What is the management of rib fractures?

Management of Rib Fractures

Multimodal analgesia is the cornerstone of rib fracture management, including regular administration of acetaminophen every 6 hours, supplemented with NSAIDs for severe pain, with opioids reserved only for breakthrough pain at the lowest effective dose for the shortest duration. 1

Initial Assessment and Risk Stratification

• Rib fractures are the most common thoracic injury, present in 10% of all traumatic injuries and almost 40% of patients with severe nonpenetrating trauma 2
• High-risk factors that predict increased complications include:
  • Age >60 years 3
  • Low oxygen saturation (SpO2 <90%) 3
  • Presence of 2-3 or more rib fractures 3
  • Unstable chest wall (flail chest) 3
  • Smoking or chronic respiratory disease 3
  • Anticoagulation therapy 3
  • Obesity or malnutrition 3

Diagnostic Approach

• Initial evaluation should include a standard posteroanterior (PA) chest radiograph, which may miss up to 50% of rib fractures but can detect important complications like pneumothorax, hemothorax, or flail chest 2
• CT examination should be performed before surgical stabilization of rib fractures (SSRF), ideally with 3D reconstruction for surgical planning 1

Pain Management

Pharmacological Approaches

• First-line: Regular administration of acetaminophen every 6 hours 1, 3
• Second-line: NSAIDs such as ketorolac for additional pain control in moderate to severe pain 3, 4
  • Ketorolac dosing: 60 mg IM every 15-30 minutes (maximum 120 mg/day) for patients 17-64 years 4
  • Contraindicated in pregnancy, cerebrovascular hemorrhage, and patients with aspirin/NSAID-induced asthma 4
• Third-line: Low-dose ketamine (0.3 mg/kg over 15 minutes) can be used as an alternative to opioids 3, 4
• Reserve opioids only for breakthrough pain at the lowest effective dose for the shortest duration 1
  • Reduce opioid doses in elderly patients due to higher risk of respiratory depression 1

Regional Anesthetic Techniques

• Thoracic epidural and paravertebral blocks are considered gold standard for severe pain or high-risk patients 3, 4, 5
• Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) are practical alternatives with lower incidence of adverse effects 5

Respiratory Care

• Regular deep breathing exercises and gentle coughing exercises to clear secretions 1
• Use of incentive spirometer while sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling 1
• Continue using the incentive spirometer for at least 2-4 weeks to prevent respiratory complications 1
• Monitor for signs requiring immediate medical attention:
  • Worsening shortness of breath 1
  • Fever above 100.4°F (38°C) 1
  • Productive cough with yellow, green, or bloody sputum 1
  • Chest pain different from the rib pain 1

Surgical Management

• Surgical stabilization of rib fractures (SSRF) should be considered in specific cases:
  • Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1, 3, 6
  • Intractable pain despite optimal medical management 1, 3
  • Respiratory failure requiring mechanical ventilation 1
  • Chest wall deformity 3, 6
• SSRF is recommended for fractures in ribs 2-10, with repair of ribs 1,11, and 12 only in highly selected circumstances 1
• Early SSRF (within 72 hours) shows better outcomes than delayed surgical intervention 3, 6

Recovery Timeline and Follow-up

• Rib fractures typically heal within 6-8 weeks, but complete recovery may take up to 2 years in some patients 3
• Pain scores typically improve significantly by 4 weeks post-injury with appropriate management 3
• Functional recovery with return to normal activities may take 8-12 weeks for simple fractures and up to 6 months for complex injuries 3

Common Pitfalls to Avoid

• Undertreatment of pain can lead to splinting, shallow breathing, poor cough, atelectasis, and pneumonia 1
• Overreliance on opioids can cause respiratory depression, especially in elderly patients 1
• Delayed consideration of SSRF in appropriate candidates can lead to prolonged pain and respiratory compromise 1
• Non-union (failure to heal) may occur in approximately 1-5% of cases, requiring surgical intervention 3