What is the treatment for rib fracture?

Treatment for Rib Fractures

The treatment for rib fractures should primarily focus on pain control using a multimodal analgesia approach, with thoracic epidural analgesia (TEA) and paravertebral blocks (PVB) considered the gold standard for severe cases, especially in elderly patients with multiple rib fractures. 1

Risk Stratification

Before determining treatment, assess risk factors that predict increased complications:

• Age > 60
• SpO2 < 90%
• Obesity/malnourished status
• 2-3 rib fractures, flail segment, or pulmonary contusion
• Smoking history/chronic respiratory disease
• Anticoagulation therapy
• Major trauma

The presence of multiple risk factors warrants more aggressive pain management strategies 1.

Pain Management Algorithm

1. Mild Pain/Low Risk (isolated rib fractures, minimal displacement)

• First-line: Oral acetaminophen (equivalent efficacy to IV formulation) 1
• Add if needed: NSAIDs if no contraindications
• Pulmonary hygiene and chest physiotherapy

2. Moderate Pain/Intermediate Risk

• Continue acetaminophen and NSAIDs
• Add: Low-dose ketamine (0.3 mg/kg over 15 min) which provides analgesic efficacy comparable to morphine with fewer cardiovascular side effects 1
• Consider limited opioids with caution, especially in elderly patients

3. Severe Pain/High Risk (multiple fractures, flail chest, elderly)

• Regional anesthesia techniques:
  • Thoracic epidural (TE): Gold standard for severe rib fractures, reduces opioid consumption and delirium in older patients 1
  • Paravertebral blocks (PVB): Alternative when TE is contraindicated
  • Newer techniques: Erector spinae plane (ESPB) and serratus anterior plane (SAPB) blocks have shown efficacy with fewer side effects 1

Important Considerations

Monitoring and Respiratory Support

• Close monitoring for respiratory compromise, especially in elderly patients
• Incentive spirometry and early mobilization to prevent atelectasis
• Oxygen supplementation as needed

Imaging

• Standard PA chest radiograph is the initial diagnostic test, primarily to detect complications rather than the fractures themselves 1
• Dedicated rib radiographs rarely change management and may delay care 1

Surgical Management

• Surgical stabilization of rib fractures (SSRF) may be considered for:
  • Flail chest
  • Severe pain unresponsive to optimal analgesia
  • Chest wall deformity 1
• However, a Cochrane meta-analysis showed no statistically significant difference in mortality between surgical and non-surgical management 1
• Surgical fixation may reduce pneumonia, chest deformity, and need for tracheostomy in selected patients 1

Pitfalls and Caveats

1. Opioid overreliance: Can lead to respiratory depression, especially dangerous in patients with rib fractures. Use multimodal analgesia to minimize opioid requirements.

2. Inadequate pain control: Leads to splinting, shallow breathing, and poor cough, resulting in atelectasis and secretion accumulation that can progress to respiratory failure 1.

3. Epidural complications: Thoracic epidurals can cause hypotension requiring vasopressors and may limit mobilization due to motor block. Close monitoring is essential 1.

4. Delayed recognition of complications: Focus should be on detecting and treating associated injuries (pneumothorax, hemothorax, pulmonary contusion) which often have greater clinical impact than the rib fractures themselves 1.

5. Undertreatment in elderly patients: Elderly patients have higher mortality rates with rib fractures and require more aggressive pain management strategies 1.

By implementing appropriate pain control strategies based on risk stratification, most patients with rib fractures can resume daily activities without significant disability.