What are the best steps for managing rib fractures?

Management of Rib Fractures

The standard treatment for rib fractures includes multimodal analgesia, pulmonary hygiene, chest physiotherapy, pleural drainage as needed, and in severe cases, intubation and mechanical ventilation, with surgical stabilization of rib fractures (SSRF) reserved for specific indications. 1

Initial Management Approach

• Multimodal analgesia is the cornerstone of rib fracture management, including regular administration of acetaminophen every 6 hours, supplemented with NSAIDs for severe pain (used cautiously in elderly patients) 2, 3
• Opioids should be reserved only for breakthrough pain at the lowest effective dose for the shortest duration to avoid respiratory depression 2, 3
• Application of ice packs to the affected area helps reduce pain and inflammation 2
• Early mobilization is crucial to prevent respiratory complications 3

Respiratory Care

• Regular deep breathing exercises (10 times every hour while awake) combined with gentle coughing exercises to clear secretions 3
• Proper use of incentive spirometer while sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling 3
• Continue using the incentive spirometer for at least 2-4 weeks to prevent respiratory complications 3
• Maintain good pulmonary hygiene to prevent atelectasis and pneumonia 2, 4

Surgical Considerations

• Surgical stabilization of rib fractures (SSRF) should be considered in specific cases 1:

  • Flail chest
  • Multiple displaced rib fractures
  • Intractable pain despite optimal medical management
  • Respiratory failure requiring mechanical ventilation
  • Chest wall instability

• CT examination should be performed before SSRF, ideally with 3D reconstruction for surgical planning 1

• SSRF is recommended within the first 7 days after trauma, preferably within the first 3 days 5

• SSRF should be considered for fractures in ribs 2-10, with repair of ribs 1,11, and 12 only in highly selected circumstances 1

Special Considerations for Elderly Patients

• Elderly patients require special attention as they are at higher risk for complications 2, 3
• Each rib fracture in elderly patients increases the risk of developing pneumonia by 27% and mortality by 19% 4
• Early SSRF in geriatric patients is associated with better in-hospital outcomes 1
• Opioid doses should be reduced in elderly patients due to higher risk of accumulation and respiratory depression 2

Monitoring for Complications

• Regular assessment for respiratory complications such as atelectasis, pneumonia, and respiratory failure 2, 3
• Monitor for signs requiring immediate medical attention:
  • Worsening shortness of breath 3
  • Fever above 100.4°F (38°C) 3
  • Productive cough with yellow, green, or bloody sputum 3
  • Chest pain different from the rib pain 3

Common Pitfalls to Avoid

• Undertreatment of pain can lead to splinting, shallow breathing, poor cough, atelectasis, and pneumonia 2, 4
• Overreliance on opioids can cause respiratory depression, especially in elderly patients 2
• Use of rib belts is discouraged as they may be associated with increased incidence of complications including pleural effusion and atelectasis 6
• Failure to recognize underlying pulmonary contusion or other associated injuries 2
• Delayed consideration of SSRF in appropriate candidates can lead to prolonged pain and respiratory compromise 1