ICU stay 1. The goal of treatment is to minimize morbidity, mortality, and improve quality of life.

• Pain management is essential and typically includes oral analgesics such as acetaminophen (1000 mg every 6 hours) and NSAIDs like ibuprofen (400-600 mg every 6 hours) for mild to moderate pain.
• For more severe pain, opioids such as oxycodone (5-10 mg every 4-6 hours) may be necessary, however, regional anesthesia techniques like intercostal nerve blocks or thoracic epidural analgesia can provide significant relief in severe cases, and have been shown to reduce opioid consumption and delirium in older patients 1.
• Deep breathing exercises and incentive spirometry (10 breaths every hour while awake) are crucial to prevent atelectasis and pneumonia.
• Patients should apply ice packs to the affected area for 20 minutes every 1-2 hours during the first 48 hours to reduce pain and swelling.
• Most rib fractures heal within 6 weeks with conservative management, however, SSRF may be considered in patients with flail chest or multiple severely displaced rib fractures, as defined by a recent multicenter prospective RCT, which found that SSRF was associated with decreased mortality and improvement in ventilator-free days and decreased length of hospitalization 1.
• The indications for SSRF include flail chest patients, and non-flail chest patients with multiple (≥ 3) ipsilateral severely displaced rib fractures, or multiple (≥ 3) ipsilateral displaced rib fractures in combination with respiratory failure despite mechanical ventilation or weaning failure or at least two pulmonary derangements in non-ventilated patients despite loco-regional anesthesia and multimodal analgesia 1.
• Patients should seek immediate medical attention if they develop increasing shortness of breath, fever, or worsening pain, as these may indicate complications such as pneumothorax or hemothorax.
• The use of pain severity score as a criterion for considering SSRF is also recommended, as patients with persistent pain despite medical treatment and respiratory impairment should be considered for SSRF 1.

From the Research

Management of Fractured Ribs

The management of fractured ribs involves a multidisciplinary approach to reduce morbidity and mortality. Key aspects of management include:

• Risk stratification to identify patients at high risk of complications
• Implementation of analgesic pathways using a multimodal approach
• Consideration of surgical stabilization of rib fractures in certain cases

Analgesic Management

Analgesic management of fractured ribs includes:

• Pharmacologic agents such as acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine 2
• Regional analgesia techniques such as thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block 2, 3, 4
• Multimodal analgesia that incorporates regional techniques, systemic analgesics, and analgesic adjuncts 3, 4

Surgical Stabilization

Surgical stabilization of rib fractures should be considered in cases of:

• Multiple bicortically displaced rib fractures
• Flail chest and/or concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture 3
• The procedure involves classifying rib fractures by location, type of fracture, and degree of displacement, and using a lateral approach to access the majority of rib fractures 3

Nonoperative Management

Nonoperative management of fractured ribs includes:

• Epidural analgesia
• Thoracic paravertebral blockage
• Intercostal nerve block
• Intravenous or enteral analgesics
• Intrapleural analgesia
• Multimodal analgesia 3, 5, 6

Clinical Pathways

The use of bundled rib fracture management protocols has been shown to reduce morbidity and mortality 5. These protocols typically involve a multidisciplinary approach to management, including risk stratification, analgesic management, and consideration of surgical stabilization.