What are the treatment options for rib pain?

Treatment of Rib Pain

Start with scheduled oral or intravenous acetaminophen 1000mg every 6 hours as first-line therapy for rib fracture pain, regardless of patient age or fracture severity. 1, 2

Risk Stratification

Before determining your analgesic approach, assess for high-risk features that predict complications and need for escalated pain management 3, 1:

• Age >60 years - each additional rib fracture increases pneumonia risk by 27% and mortality by 19% 3
• SpO2 <90% 1
• Obesity or malnutrition 1
• ≥2-3 rib fractures, flail segment, or pulmonary contusion 1
• Smoking or chronic respiratory disease 1
• Anticoagulation therapy 1
• Major trauma 1

The presence of multiple risk factors significantly increases complication likelihood and should trigger more aggressive pain management. 1

Analgesic Algorithm

Step 1: Acetaminophen (All Patients)

• Oral acetaminophen is equivalent to IV acetaminophen for pain control with no difference in morbidity or mortality 1, 4
• Dose: 1000mg every 6 hours scheduled (not as-needed) 1, 2
• This should be the foundation regardless of fracture severity 1

Step 2: Add NSAIDs for Moderate Pain (Low-Risk Patients)

• Add ketorolac or ibuprofen for patients without high-risk features who have inadequate pain control on acetaminophen alone 1, 5
• Ketorolac dosing: 60mg IM/IV initially, then 30mg every 6 hours (maximum 120mg/day for ages 17-64) 5
• Ibuprofen dosing: 400mg every 4-6 hours as needed 6
• Contraindications: aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, active GI bleeding 5, 6
• Use with extreme caution in elderly patients and those on anticoagulation 5

Step 3: Regional Anesthesia (High-Risk or Severe Pain)

For patients with uncontrolled pain despite oral/IV medications OR presence of ≥2 risk factors, escalate to regional techniques: 3, 1

• Thoracic epidural (TE) or paravertebral blocks (PVB) remain the gold standard for severe rib fracture pain 3
• These techniques reduce opioid consumption, delirium, and improve respiratory function in elderly patients 3
• Newer alternatives: Erector spinae plane block (ESPB) or serratus anterior plane block (SAPB) are safe, effective options that significantly reduce tramadol consumption and chronic pain development 3
• Caution: Hypotension commonly occurs after thoracic epidural and may require vasopressors; motor block can limit mobilization 3

Step 4: Ketamine (Opioid Alternative)

• Low-dose ketamine (0.3mg/kg IV over 15 minutes) provides analgesic efficacy comparable to morphine 3, 1
• Use as an alternative to opioids in patients with contraindications to regional blocks or inadequate response to NSAIDs 1, 2
• Trade-off: Higher rates of psycho-perceptual adverse effects (confusion, dissociation) but fewer cardiovascular events and life-threatening complications compared to opioids 3, 1
• Particularly useful in major trauma patients (ISS >15) where it reduces morphine requirements in the first 24 hours 3

Step 5: Opioids (Last Resort Only)

• Reserve opioids only for breakthrough pain when all other modalities have failed 2
• Use the lowest effective dose for the shortest duration 2
• Opioids increase risk of delirium, respiratory depression, and over-sedation, especially in elderly patients 2

Non-Pharmacological Adjuncts

• Immobilization techniques and proper positioning reduce pain 1, 2
• Cold compresses or ice packs applied to the affected area in conjunction with medications 1, 2
• These should never replace pharmacological therapy but enhance its effectiveness 2

Surgical Fixation Considerations

Consider surgical stabilization of rib fractures (SSRF) for: 1

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places) 1
• Severe refractory pain despite maximal medical management 1
• Chest wall deformity 1
• ≥3 displaced fractures with respiratory failure 1

Timing is critical: SSRF should be performed within 48-72 hours of injury for optimal outcomes; delaying beyond 72 hours reduces benefits 1. A Cochrane meta-analysis found no mortality difference between surgical and conservative management, but surgery reduced pneumonia, chest deformity, and tracheostomy rates 3, 1. Elderly patients may benefit more from SSRF than younger patients as they deteriorate faster with rib fractures 1.

Common Pitfalls

• Failing to identify high-risk elderly patients who need aggressive multimodal analgesia rather than simple oral medications 1
• Over-relying on opioids instead of regional techniques in appropriate candidates, leading to increased delirium and respiratory complications 3, 2
• Using IV acetaminophen when oral is available - this wastes resources with no clinical benefit 4
• Delaying regional anesthesia consultation in patients with multiple risk factors until they develop respiratory failure 3
• Not considering surgical fixation early (within 72 hours) in appropriate candidates with flail chest or multiple displaced fractures 1