What is the recommended treatment for rib fractures?

Management of Rib Fractures

The recommended treatment for rib fractures is a multimodal approach with pain management as the cornerstone, using intravenous acetaminophen as first-line treatment, considering regional anesthesia techniques for multiple fractures, and reserving surgical stabilization for specific indications such as flail chest or multiple severely displaced fractures. 1

Pain Management Algorithm

1. First-line treatment:

   • Intravenous acetaminophen (1 gram every 6 hours) 1
   • Oral acetaminophen is equally effective in elderly patients (≥65 years) and should be preferred when possible 2

2. Additional analgesics as needed:

   • NSAIDs
   • Opioids (use hydromorphone over morphine, at lowest effective dose for shortest duration)
   • Ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 1

3. Regional anesthesia techniques for multiple fractures or inadequate pain control:

   • Thoracic Epidural (TE): Most established technique but has contraindications 1, 3
   • Paravertebral Blocks (PVB): Alternative when TE is contraindicated 1, 3
   • Erector Spinae Plane Blocks (ESPB): Fewer side effects, can be performed by trained emergency physicians 1, 3
   • Serratus Anterior Plane Blocks (SAPB): Fewer side effects 1, 3

Indications for Surgical Stabilization

Surgical stabilization of rib fractures (SSRF) should be considered for:

• Flail chest
• Multiple (≥3) ipsilateral severely displaced rib fractures
• Chest wall deformity affecting lung function or showing mechanical instability
• Severe pain non-responsive to other treatments
• Multiple displaced rib fractures with respiratory failure or weaning failure 1

Risk Stratification and Monitoring

High-Risk Patients Requiring ICU Admission:

• Elderly patients (>60 years) with ≥3 rib fractures
• Flail chest
• Significant respiratory compromise
• Poor functional respiratory status (FVC <50% predicted)
• Underlying respiratory disease or COVID-19 1

Respiratory Support:

• Consider non-invasive ventilation (NIV) for chest trauma patients with acute respiratory failure
• NIV decreases mortality, reduces intubation needs, and lowers nosocomial pneumonia incidence 1

Follow-up Care

• Surgical stabilization patients: Initial follow-up within 1-2 weeks of discharge
• All patients: Follow-up in clinic within 2-3 weeks after hospital discharge
• Evaluate: Pain control, respiratory function, functional status, need for additional imaging 1

Clinical Pearls and Pitfalls

1. Elderly patients have significantly higher mortality with rib fractures and require more aggressive monitoring and management 1

2. Regional blocks tend to be more effective than systemic opioids and produce fewer systemic side effects, though they are more invasive 4

3. Don't underestimate seemingly minor injuries such as first rib fractures or lower rib fractures, which may indicate significant energy transfer and potential for internal organ injury 1

4. Avoid respiratory compromise by instituting early and effective pain relief, as pain can seriously compromise respiratory mechanics 4

5. Consider multimodal analgesia started promptly and proactively on hospital admission to prevent complications 5

The most recent evidence strongly supports a multimodal approach to rib fracture management with appropriate pain control as the foundation of treatment. While regional anesthesia techniques show promise, the specific technique should be selected based on patient factors and available expertise 1, 3, 6.