From the Guidelines
Treatment for rib fractures should prioritize surgical stabilization of rib fractures (SSRF) in patients with flail chest or non-flail chest patients with multiple severely displaced rib fractures, as it can improve outcomes and reduce morbidity and mortality, as recommended by the most recent guidelines 1.
Overview of Treatment
The primary goal of treating rib fractures is to manage pain, prevent complications, and improve quality of life. According to recent studies, SSRF should be considered in all flail chest patients and in non-flail chest patients with specific criteria, such as multiple severely displaced rib fractures or respiratory failure despite mechanical ventilation 1.
Pain Management
For patients who do not require SSRF, pain management is crucial. Over-the-counter medications like acetaminophen (Tylenol) at 650-1000mg every 6 hours or ibuprofen (Advil, Motrin) at 400-600mg every 6-8 hours with food can be effective for mild to moderate pain. For severe pain, stronger medications like tramadol or short-term opioids may be prescribed by a doctor.
Preventing Complications
Deep breathing exercises, such as taking 10 slow, deep breaths every hour while awake, are essential to prevent pneumonia. Applying ice packs to the injured area for 15-20 minutes several times daily can reduce pain and swelling. During recovery, it is recommended to avoid activities that worsen pain, sleep in a semi-upright position if lying flat is uncomfortable, and hold a pillow against the chest when coughing or sneezing to stabilize the area.
Recent Guidelines and Studies
Recent studies, such as the 2023 WSES guidelines on the management of trauma in elderly and frail patients, suggest that surgical rib fixation can be beneficial in certain cases, but the individual contribution of operative and conservative treatment in reducing morbidity and mortality is still unclear 1. However, the most recent and highest-quality study, the WSES and CWIS position paper on SSRF, provides clear recommendations for SSRF indications 1.
Key Recommendations
- SSRF should be considered in all flail chest patients and in non-flail chest patients with multiple severely displaced rib fractures or respiratory failure despite mechanical ventilation 1.
- Pain management should prioritize over-the-counter medications and deep breathing exercises to prevent complications.
- Recent guidelines and studies emphasize the importance of individualized treatment approaches, considering factors such as patient age, comorbidities, and fracture severity.
From the Research
Treatment Options for Rib Fractures
- Surgical stabilization of rib fractures is a treatment option that has shown improved outcomes 2
- Nonoperative treatment alternatives include:
- Epidural analgesia
- Thoracic paravertebral blockage
- Intercostal nerve block
- Intravenous or enteral analgesics (e.g., opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs))
- Intrapleural analgesia
- Multimodal analgesia that incorporates regional techniques, systemic analgesics, and analgesic adjuncts 2
- Regional anesthesia techniques, such as thoracic epidural analgesia (TEA), paravertebral block (PVB), serratus anterior plane blocks (SAPB), and erector spinae blocks (ESPB), have been shown to be effective in managing pain related to rib fractures 3, 4
- Intercostal nerve block (ICNB) has been shown to have less analgesic impact compared to other regional anesthesia techniques 4
- Surgical fixation of rib fractures has been shown to decrease ICU length of stay, ventilator days, and pneumonia rates in patients with multiple rib fractures 5
Considerations for Treatment
- The choice of treatment depends on the patient's case and the team's preferences 4
- Careful assessment to identify patients at high risk of complications is essential, and calculation of a rib fracture score can aid management decisions 6
- Pain from rib fractures can be severe and requires multimodal analgesia started promptly and proactively on hospital admission 6
- Regional anaesthetic techniques, such as thoracic epidurals and erector spinae blocks, may be considered for patients with significant chest trauma or those at high risk of pulmonary complications 6