What is the management for a patient with left rib fractures?

Management of Left Rib Fractures

Begin with immediate risk stratification and multimodal analgesia centered on scheduled acetaminophen, with regional anesthesia (thoracic epidural or paravertebral block) for high-risk patients, and consider surgical stabilization within 72 hours for flail chest or ≥3 severely displaced fractures. 1

Initial Risk Stratification

Immediately assess the following risk factors that predict complications and guide management intensity 1:

• Age >60 years - significantly increases morbidity and mortality 1
• SpO2 <90% - indicates respiratory compromise 1
• Number of fractures: 2-3 fractures, flail segment, or pulmonary contusion 1
• Obesity or malnutrition 1
• Smoking or chronic respiratory disease 1
• Anticoagulation therapy - increases bleeding risk 1
• Major trauma mechanism 1

Obtain CT imaging to assess fracture displacement (>50% displacement predicts prolonged healing and chronic pain), location (ribs 3-10 most symptomatic), and identify flail chest (≥3 consecutive ribs each fractured in ≥2 places) 1.

Pain Management Algorithm

First-Line: Scheduled Acetaminophen

• Administer IV or oral acetaminophen 1000mg every 6 hours (both routes are equivalent in efficacy) 1
• This serves as the foundation for all patients regardless of fracture severity 1

Second-Line: Add NSAIDs for Moderate Pain

• Add ketorolac 60mg IM/IV for patients 17-64 years (maximum 120mg/day) for additional pain control 2
• Avoid in aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, and use cautiously in elderly 2

Gold Standard for High-Risk Patients: Regional Anesthesia

Thoracic epidural analgesia (TEA) is the gold standard for patients with multiple risk factors or severe pain, providing superior pain relief and improved respiratory function compared to all other modalities 3. TEA reduces opioid consumption, delirium in elderly patients, and improves pulmonary outcomes 3.

Use paravertebral block (PVB) instead of TEA when 3:

• Patient is anticoagulated or coagulopathic (PVB has fewer restrictions)
• Hemodynamic instability present (PVB causes less hypotension)
• Need to preserve mobility (PVB causes less motor block)

Newer alternatives (erector spinae plane block or serratus anterior plane block) can be performed by trained emergency physicians and serve as practical alternatives when TEA/PVB are unavailable, with lower adverse effect profiles 4, 5. However, these lack the robust guideline support of TEA/PVB.

Opioid-Sparing Alternative

• Low-dose ketamine 0.3 mg/kg IV over 15 minutes provides analgesia comparable to morphine but with more psycho-perceptual side effects 1
• Reserve for patients who cannot tolerate or have contraindications to other modalities

Surgical Stabilization Criteria

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

• Flail chest (unstable chest wall with paradoxical movement)
• ≥3 ipsilateral severely displaced fractures (>50% displacement on CT)
• Severe refractory pain despite optimal medical management
• Chest wall deformity
• ≥3 displaced fractures in ribs 3-10 with respiratory failure or at least two pulmonary derangements despite adequate pain control

SSRF reduces pneumonia, chest deformity, tracheostomy rates, and long-term complications including chronic pain 1. Elderly patients (>60 years) may benefit more from SSRF than younger patients as they deteriorate faster and tolerate fractures poorly, with several studies showing reduced mortality 1.

Delaying surgery beyond 72 hours significantly reduces benefits 1. Ribs 3-8 are most commonly plated; first, second, eleventh, and twelfth ribs typically not fixed unless significantly displaced 1.

Respiratory Support and Mobilization

• Incentive spirometry should show progressive improvement over 2-4 weeks 1
• Early mobilization is critical to prevent atelectasis and pneumonia 7
• Meticulous pulmonary hygiene prevents delayed complications from hypoventilation 7

Expected Recovery Timeline

• Pain scores improve significantly by 4 weeks with appropriate management 1
• Functional recovery: 8-12 weeks for simple fractures, up to 6 months for complex injuries 1
• Complete bone healing: 6-8 weeks typical, but complete recovery with pain resolution may take up to 2 years in some patients with multiple or displaced fractures 1
• Chronic pain develops in up to 40% of patients, extending functional recovery 1

Critical Pitfalls to Avoid

• Inadequate pain control leads to shallow breathing, atelectasis, and pneumonia - this is the primary cause of morbidity 3
• Failure to identify high-risk patients (especially elderly >60 years) who need aggressive regional anesthesia rather than oral analgesics alone 1
• Missing flail chest or severely displaced fractures that warrant surgical consultation within 72 hours 1
• Delaying surgical fixation beyond 72 hours in appropriate candidates reduces SSRF benefits 1