What is the initial management for a patient with displaced ribs from a fall?

Management of Displaced Ribs from Fall

The initial management for a patient with displaced ribs from a fall should focus on adequate pain control, respiratory support, and assessment for surgical stabilization of rib fractures (SSRF) in cases with significant displacement or respiratory compromise. 1, 2

Initial Assessment and Risk Stratification

• Evaluate the number, location, and degree of displacement of rib fractures using CT imaging 1, 3
• Assess for flail chest (clinical finding characterized by paradoxical movement of a chest wall segment) or flail segment (radiographic finding of 3+ consecutive ribs fractured in 2+ places) 1
• Identify high-risk factors that increase complication risk:
  • Age >60 years 2
  • Low oxygen saturation (SpO2 <90%) 2
  • Obesity or malnutrition 2
  • Presence of 2-3 rib fractures, flail segment, or pulmonary contusion 2
  • Smoking or chronic respiratory disease 2
  • Anticoagulation therapy 2
  • Major trauma 2

Pain Management

• Implement multimodal analgesia to control pain and allow for adequate respiratory effort 2, 4:
  • First-line: Regular administration of acetaminophen (oral is equivalent to IV in effectiveness) 2
  • Second-line: NSAIDs such as ketorolac (if no contraindications) 2
  • Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 2
  • For severe pain or high-risk patients, consider regional anesthetic techniques:
    • Thoracic epidural analgesia 2, 5
    • Paravertebral blocks 2, 5
    • Serratus anterior or erector spinae plane nerve blocks 5
    • Intercostal nerve blocks 5

Respiratory Support

• Encourage deep breathing exercises and incentive spirometry to prevent atelectasis and pneumonia 3, 4
• Early mobilization to prevent pulmonary complications 3
• Monitor for signs of respiratory compromise (increased respiratory rate, decreased oxygen saturation) 3
• Be vigilant for development of pneumonia, which is the common pathway to respiratory failure in patients with rib fractures 4

Surgical Management Considerations

• SSRF should be considered in patients with any of the following conditions:

  • Flail chest (clinical finding with paradoxical movement) 1, 5
  • Multiple (≥3) ipsilateral severely displaced rib fractures 1, 6
  • Multiple (≥3) ipsilateral displaced rib fractures in ribs 3-10 with respiratory failure or at least two pulmonary derangements despite adequate pain control:
    • Respiratory rate >20 breaths/minute 1
    • Incentive spirometry <50% predicted 1
    • Numeric pain score >5/10 1
    • Poor cough 1
  • Chest wall deformity significantly affecting lung function 1
  • Severe pain non-responsive to other treatments 1, 3

• SSRF is most beneficial when performed within the first 72 hours after injury, preferably within the first 48 hours 2, 5

• Ribs 3-8 are most commonly plated, while first, second, eleventh, and twelfth ribs are typically not fixed unless significantly displaced 1, 5

Monitoring and Follow-up

• Regular reassessment of pain control and respiratory status 3
• Monitor for complications such as pneumothorax, hemothorax, pneumonia, and respiratory failure 3, 4
• Be aware that complete healing of rib fractures typically takes 6-8 weeks, but full recovery with resolution of pain may take up to 2 years in some patients 2

Pitfalls to Avoid

• Inadequate pain control leading to splinting, poor respiratory effort, and atelectasis 3, 4
• Failure to identify high-risk patients who need more aggressive pain management or surgical intervention 2
• Delayed surgical intervention when indicated, as SSRF is most effective when performed early (within 72 hours) 2, 5
• Underestimating the impact of rib fractures in elderly patients, who have significantly higher morbidity and mortality 2, 4