Treatment of Rib Fractures
The recommended treatment for rib fractures is a multimodal analgesic approach with regular administration of acetaminophen as first-line therapy, supplemented with non-pharmacological measures and consideration of regional anesthetic techniques for severe cases or high-risk patients. 1, 2
Risk Stratification
Risk factors that predict increased complications in patients with rib fractures include:
- Age >60 years 2, 1
- Low oxygen saturation (SpO2 <90%) 2, 1
- Obesity or malnutrition 2, 1
- Presence of 2-3 rib fractures, flail segment, or pulmonary contusion 2, 1
- Smoking or chronic respiratory disease 1
- Anticoagulation therapy 2, 1
- Major trauma 2, 1
Analgesic Management
First-Line Treatment
- Regular administration of acetaminophen (oral or intravenous) every 6 hours 1, 2
- Oral acetaminophen is equivalent to intravenous acetaminophen for pain control in elderly trauma patients with rib fractures, with no difference in morbidity or mortality 2, 3
Second-Line Treatment
- NSAIDs can be added for patients with severe pain, with careful consideration of potential adverse events and drug interactions 1, 4
- Low-dose ketamine (0.3 mg/kg over 15 minutes) provides analgesic efficacy comparable to morphine but with higher rates of psycho-perceptual adverse effects 2, 1
Advanced Analgesic Techniques
- Regional anesthetic techniques such as thoracic epidural or paravertebral blocks should be considered for severe pain or high-risk patients 5, 6
- Erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB) are viable alternatives with lower incidence of adverse effects 6
Non-Pharmacological Measures
- Application of ice packs to reduce pain and inflammation 7
- Immobilization of the affected area to provide pain relief 7
- Pulmonary hygiene and chest physiotherapy to prevent atelectasis and pneumonia 7
Surgical Management
Surgical fixation should be considered in the following scenarios:
- Patients with unstable chest walls (flail chest) 2, 1
- Severe refractory pain 2, 1
- Chest wall deformity 2, 1
Important considerations for surgical management:
- A Cochrane meta-analysis found no statistically significant difference in mortality between non-operative and operative groups, but surgical fixation reduced pneumonia, chest deformity, and tracheostomy 2, 1
- Surgical fixation is most favorable for patients with flail chest and those who undergo fixation within 72 hours 2, 1
- For patients over 60 years old, conservative management may be more beneficial in terms of hospital stay and mechanical ventilation duration 2, 1
Monitoring and Follow-up
- Regular pain assessment to ensure adequate pain control 7
- Monitoring for respiratory complications such as atelectasis, pneumonia, and respiratory failure 7, 5
- Rib fractures typically heal within 6-8 weeks, but complete recovery may take up to 2 years in some patients 1
Common Pitfalls to Avoid
- Undertreatment of pain can lead to splinting, shallow breathing, poor cough, atelectasis, and pneumonia 7, 8
- Overreliance on opioids can cause respiratory depression, especially in elderly patients 7, 5
- Failure to recognize underlying pulmonary contusion or other associated injuries 7
- Delayed surgical intervention (beyond 72 hours) may reduce benefits in patients who are candidates for fixation 1