What is the evaluation and treatment for rib pain after a traumatic injury?

From the Guidelines

Evaluation and treatment of rib pain after traumatic injury should begin with a thorough assessment to rule out serious complications, and surgical stabilization of rib fractures (SSRF) should be considered for patients with flail chest or multiple and displaced rib fractures, as it has been shown to reduce the duration of mechanical ventilation, pneumonia/tracheostomy rates, ICU stay, and costs compared to non-operative management, as stated in the 2024 study by the World Society of Emergency Surgery (1). Initial evaluation includes a physical exam, chest X-ray, and possibly CT scan to identify fractures, pneumothorax, or internal organ damage, as recommended by the American College of Radiology (1). For uncomplicated rib injuries, pain management is the primary treatment, starting with acetaminophen (650-1000mg every 6 hours) and NSAIDs like ibuprofen (400-600mg every 6-8 hours) for 5-7 days, as well as short-term opioids for moderate to severe pain, such as hydrocodone/acetaminophen 5/325mg every 6 hours for 3-5 days (1). Adequate pain control is crucial as it allows for deep breathing and coughing, which prevents atelectasis and pneumonia, and ice packs applied for 20 minutes every 1-2 hours for the first 48 hours can reduce inflammation, after which heat therapy may provide relief (1). Breathing exercises should be performed hourly while awake to maintain lung function, and most rib injuries heal within 4-6 weeks without intervention (1). Patients should seek immediate medical attention if they experience increasing pain, shortness of breath, fever, or coughing up blood, as these may indicate complications requiring urgent care. Some key points to consider in the evaluation and treatment of rib pain after traumatic injury include:

• The importance of early and accurate diagnosis of rib fractures and associated complications, such as pneumothorax or internal organ damage (1)
• The use of SSRF in patients with flail chest or multiple and displaced rib fractures to reduce the duration of mechanical ventilation, pneumonia/tracheostomy rates, ICU stay, and costs (1)
• The role of pain management in preventing complications, such as atelectasis and pneumonia, and promoting deep breathing and coughing (1)
• The use of ice packs and heat therapy to reduce inflammation and promote healing (1)
• The importance of breathing exercises to maintain lung function and prevent complications (1)
• The need for patients to seek immediate medical attention if they experience increasing pain, shortness of breath, fever, or coughing up blood, as these may indicate complications requiring urgent care.

From the Research

Evaluation of Rib Pain

• The evaluation of rib pain after a traumatic injury involves assessing the severity of the injury and identifying any potential complications, such as pneumothorax or hemothorax 2, 3.
• A comprehensive review of the patient's medical history, physical examination, and imaging studies, such as computed tomography (CT) scans, is necessary to determine the extent of the injury 4.
• The patient's age, number of fractured ribs, and presence of associated injuries are also important factors to consider when evaluating rib pain 2, 3.

Treatment of Rib Pain

• The treatment of rib pain after a traumatic injury typically involves a multimodal approach, including pharmacologic and noninvasive means of managing pain, as well as alternative invasive methods of pain control 5, 6.
• Regional anesthesia techniques, such as paravertebral blocks and myofascial plane blocks, can be effective in reducing pain and improving patient outcomes 6.
• A practical guideline for managing patients with pain from rib fractures should include a brief review of the anatomy of the thorax, the latest trends in pharmacologic and noninvasive means of managing rib pain, and a review of the recent literature on rib plating 5.
• Close observation and monitoring are crucial in patients with minor rib fractures, as delayed complications such as pneumothorax can occur 3.

Potential Complications

• Rib fractures can lead to significant complications, including pneumothorax, hemothorax, and lung contusion 2, 3.
• Delayed chest wall hematoma is a potential complication of rib fractures, and can be effectively diagnosed and treated via contrast-enhanced computed tomography and angiographic embolization 4.
• The presence of subcutaneous emphysema is a risk factor for the development of delayed pneumothorax, and patients with this condition should be admitted for close observation 3.