What are the treatment options for fractured ribs in the geriatric population?

From the Guidelines

The primary treatment for fractured ribs in the geriatric population should focus on pain management and preventing complications, with a multimodal approach including acetaminophen and NSAIDs, as well as considering surgical stabilization of rib fractures (SSRF) in selected cases, as recommended by the 2023 WSES guidelines 1. The treatment of fractured ribs in elderly patients is crucial to prevent complications and improve quality of life. Key considerations include:

• Pain management with acetaminophen (500-1000mg every 6 hours) and NSAIDs like ibuprofen (400-600mg every 6-8 hours) if not contraindicated 1
• Avoiding binding or wrapping the chest to prevent respiratory restriction and pneumonia
• Performing deep breathing exercises hourly to prevent lung complications
• Applying ice packs for 15-20 minutes several times daily to reduce pain and inflammation
• Maintaining mobility while avoiding strenuous activities that exacerbate pain
• Monitoring closely for complications like pneumonia, which presents with increased shortness of breath, fever, or productive cough 1 In selected cases, surgical stabilization of rib fractures (SSRF) may be considered to improve pain control and reduce complications, particularly in patients with flail chest or severe pain, as suggested by recent studies 1. However, the decision to perform SSRF should be made on a case-by-case basis, taking into account the individual patient's risk factors and comorbidities. It is essential to weigh the potential benefits of SSRF against the risks of surgery in elderly patients, as the evidence is still unclear on the individual contribution of operative and conservative treatment in reducing morbidity and mortality in this population 1.

From the Research

Treatment Options for Fractured Ribs in the Geriatric Population

• The primary goal of care for geriatric patients with fractured ribs is to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications 2
• A multimodal analgesia approach is recommended, including risk stratification tools and pharmacologic and regional analgesic blocks 3
• Regional anesthesia techniques, such as thoracic epidural analgesia (TEA), thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block, have been shown to be effective in managing pain associated with rib fractures 3, 4
• Other treatment options include:
  • Pharmacologic analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine 3
  • Intercostal nerve block (ICNB) 4
  • Surgical fixation of rib fractures, although the current role for this remains unclear for older adults 2
• Epidural analgesia (EA) has been studied as a potential treatment option, but its effectiveness in decreasing the need for invasive mechanical ventilation (IMV) is unclear 5

Considerations for Geriatric Patients

• Geriatric patients with fractured ribs are at higher risk of mortality and morbidity due to pain-induced hypoventilation, pneumonia, and respiratory failure 2
• Older adults with rib fractures often have multi-morbidity and frailty, which can complicate their injuries 2
• Comprehensive geriatric assessment is essential in the management of rib fractures in older adults 2