What is the best course of treatment for a patient with a persistent left rib pain due to an old (greater than 1 week) rib fracture diagnosed by computed tomography (CT) scan of the chest?

Management of Persistent Rib Pain from an Old Rib Fracture

For persistent rib pain from an old rib fracture (>1 week), regular administration of acetaminophen (1 gram every 6 hours) is the recommended first-line treatment, with cautious addition of NSAIDs if pain persists. 1

Pain Management Algorithm

1. First-line treatment:

   • Acetaminophen 1 gram every 6 hours intravenously or orally
   • Dose adjustment based on age and renal function
   • Provides effective pain relief with minimal side effects 1

2. Second-line options (if pain persists):

   • Add NSAIDs with caution, especially in elderly patients
     • Consider gastrointestinal, renal, and cardiovascular risks
     • Monitor for drug interactions 1
   • Ice application to reduce local inflammation 2

3. For breakthrough pain:

   • Opioids at lowest effective dose for shortest duration
     • Use cautiously, especially in elderly patients
     • Monitor for respiratory depression, sedation, and delirium 1
   • Consider ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids with fewer cardiovascular side effects 1

4. Physical support options:

   • Rib belt or tape for stabilization
   • Should not restrict breathing 2

Regional Anesthesia Considerations

For patients with severe pain not responding to oral/IV medications, regional anesthesia techniques may be considered:

Technique	Benefits
Thoracic Epidural	Reduces opioid consumption, decreases delirium in older patients
Paravertebral Blocks	Similar benefits to epidural with potentially fewer side effects
Erector Spinae Plane Blocks	Fewer side effects than epidural/paravertebral blocks
Serratus Anterior Plane Blocks	Good option for lateral rib pain with fewer side effects [1]

Monitoring and Follow-up

• Follow-up within 2-3 weeks to evaluate:

  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

• Monitor for potential complications:

  • Pneumothorax
  • Hemothorax
  • Pneumonia
  • Respiratory compromise 1

Important Considerations

• Rib fractures can worsen in displacement over time, which may explain persistent pain 3
• Isolated rib fractures generally have low morbidity but can impair ventilation and compromise recovery 1
• Healing should be well established before return to sports or strenuous activities 2

Special Circumstances

• If the fracture involves ribs 1-2 or 11-12, more careful monitoring is warranted as these can indicate more severe trauma or have higher complication rates 1, 4
• For significantly displaced fractures causing persistent severe pain or respiratory compromise, surgical stabilization may be considered, though this is less common for old fractures 1, 5

Pitfalls to Avoid

• Don't underestimate rib fractures: Even isolated rib fractures can lead to significant morbidity and may be markers of severe injury 6
• Don't overlook respiratory function: Monitor for signs of respiratory compromise, especially in elderly patients or those with underlying lung disease 1
• Don't rely solely on opioids: They carry significant risks, especially in elderly patients, and should be used only for breakthrough pain 1
• Don't neglect follow-up: Rib fractures can worsen in displacement over time, potentially requiring adjustment of pain management strategy 3