Treatment of Costochondritis and Rib Fractures
For both costochondritis and rib fractures, conservative management with regular acetaminophen (1 gram every 6 hours) is strongly recommended as first-line treatment, supplemented with non-pharmacological approaches such as immobilization and ice packs. 1
Diagnosis and Differentiation
Costochondritis
- Diagnosis is primarily clinical, based on:
- Reproducible pain on palpation of costal cartilages
- Absence of swelling or erythema
- Normal laboratory values and imaging studies 2
Rib Fractures
- Standard posteroanterior chest radiograph is recommended as the initial diagnostic test 1
- CT is more sensitive (detects 65% of fractures vs 25% with radiography) and may be indicated when complications are suspected 1
- High-risk factors requiring more aggressive management:
- Age >60 years
- ≥3 rib fractures
- Flail chest
- Underlying respiratory disease
- Significant respiratory compromise 1
Treatment Algorithm
1. Pain Management
Pharmacological Interventions
- First-line: Acetaminophen 1g every 6 hours (dose-adjust for age and renal function) 1
- Second-line: NSAIDs with caution, especially in elderly patients 1
- For breakthrough pain: Opioids at lowest effective dose for shortest period 1
- Alternative to opioids: Ketamine (0.3 mg/kg over 15 minutes) 1
Regional Anesthesia Techniques (for severe rib fracture pain)
- Thoracic Epidural (TE)
- Paravertebral Blocks (PVB)
- Erector Spinae Plane Blocks (ESPB)
- Serratus Anterior Plane Blocks (SAPB) 1
2. Non-Pharmacological Interventions
For Costochondritis
- Stretching exercises have shown significant improvement in pain compared to control groups 3
- Avoid activities that produce chest muscle overuse 2
- Consider manipulative therapy and soft tissue mobilization for persistent cases 4
For Rib Fractures
- Immobilization of affected area
- Ice packs application 1
- Rigid immobilization is preferred over removable splints 5
3. Surgical Interventions (Rib Fractures Only)
Consider surgical fixation for rib fractures with:
- Postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 5
- Significant displacement
- Damage to blood vessels or nerves
- Fractures in anterior or anterolateral location
- Ribs 3-8 may be considered for surgical stabilization 1
Monitoring and Follow-up
For Rib Fractures
- Monitor for complications: pneumothorax, hemothorax, pulmonary contusion, pneumonia, respiratory failure 1
- ICU admission criteria:
- ≥3 rib fractures in elderly patients (>60 years)
- Flail chest
- Significant respiratory compromise
- Poor functional respiratory status 1
- Consider non-invasive ventilation for chest trauma patients with acute respiratory failure 1
- Follow-up within 2-3 weeks after discharge 1
For Costochondritis
- Reassurance about benign nature of condition 2
- Follow-up to ensure resolution of symptoms
- Typical cases resolve within weeks, but atypical cases may persist 4
Important Caveats
- Costochondritis is a diagnosis of exclusion - serious causes of chest pain must be ruled out first 4, 2
- Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 2
- Patients >35 years, those with cardiac risk factors, or cardiopulmonary symptoms should have ECG and possibly chest radiograph 2
- Isolated rib fractures have relatively low morbidity and mortality, but underlying organ injuries can have significant clinical impact 5
- Surgical fixation of rib fractures within 72 hours post-injury may lead to better outcomes in selected patients, but conservative treatment remains the standard for most patients 6