What is the management of displaced rib fractures?

Management of Displaced Rib Fractures

Surgical stabilization should be considered for significantly displaced rib fractures, especially when they cause damage to blood vessels or nerves, or are fractured in an anterior or anterolateral location. 1

Assessment and Diagnosis

• CT scan of the chest is recommended to evaluate:

  • Number of fractured ribs
  • Degree of displacement
  • Presence of flail chest
  • Anatomic distribution of fractures
  • First rib involvement 1

• RibScore variables that predict adverse pulmonary outcomes:

  1. ≥6 rib fractures
  2. Bilateral fractures
  3. Flail chest
  4. ≥3 severely displaced fractures
  5. First rib fracture
  6. Fractures in all 3 anatomic areas (anterior, lateral, posterior) 1

Management Approach

Surgical Management

• Surgical stabilization is indicated for:

  • Significantly displaced fractures
  • Fractures causing damage to blood vessels or nerves
  • Fractures in anterior or anterolateral locations
  • Multiple bicortically displaced fractures
  • Flail chest
  • Concomitant ipsilateral displaced clavicular or sternal fracture 1, 2

• Ribs 3-8 are most commonly plated 1, 2

• Timing: Surgical stabilization is recommended within the first 7 days after trauma, preferably within the first 3 days 2

• Surgical techniques:

  • Precontoured side and rib-specific plates with threaded holes and self-tapping locking screws
  • Polymer cable cerclage for longitudinal fractures, fractures near spine, osteoporotic ribs, and rib cartilage injuries 2

Pain Management

1. First-line pharmacological treatment:

   • Regular intravenous acetaminophen (1 gram every 6 hours) 1
   • Acetaminophen has shown similar efficacy to morphine with fewer side effects 3

2. Additional pain management options:

   • NSAIDs with caution, especially in elderly patients 1
   • Opioids at lowest effective dose for shortest possible period (hydromorphone preferred over morphine) 1
   • Ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 1

3. Regional anesthesia techniques:

   • Thoracic Epidural (TE): Reduces opioid consumption and delirium in older patients 1, 4
   • Paravertebral Blocks (PVB): Alternative when TE is contraindicated 1, 5
   • Erector Spinae Plane Blocks (ESPB): Fewer side effects than TE/PVB 1, 5
   • Serratus Anterior Plane Blocks (SAPB): Fewer side effects than TE/PVB 1, 5

4. Non-pharmacological management:

   • Ice application for 20-30 minutes, 3-4 times daily 1
   • Activity modification to avoid pain-provoking movements 1

Monitoring and Follow-up

• 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

• ICU admission criteria:

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

• Consider non-invasive ventilation for patients with acute respiratory failure 1

• Monitor for complications:

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

• Follow-up schedule:

  • Within 1-2 weeks of discharge for surgically stabilized patients
  • Within 2-3 weeks after hospital discharge for all patients 1

Pitfalls and Caveats

• Epidural analgesia, while effective, has numerous contraindications in trauma patients 4, 6
• Regional blocks may have failure rates up to 10% and potential complications 5
• Patients with underlying respiratory disease or COVID-19 require closer monitoring 1
• Surgical stabilization has shown improved outcomes compared to traditional non-operative management but requires careful patient selection 2