What is the treatment for a displaced rib?

Treatment of Displaced Rib Fractures

Surgical stabilization of rib fractures (SSRF) should be considered for all displaced rib fractures, especially when there are multiple (≥3) ipsilateral severely displaced fractures or a flail segment. 1

Indications for Surgical vs. Non-Surgical Management

Surgical Management Indicated For:

• Flail chest (clinical finding with paradoxical movement of chest wall segment) 1
• Multiple (≥3) ipsilateral severely displaced rib fractures 1
• Multiple (≥3) ipsilateral displaced rib fractures in ribs 3-10 with either:
  • Respiratory failure despite mechanical ventilation
  • Weaning failure
  • At least two pulmonary derangements despite optimal pain management:
    • Respiratory rate >20 breaths per minute
    • Incentive spirometry <50% predicted
    • Numeric pain score >5/10
    • Poor cough 1
• Chest wall deformity affecting lung function or showing mechanical instability 1
• Severe pain non-responsive to other treatments 1

Non-Surgical Management For:

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

Non-Surgical Management Protocol

Pain Management (Critical Component)

1. Multimodal Analgesic Approach:

   • First-line: Regular acetaminophen (IV or oral)
   • Second-line: NSAIDs (if no contraindications)
   • Breakthrough pain: Hydromorphone 0.015 mg/kg IV (approximately 1-1.5 mg for most adults) every 2-3 hours 3

2. Regional Anesthesia Techniques:

   • Gold standard options:
     • Thoracic epidural
     • Paravertebral blocks
   • Newer techniques with fewer side effects:
     • Erector spinae plane blocks
     • Serratus anterior plane blocks 3

3. Alternative Agents:

   • Ketamine (0.3 mg/kg over 15 minutes) - fewer cardiovascular side effects 3

Respiratory Care

• Encourage deep breathing exercises and incentive spirometry 3
• Close monitoring for respiratory compromise, especially in high-risk patients 3
• Early intervention for inadequate pain control to prevent splinting, shallow breathing, and secretion accumulation 3

Surgical Management Protocol

Timing

• SSRF is recommended within the first 7 days after trauma, preferably within the first 3 days 2

Surgical Approach

• Incision selection depends on fracture location:
  • Lateral approach (main surgical approach) - curvilinear skin incision overlying fractured ribs
  • Posterior rib fractures - vertical incision within triangle of auscultation
  • Anterior fractures - transverse inframammary incision 2

Fixation Techniques

• Precontoured side and rib-specific plates with threaded holes and self-tapping locking screws
• Polymer cable cerclage for:
  • Longitudinal fractures
  • Rib fractures near the spine
  • Osteoporotic ribs
  • Injuries of rib cartilage 2

Cautions and Pitfalls

Avoid Rib Belts

• Despite patient acceptance, rib belts have been associated with increased complications:
  • Pleural effusion
  • Atelectasis
  • Contact dermatitis 4
• No significant reduction in pain severity with rib belts 4

Monitor for Complications

• Respiratory failure
• Pneumonia
• Atelectasis
• Pleural effusions 3, 5

Benefits of Surgical Stabilization

• Reduced chest tube duration (6.5 vs 8.4 days) 6
• Improved pulmonary function
• Decreased pain medication requirements
• Prevention of chest wall deformity
• Reduced morbidity and mortality 2

Special Considerations

• CT imaging is required for proper evaluation of rib fractures, especially to assess displacement or deformity 3
• SSRF is optimally performed in dedicated centers with multidisciplinary teams 1
• Patients with flail chest have increased risk of respiratory failure and mortality 1

Remember that adequate pain control coupled with meticulous respiratory care is essential to prevent complications in all patients with rib fractures, regardless of management approach 5.