What is the management for a patient with a rib fracture?

Management of Rib Fractures

The management of rib fractures should focus on multimodal pain control with regular intravenous acetaminophen as first-line treatment, consideration of regional anesthesia techniques for moderate to severe pain, and surgical stabilization only for specific indications such as flail chest or multiple severely displaced fractures with respiratory compromise. 1

Initial Assessment and Risk Stratification

• The number of fractured ribs correlates with morbidity and mortality, particularly in elderly patients 1
• High-risk factors requiring more aggressive management:
  • Age >60 years
  • ≥3 rib fractures
  • Flail chest
  • Underlying respiratory disease
  • Significant respiratory compromise
  • Poor functional respiratory status 1
• Lower ribs (7-9) are less likely to cause respiratory compromise than upper ribs, but still require careful management 1
• First rib fractures may indicate significant energy transfer and potential for internal organ injury 1

Pain Management Algorithm

1. First-line treatment:

   • Regular intravenous acetaminophen (1 gram every 6 hours) 1

2. If pain persists:

   • Consider adding NSAIDs with caution in elderly patients, accounting for potential adverse events and drug interactions 1

3. For breakthrough pain:

   • Opioids at lowest effective dose for shortest possible period (hydromorphone preferred over morphine) 1
   • Alternative: Ketamine (0.3 mg/kg over 15 minutes) with fewer cardiovascular side effects 1

4. For moderate to severe pain despite above measures:

   • Regional anesthesia techniques 1:
     • Thoracic Epidural (TE)
     • Paravertebral Blocks (PVB)
     • Erector Spinae Plane Blocks (ESPB)
     • Serratus Anterior Plane Blocks (SAPB)

Respiratory Support

• Monitor closely for signs of respiratory failure:

  • Decreased oxygen saturation
  • Increased respiratory rate
  • Inability to clear secretions
  • Decreased incentive spirometry volumes 1

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

Surgical Management

Surgical stabilization of rib fractures (SSRF) is indicated for:

• Flail chest
• Multiple (≥3) ipsilateral severely displaced rib fractures
• Multiple (≥3) ipsilateral displaced rib fractures in ribs 3-10 with:
  • Respiratory failure
  • Weaning failure
  • At least two pulmonary derangements despite optimal pain management 1

Benefits of SSRF include:

• Reduced duration of mechanical ventilation
• Decreased rates of pneumonia and sepsis
• Shorter ICU stays
• Improved functional outcomes
• Lower total medical expenses 1

Early rib fracture fixation (≤48 hours) decreases ICU length of stay, overall hospital stay, ventilation days, and hospitalization costs compared to delayed fixation 1

Admission Criteria and Monitoring

• Consider admission for observation in elderly patients with multiple rib fractures, even if currently stable 1
• Monitor for 24-48 hours for development of delayed complications 1
• ICU admission criteria:
  • ≥3 rib fractures in elderly patients (>60 years)
  • Flail chest
  • Significant respiratory compromise
  • Poor functional respiratory status (FVC <50% predicted) 1

Follow-up Care

• Patients who have undergone surgical stabilization: initial follow-up within 1-2 weeks of discharge
• All patients: follow-up in clinic within 2-3 weeks after hospital discharge to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Cautions and Pitfalls

• Avoid rib belts, as they appear to be associated with an increased incidence of complications including pleural effusion, atelectasis, and contact dermatitis 2
• Undertriage of seemingly minor injuries can lead to missed significant internal injuries 1
• Delayed recognition of respiratory compromise can lead to pneumonia and respiratory failure 3
• Patients with underlying respiratory disease or COVID-19 require closer monitoring due to higher risk of respiratory compromise 1