What is the recommended treatment for a mildly displaced rib fracture?

Treatment of Mildly Displaced Rib Fractures

For mildly displaced rib fractures, multimodal analgesia with oral acetaminophen as first-line treatment is recommended, with NSAIDs and low-dose ketamine as adjuncts if needed, while reserving surgical stabilization for cases with persistent severe pain or respiratory compromise despite optimal medical management. 1

Pain Management Algorithm

First-Line Treatment

• Oral acetaminophen: Evidence shows oral acetaminophen is equivalent to IV for pain control in rib fractures, particularly in elderly patients 2, 1
• NSAIDs: Add if no contraindications exist (avoid in patients with renal impairment, active GI bleeding, or on anticoagulation) 1

Second-Line Treatment (if inadequate pain control)

• Low-dose ketamine: 0.3 mg/kg over 15 minutes provides analgesic efficacy comparable to morphine with fewer cardiovascular side effects 2, 1
• Opioids: Use cautiously due to risks of respiratory depression, nausea, constipation, and delirium, particularly in elderly patients 1

Advanced Pain Control (for high-risk patients or inadequate pain control)

• Regional anesthetic techniques: Consider thoracic epidural, paravertebral blocks, erector spinae plane blocks, or serratus anterior plane blocks 1, 3
• These techniques reduce opioid consumption and decrease delirium in older patients 1

Risk Assessment

Identify patients at higher risk for complications who may need more aggressive management:

• Age > 60
• SpO₂ < 90%
• Obesity/malnourishment
• Multiple rib fractures (≥2-3)
• Flail segment or pulmonary contusion
• Smoking/chronic respiratory disease
• Anticoagulation use
• Major trauma 2, 1

Surgical Considerations

Surgical stabilization of rib fractures (SSRF) is generally not indicated for mildly displaced single rib fractures but may be considered in select cases:

• Consider SSRF if:

  • Persistent severe pain despite optimal medical management
  • Respiratory compromise (respiratory rate >20, poor incentive spirometry <50% predicted)
  • Multiple (≥3) displaced rib fractures, especially ribs 3-10 2, 1
  • Significant chest wall deformity 2

• SSRF contraindications:

  • Hemodynamically unstable patients 2
  • Single, minimally displaced fractures with adequate pain control 2, 3
  • Fractures of ribs 1,11, and 12 (unless markedly displaced) 2

Additional Management Considerations

• Avoid rib belts: Despite being widely accepted by patients, they appear to be associated with an increased incidence of complications including pleural effusion and atelectasis 4

• Encourage deep breathing exercises and incentive spirometry to prevent atelectasis and pneumonia 3, 5

• Monitor closely for respiratory compromise, particularly in high-risk patients 1

• CT imaging is recommended for proper evaluation of rib fractures, especially to assess displacement that might influence management decisions 1

• Early intervention is critical, as inadequate pain control leads to splinting, shallow breathing, poor cough, atelectasis, and potential respiratory failure 1

The management of mildly displaced rib fractures should focus on effective pain control to prevent respiratory complications while avoiding excessive opioid use. Surgical intervention should be reserved for cases where conservative management fails to provide adequate pain control or respiratory function.