What is the treatment for a patient with a fractured rib?

Treatment for Broken Rib

The treatment for a fractured rib should focus on pain management with regular administration of intravenous acetaminophen (1 gram every 6 hours) as first-line treatment, especially in elderly patients, while applying ice as the preferred initial therapy to decrease pain and swelling. 1

Pain Management

First-Line Treatments

• Ice application: Apply ice using water surrounded by a damp cloth for 20-30 minutes, 3-4 times daily 1

  • Avoid direct ice-to-skin contact to prevent cold injury
  • A randomized controlled trial showed improved pain scores at weeks 1,2, and 4 after injury

• Acetaminophen: Regular administration (1 gram every 6 hours) 1

  • IV acetaminophen is recommended, though research shows oral acetaminophen is equally effective in elderly patients 2

Second-Line Treatments

• NSAIDs: Consider adding with caution, especially in elderly patients 1

  • Account for potential adverse events and drug interactions

• Opioids: Use for shortest possible period at lowest effective dose 1

  • Hydromorphone preferred over morphine
  • Use with caution due to adverse effects 3

Regional Anesthesia Techniques

For moderate to severe pain despite above measures, consider: 1, 3

1. Thoracic Epidural (TE)

   • Highly effective but contraindicated for many patients
   • Reduces opioid consumption and decreases delirium in older patients

2. Paravertebral Blocks (PVB)

   • Alternative for those with contraindications to TE
   • Has up to 10% failure rate

3. Erector Spinae Plane Blocks (ESPB)

   • Practical alternative with lower incidence of adverse effects
   • Can be performed by trained emergency physicians

4. Serratus Anterior Plane Blocks (SAPB)

   • Similar efficacy to ESPB with fewer side effects

5. Ketamine: Consider 0.3 mg/kg over 15 minutes as an alternative to opioids 1

Activity Recommendations

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

Monitoring and Risk Assessment

High-Risk Factors Requiring More Aggressive Management 1

• Age >60 years
• ≥3 rib fractures
• Flail chest
• Underlying respiratory disease
• Significant respiratory compromise
• Poor functional respiratory status

ICU Admission Criteria 1

Admit patients with rib fractures to ICU if they have any of the following:

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

Complications to Monitor For 1

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

Imaging and Diagnosis

• CT scan of the chest is recommended to evaluate: 1
  • Number of fractured ribs
  • Displacement of fractures
  • Presence of flail chest
  • Anatomic distribution of fractures
  • First rib fractures

RibScore Variables to Predict Adverse Pulmonary Outcomes 1

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

Surgical Considerations

Consider surgical stabilization for rib fractures when: 1

• Significantly displaced
• Causing damage to blood vessels or nerves
• Fractured in an anterior or anterolateral location
• Ribs 3-8 are commonly plated based on displacement and impact on respiratory mechanics

Follow-up

• Initial follow-up within 1-2 weeks of discharge for surgically stabilized patients 1
• All patients should have follow-up in clinic within 2-3 weeks after hospital discharge to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging

Special Considerations

• Non-invasive ventilation (NIV) should be considered for chest trauma patients with acute respiratory failure 1
• Patients with underlying respiratory disease or COVID-19 are at higher risk of respiratory compromise and may require closer monitoring 1
• In elderly patients, each rib fracture increases the risk of developing pneumonia by 27% and the risk of dying by 19% 4