What is the optimal management for patients with rib fractures?

Management of Rib Fractures

The optimal management of rib fractures requires a multimodal approach with regular administration of intravenous acetaminophen (1 gram every 6 hours) as first-line treatment for pain management, consideration of regional anesthesia techniques for moderate to severe pain, and surgical stabilization for significantly displaced fractures. 1

Initial Assessment and Risk Stratification

• Initial imaging should include a standard posteroanterior (PA) chest radiograph, despite potentially missing up to 50% of rib fractures, as it can detect complications like pneumothorax, hemothorax, and flail chest 1

• CT scanning is more sensitive, detecting rib fractures in 65% of cases compared to 25% with chest radiography, and may reveal fracture-related complications in approximately 15% of patients 1

• High-risk factors requiring more aggressive management include:

  • Age >60 years
  • ≥3 rib fractures
  • Flail chest
  • Underlying respiratory disease
  • Significant respiratory compromise
  • Poor functional respiratory status 1

• The RibScore can predict adverse pulmonary outcomes based on:

  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) 1

Pain Management Algorithm

Step 1: Non-opioid Analgesics

• Begin with intravenous acetaminophen 1 gram every 6 hours 1
• Consider adding NSAIDs with caution in elderly patients, accounting for potential adverse events and drug interactions 1

Step 2: For Moderate to Severe Pain Despite Step 1

• Consider regional anesthesia techniques:
  • Thoracic Epidural (TE): Reduces opioid consumption and decreases delirium in older patients 1
  • Paravertebral Blocks (PVB): Alternative to TE with promising outcomes 1, 2
  • Erector Spinae Plane Blocks (ESPB): Fewer side effects than TE/PVB, can be performed by trained emergency physicians 1, 2, 3
  • Serratus Anterior Plane Blocks (SAPB): Fewer side effects than TE/PVB 1, 2, 3

Step 3: If Regional Techniques Contraindicated or Unavailable

• Use opioids for the shortest possible period at the lowest effective dose
• Hydromorphone is preferred over morphine 1
• Consider ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids with fewer cardiovascular side effects 1

Surgical Management

• Consider surgical stabilization for rib fractures when:
  • Significantly displaced
  • Causing damage to blood vessels or nerves
  • Fractured in an anterior or anterolateral location 1
• Ribs 3-8 are commonly plated, with the decision based on displacement and impact on respiratory mechanics 1

Respiratory Support

• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure, as it:
  • Decreases mortality
  • Reduces need for intubation
  • Lowers incidence of nosocomial pneumonia 1

Monitoring and Admission Criteria

• Admit to ICU if any of the following:

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

• Monitor for complications:

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

Follow-up

• 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

Clinical Pearls and Pitfalls

• Regional anesthesia techniques are generally more effective than systemic opioids and produce fewer systemic side effects 4
• Thoracic epidural analgesia, while effective, may be contraindicated in many trauma patients (e.g., those with coagulopathy or spinal injuries) 2, 3
• Newer myofascial plane blocks (ESPB and SAPB) provide excellent analgesia with minimal side effects and can be used in anticoagulated patients or those with vertebral fractures 3
• Pain from rib fractures can lead to respiratory compromise, which may exacerbate underlying lung injury and pre-existing respiratory disease 5, 4
• Patients with underlying respiratory disease or COVID-19 are at higher risk of respiratory compromise and may require closer monitoring 1