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

Management of Rib Fractures

The management of rib fractures should prioritize multimodal pain control with regular administration of intravenous acetaminophen (1 gram every 6 hours) as first-line treatment, application of ice therapy 3-4 times daily for 20-30 minutes, consideration of regional anesthesia techniques for moderate to severe pain, and surgical stabilization only for specific indications such as flail chest with respiratory failure or significantly displaced fractures causing vascular or nerve damage. 1

Initial Assessment and Risk Stratification

• Obtain CT scan of the chest to evaluate:

  • Number of fractured ribs
  • Displacement of fractures
  • Presence of flail chest
  • Anatomic distribution of fractures
  • First rib involvement 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

• Consider ICU admission for patients with:

  • ≥3 rib fractures in elderly patients (>60 years)
  • Flail chest
  • Significant respiratory compromise
  • Poor functional respiratory status (FVC <50% predicted) 1

Pain Management Algorithm

First-Line Treatments

1. Ice therapy

   • Apply ice and water surrounded by a damp cloth
   • Limit application to 20-30 minutes per session
   • Apply 3-4 times daily
   • Avoid direct ice-to-skin contact 1

2. Acetaminophen

   • Regular administration of IV acetaminophen (1 gram every 6 hours) 1
   • Particularly beneficial in elderly patients

Second-Line Treatments

1. NSAIDs

   • Add with caution, especially in elderly patients
   • Consider potential adverse events and drug interactions 1
   • Early IV ibuprofen has been shown to decrease narcotic requirements and hospital length of stay 2

2. Opioids

   • Use for shortest possible period at lowest effective dose
   • Hydromorphone preferred over morphine 1
   • Monitor for respiratory depression

Third-Line Treatments (For Moderate to Severe Pain)

1. Regional anesthesia techniques:

   • Thoracic Epidural (TE): Reduces opioid consumption and delirium in older patients
   • Paravertebral Blocks (PVB): Alternative when TE is contraindicated
   • Erector Spinae Plane Blocks (ESPB): Fewer side effects than TE/PVB
   • Serratus Anterior Plane Blocks (SAPB): Fewer side effects than TE/PVB 1, 3, 4

2. Ketamine

   • Consider 0.3 mg/kg over 15 minutes as an alternative to opioids
   • Has fewer cardiovascular side effects 1

Surgical Management

Indications for Surgical Stabilization of Rib Fractures (SSRF)

• Flail chest with respiratory failure
• ≥3 severely displaced rib fractures
• ≥5 consecutive rib fractures
• Fractures causing damage to blood vessels or nerves
• Fractures in anterior or anterolateral location 1

Timing of Surgery

• Early SSRF (≤48 hours) is associated with:
  • Decreased ICU length of stay
  • Reduced overall hospital stay
  • Fewer ventilation days
  • Lower costs compared to delayed fixation 1

Surgical Considerations by Rib Location

• First, second, and third ribs: Surgical stabilization NOT recommended unless significantly displaced or causing vascular/nerve damage
• Ribs 3-8: May be considered for surgical stabilization based on displacement and impact on respiratory mechanics 1

Monitoring and Follow-up

• Monitor for complications:

  • Pneumothorax
  • Hemothorax
  • Pulmonary contusion
  • Pneumonia
  • Respiratory failure
  • Vascular injuries (especially with first rib fractures) 1

• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure

  • Decreases mortality
  • Reduces need for intubation
  • Lowers incidence of nosocomial pneumonia 1

• Follow-up schedule:

  • Surgical patients: Initial follow-up within 1-2 weeks of discharge
  • All patients: Clinic follow-up within 2-3 weeks after discharge
  • Evaluate pain control, respiratory function, functional status, and need for additional imaging 1

Special Considerations

• Patients with underlying respiratory disease or COVID-19 are at higher risk of respiratory compromise and require closer monitoring 1

• Lower rib fractures may indicate abdominal organ injury and should prompt appropriate evaluation 1

• Concurrent traumatic brain injury increases risk of poor outcomes 1

• Avoid activities that cause pain and limit use of the injured area to prevent worsening 1