What are the treatment options for rib fractures in the geriatric population?

From the Guidelines

Treatment of rib fractures in elderly patients should prioritize a multimodal approach, focusing on pain control, respiratory support, and prevention of complications, with consideration of surgical fixation for flail chest or severely displaced fractures. Pain management should include scheduled acetaminophen (1000 mg every 6 hours) as the first line treatment, as recommended by the 2023 WSES guidelines 1, combined with NSAIDs like ibuprofen (400-600 mg every 6 hours) if not contraindicated by renal function or bleeding risk. For moderate to severe pain, add opioids such as oxycodone 5-10 mg every 4-6 hours as needed, while monitoring for respiratory depression and constipation. Regional anesthesia techniques like intercostal nerve blocks or thoracic epidural analgesia may provide superior pain control for multiple fractures, as supported by the 2023 WSES guidelines 1 and a systematic review 1. Respiratory care is crucial and includes incentive spirometry every 1-2 hours while awake, deep breathing exercises, and early mobilization to prevent atelectasis and pneumonia. Supplemental oxygen should be provided to maintain oxygen saturation above 92%. Some key points to consider in the management of rib fractures in the elderly include:

• The use of ketamine as an alternative to opioids for pain management, as it has been shown to have fewer side effects and similar efficacy 1
• The consideration of surgical fixation for patients with flail chest or severely displaced fractures, as it may reduce mortality and improve outcomes, although the evidence is still limited and inconclusive 1
• The importance of individualizing treatment based on the patient's age, comorbidities, and clinical condition, as advanced age and comorbidities may increase the risk of post-operative morbidity, but may also benefit from surgical fixation 1 Elderly patients with multiple rib fractures often benefit from admission for observation and pain control, particularly those with three or more fractures, underlying pulmonary disease, or who use anticoagulants. Close follow-up is essential, with reassessment within 1-2 weeks to monitor healing and adjust pain management. This comprehensive approach addresses the higher complication rates in elderly patients, whose decreased physiological reserve and comorbidities increase their vulnerability to complications like pneumonia and respiratory failure.

From the Research

Treatment Options for Rib Fractures in the Geriatric Population

• The primary goal of care for rib fractures in the geriatric population is to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications 2.
• A multimodal analgesia approach is recommended, including pharmacologic and regional analgesic blocks, to reduce morbidity and mortality associated with rib fractures 3.
• Oral acetaminophen is equivalent to intravenous acetaminophen for pain control in elderly trauma patients with rib fractures, with no difference in morbidity or mortality 4.
• Novel regional anesthesia techniques, such as thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block, can be used to provide analgesia 3.
• Nerve blocks, including intercostal nerve blocks, can be instrumental in treating rib fracture pain, and can be used in conjunction with opioids and non-opioids as part of a multimodal approach to pain management 5.
• Surgical fixation of rib fractures may be considered in certain cases, and has been shown to decrease ICU length of stay, ventilator days, and pneumonia in patients with multiple rib fractures 6.

Analgesia Options

• Pharmacologic options for analgesia include acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine 3.
• Regional analgesia options include thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block 3.
• Oral acetaminophen is a viable option for pain control in elderly trauma patients with rib fractures, and can be used as an alternative to intravenous acetaminophen 4.

Management Strategies

• A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality in patients with rib fractures 3.
• Risk stratification tools, such as the Study of the Management of Blunt Chest Wall Trauma score, can be used to identify patients at high risk of deterioration 3.
• Comprehensive geriatric assessment can be used to deliver quality care to older adults with rib fractures, who often have multi-morbidity and frailty that complicate their injuries 2.