What is the appropriate management for a patient with multiple rib fractures?

Management of Multiple Rib Fractures

Multiple rib fractures should be managed with a multimodal approach including pain management as the cornerstone, consideration of regional anesthesia techniques, and surgical stabilization for specific indications such as flail chest or multiple severely displaced fractures. 1

Assessment and Risk Stratification

• High-risk factors requiring more aggressive management:

  • Age >60 years (significantly higher mortality)
  • ≥3 rib fractures
  • Flail chest (paradoxical movement of chest wall segment)
  • Underlying respiratory disease
  • Significant respiratory compromise
  • Poor functional respiratory status (FVC <50% predicted)

• Patients with ≥3 rib fractures who are elderly (>60 years) should be admitted to the ICU for closer monitoring 1

Pain Management Algorithm

1. First-line treatment:

   • Intravenous acetaminophen (1 gram every 6 hours) 1

2. Additional analgesics as needed:

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

3. Regional anesthesia techniques (especially for multiple fractures):

   • Thoracic Epidural (TE)
   • Paravertebral Blocks (PVB)
   • Erector Spinae Plane Blocks (ESPB)
   • Serratus Anterior Plane Blocks (SAPB)

   These techniques reduce opioid consumption and decrease delirium in older patients 1

Respiratory Support

• Aggressive pulmonary hygiene measures
• Early mobilization
• Incentive spirometry
• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure 1
  • Decreases mortality
  • Reduces need for intubation
  • Lowers incidence of nosocomial pneumonia

Surgical Stabilization of Rib Fractures (SSRF)

Indications for SSRF 2, 1:

1. Flail chest (highest level of evidence)
2. Multiple (≥3) ipsilateral severely displaced rib fractures
3. Multiple (≥3) ipsilateral displaced rib fractures in ribs 3-10 with:
   • Respiratory failure despite mechanical ventilation OR
   • Weaning failure OR
   • 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
4. Chest wall deformity affecting lung function or showing mechanical instability
5. Severe pain non-responsive to other treatments

Benefits of SSRF 1:

• Reduced duration of mechanical ventilation
• Decreased rates of pneumonia and sepsis
• Shorter ICU stays
• Improved functional outcomes
• Lower total medical expenses and faster return to work

Timing: Early rib fracture fixation (≤48 hours) has been shown to decrease ICU length of stay, overall hospital stay, ventilation days, and hospitalization costs compared to delayed fixation 3

Follow-up and Monitoring

• Initial follow-up within 1-2 weeks of discharge for surgical patients
• All patients should have follow-up within 2-3 weeks after hospital discharge
• Evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Pitfalls and Caveats

1. Undertriage risk: First rib fractures or lower rib fractures may indicate significant energy transfer and potential internal organ injury 1

2. Concomitant injuries: Severe pulmonary contusion may limit the benefits of SSRF in terms of mechanical ventilator time and ICU stay reduction 2

3. Elderly patients: More aggressive monitoring and management is recommended due to significantly higher mortality with rib fractures 1

4. Opioid management: Careful titration in elderly patients to avoid delirium while maintaining adequate pain control 1

5. Optimal timing: SSRF is most beneficial when performed early (≤48 hours) after injury 3