What are the discharge and follow-up instructions for patients with rib fractures?

Discharge and Follow-up Instructions for Patients with Rib Fractures

Patients with rib fractures should follow up in clinic within 2-3 weeks after hospital discharge to monitor recovery and prevent complications, with timing adjusted based on risk factors such as age, number of fractures, and presence of pulmonary contusions. 1

Discharge Instructions

Pain Management

• Implement a multimodal pain management approach:
  • Acetaminophen 1 gram every 6 hours as first-line treatment 1
  • NSAIDs for patients with severe pain who don't have contraindications
  • Limited opioid prescriptions at the lowest effective dose for the shortest possible period 1
  • Consider tapering schedules for patients requiring opioids beyond 1 week

Respiratory Care

• Breathing exercises:
  • Incentive spirometry every 1-2 hours while awake
  • Deep breathing exercises 10 times per hour
  • Controlled coughing techniques with splinting (holding a pillow against the chest)
• Warning signs requiring immediate medical attention:
  • Increasing shortness of breath
  • Fever above 101°F (38.3°C)
  • Worsening pain not controlled by prescribed medications
  • Coughing up colored or bloody sputum

Activity Guidelines

• Gradually increase activity as tolerated
• Avoid heavy lifting (>10 pounds) for at least 6 weeks
• Sleep with head elevated 30-45 degrees to improve breathing comfort
• Avoid contact sports or activities with high risk of falls for at least 8 weeks

Follow-up Instructions

Timing of Follow-up

• Standard follow-up: 2-3 weeks after discharge 1
• Earlier follow-up (1-2 weeks) for:
  • Elderly patients (>60 years)
  • Patients with ≥3 rib fractures
  • Patients with flail chest
  • Patients who underwent surgical stabilization of rib fractures 1
  • Patients with pulmonary contusions

Assessment During Follow-up

• Evaluation of:
  • Pain control and medication requirements
  • Respiratory function (oxygen saturation, respiratory rate, lung sounds)
  • Functional status and return to activities of daily living
  • Signs of complications (pneumonia, delayed hemothorax)
  • Opioid tapering if still in use 1

Imaging at Follow-up

• Routine follow-up imaging is not required for uncomplicated rib fractures
• Consider chest X-ray for:
  • Persistent respiratory symptoms
  • Suspicion of delayed complications
  • Patients who underwent surgical fixation to assess hardware position 1

Special Considerations

Elderly Patients

• Higher risk of complications and mortality with each additional rib fracture 1
• More frequent follow-up may be necessary (1-2 weeks after discharge)
• Lower threshold for imaging and intervention for respiratory symptoms

Surgical Patients

• Initial follow-up within 1-2 weeks of discharge 1
• Assessment of:
  • Surgical site healing
  • Hardware position
  • Respiratory function
  • Pain control

Return to Work Guidelines

• Sedentary work: Usually 2-4 weeks depending on pain control
• Light physical work: 4-6 weeks
• Heavy physical work: 8-12 weeks or longer based on healing and functional recovery

Common Pitfalls and Caveats

• Undertriage of seemingly minor injuries like first rib fractures or lower rib fractures, which may indicate significant energy transfer and potential for internal organ injury 1
• Inadequate pain control leading to respiratory compromise and complications
• Premature discontinuation of breathing exercises after discharge
• Failure to recognize delayed complications such as pneumonia, pleural effusion, or delayed hemothorax
• Overreliance on opioids for pain management without appropriate tapering plan