What are the management options for rib fractures?

Management of Rib Fractures

Pain Management Algorithm

Start with scheduled oral acetaminophen 1000mg every 6 hours as first-line therapy for all patients with rib fractures, regardless of severity. 1, 2

Stepwise Analgesic Approach:

First-line:

• Acetaminophen every 6 hours (oral equivalent to IV formulation in elderly patients) 2

Second-line additions for inadequate pain control:

• NSAIDs (e.g., ibuprofen) for severe pain, weighing GI/renal/cardiovascular risks 1, 2
• Ketorolac 60mg IM/IV for moderate pain in patients aged 17-64 without contraindications (aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, or anticoagulation) 1, 2, 3

Third-line for severe refractory pain:

• Low-dose ketamine 0.3 mg/kg IV over 15 minutes (comparable efficacy to morphine but with psycho-perceptual side effects) 1, 2
• Regional anesthesia techniques (see below) 2, 4

Regional Anesthesia for High-Risk or Severe Cases:

Thoracic epidural analgesia (TEA) or paravertebral block (PVB) are gold standard for severe pain or high-risk patients (≥3 fractures, flail chest, age >60, chronic respiratory disease). 2, 4

Alternative peripheral nerve blocks when TEA/PVB contraindicated or unavailable:

• Erector spinae plane block (ESPB) - can be performed by trained emergency physicians, lower complication rates 4
• Serratus anterior plane block (SAPB) - similar efficacy to TEA/PVB with fewer adverse effects 4
• Intercostal nerve blocks - less effective, requires concurrent IV analgesia 4, 5

Risk Stratification (Identifies Need for Aggressive Management)

High-risk patients requiring closer monitoring and consideration for regional anesthesia or surgical consultation: 1, 2

• Age >60 years 1, 2
• SpO2 <90% 2
• ≥3 rib fractures 1, 2
• Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1, 2
• Pulmonary contusion 1, 2
• Chronic respiratory disease or smoking 1, 2
• Obesity or malnutrition 1, 2
• Anticoagulation therapy 1, 2
• Major trauma mechanism 2

Respiratory Care Protocol

• Incentive spirometry targeting >50% predicted volume 1
• Monitor respiratory rate (>20 breaths/minute indicates compromise) 1
• Teach coughing techniques with chest wall support 1

Surgical Stabilization Indications

Consider surgical stabilization of rib fractures (SSRF) within 48-72 hours for: 1, 2, 6

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1, 2
• ≥3 ipsilateral severely displaced fractures (>50% displacement on CT) 2, 6
• Severe refractory pain despite multimodal analgesia 1, 2
• Chest wall deformity 1, 2
• Respiratory failure with multiple displaced fractures in ribs 3-10 2

Surgical benefits: Reduced pneumonia, chest deformity, tracheostomy rates, and faster return to work (3-6 months vs longer with conservative management). 2, 6 No mortality difference in meta-analysis, but timing matters—fixation within 72 hours shows better outcomes than delayed surgery. 2, 6

Note: In patients >60 years, evidence for surgical benefit is mixed; some studies show reduced mortality with SSRF in elderly, while others favor conservative management for hospital stay and ventilation duration. 2 Individualize based on fracture severity and respiratory status.

Recovery Timeline and Follow-up

Typical healing: 6-8 weeks for bone union, but complete functional recovery may take up to 2 years. 1, 2

Return to work expectations: 1, 2

• Simple fractures: 8-12 weeks
• Complex injuries: up to 6 months
• Post-SSRF: 3-6 months with improved outcomes

Follow-up monitoring: 1, 2

• Pain should significantly improve by 4 weeks 1, 2
• Evaluate for chronic pain syndromes (develop in 40% of patients) 1, 2
• Consider imaging for severely displaced fractures to assess healing 1
• Monitor for non-union (1-5% incidence, may require surgery) 1, 2

Warning Signs Requiring Immediate Evaluation

Instruct patients to seek emergency care for: 1

• Worsening shortness of breath or difficulty breathing 1
• Increasing chest pain uncontrolled by medications 1
• Dizziness, confusion, or extreme fatigue 1

Critical Pitfalls to Avoid

• Underestimating elderly risk: Patients >60 have significantly higher morbidity/mortality; lower threshold for regional anesthesia and admission 1, 2, 3
• Delayed regional anesthesia: High-risk patients benefit from early TEA/PVB rather than escalating through systemic opioids 2, 4
• Missing surgical window: SSRF most beneficial within 48-72 hours; delayed fixation reduces benefits 2, 6
• Inadequate respiratory support: Failure to implement incentive spirometry and monitor respiratory rate leads to pneumonia and respiratory failure 1