What is the management for a mildly displaced rib fracture?

Management of Mildly Displaced Rib Fractures

For mildly displaced rib fractures, initiate aggressive multimodal analgesia with acetaminophen and NSAIDs as the foundation of treatment, combined with respiratory physiotherapy, reserving surgical stabilization only for patients who develop flail chest, severe refractory pain despite optimal medical management including regional blocks, or respiratory failure requiring mechanical ventilation. 1, 2

Immediate Pain Management Protocol

Start with scheduled acetaminophen 1000mg every 6 hours (oral or IV are equivalent) as your first-line agent. 1, 2 This should be given around-the-clock, not as needed, to maintain consistent analgesia. 3

Add NSAIDs such as ketorolac as second-line for breakthrough pain, but avoid in patients with:

• Aspirin/NSAID-induced asthma 1
• Pregnancy or cerebrovascular hemorrhage 1
• Active GI bleeding risk 1

Reserve opioids strictly for breakthrough pain at the lowest effective doses and shortest duration possible. 1, 2 This is critical because excessive opioid use causes respiratory depression, particularly in elderly patients, which directly increases pneumonia risk and mortality. 2, 3

Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an opioid alternative if pain remains severe, though expect more psychoperceptual side effects. 1, 3

For severe pain or high-risk patients, thoracic epidural or paravertebral blocks are the gold standard and should be implemented early rather than waiting for pain to become intractable. 1, 4

Respiratory Care Protocol (Critical to Prevent Pneumonia)

Perform deep breathing exercises and gentle coughing regularly to clear secretions—this is not optional. 1, 2 Under-treatment of pain leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia, which is the common pathway to respiratory failure and death in rib fracture patients. 2, 5

Use incentive spirometry while sitting, taking slow deep breaths and holding 3-5 seconds before exhaling. 1, 2 Continue this for at least 2-4 weeks. 1, 2

Each rib fracture in elderly patients increases pneumonia risk by 27% and mortality by 19%, making aggressive respiratory care non-negotiable. 5

Risk Stratification (Determines Intensity of Management)

Assess for high-risk features requiring more aggressive pain management and closer monitoring:

• Age >60 years 1, 2, 3
• SpO2 <90% 1, 3
• Presence of 5 consecutive rib fractures 1
• Obesity or malnutrition 1, 3
• Smoking or chronic respiratory disease 1, 3
• Anticoagulation 1, 3

Patients with multiple risk factors need early consideration of regional anesthesia techniques rather than waiting to see if oral medications suffice. 1, 2

Understanding "Mildly Displaced" in Context

Based on the 2024 WSES classification system, displacement is defined by cross-sectional overlap on CT:

• Non-displaced: >90% overlap
• Offset: 50-90% overlap
• Displaced: >0 to <50% overlap
• Severely displaced: no overlap 6

"Mildly displaced" likely corresponds to the "offset" category (50-90% overlap), which does not automatically require surgical intervention unless specific complications develop. 6

When Surgical Stabilization Becomes Indicated

Absolute indications for SSRF (must be considered):

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places with paradoxical movement) 1, 7
• Severe refractory pain despite optimal multimodal analgesia including regional blocks 1, 2
• Respiratory failure requiring mechanical ventilation 1, 7
• Chest wall deformity causing functional impairment 1

Relative indication:

• ≥3 ipsilateral displaced fractures (>50% rib width displacement on CT) in ribs 3-10 with at least two pulmonary derangements (respiratory rate >20, incentive spirometry <50% predicted, pain score >5/10, poor cough) 6, 1

The 2024 WSES guideline notes that recent evidence from Pieracci et al. showed SSRF in non-flail, non-ventilated patients with ≥3 displaced fractures resulted in lower pleural complications, lower pain scores, and improved quality of life at 2 weeks. 6 However, for truly "mildly displaced" fractures without these complications, conservative management remains the standard. 1, 2

Timing Considerations for Surgery (If Indicated)

If surgical stabilization becomes necessary, it should be performed within 48-72 hours of injury for optimal outcomes. 1, 3 Delaying beyond 72 hours reduces benefits and increases technical difficulty due to early callous formation. 3

Monitoring for Complications Requiring Escalation

Watch for signs requiring immediate medical attention:

• Worsening dyspnea or respiratory distress 1, 2
• Fever >38°C 1, 2
• Productive cough with yellow, green, or bloody sputum 1, 2
• Progressive oxygen desaturation despite interventions 1, 2
• Chest pain different from rib pain, especially with shortness of breath 1

Expected Recovery Timeline

• Pain scores should improve significantly by 4 weeks with appropriate management 1, 3
• Rib fractures typically heal in 6-8 weeks 1, 3
• Functional recovery with return to normal activities takes 8-12 weeks for simple fractures 1, 3
• Complete resolution of pain may take up to 2 years in some patients with multiple displaced fractures 1, 3

Only 59% of patients return to work at 6 months, highlighting the significant long-term morbidity even with "mild" injuries. 5

Common Pitfalls to Avoid

Under-treatment of pain is the most dangerous error—it leads directly to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia. 1, 2 This is not about patient comfort; it's about preventing life-threatening complications.

Excessive reliance on opioids causes respiratory depression, especially in elderly patients, creating the same respiratory complications you're trying to prevent. 1, 2

Late consideration of SSRF in appropriate candidates (those with ≥3 displaced fractures and persistent respiratory compromise) leads to prolonged morbidity and missed opportunity for improved outcomes. 1, 2

Failing to identify high-risk patients who need regional anesthesia from the outset rather than escalating through inadequate oral medications. 1, 3

Imaging Considerations

The initial chest X-ray is sufficient for conservative management of mildly displaced fractures. 1 Dedicated rib series radiographs rarely add information that changes management (only 0.23% of cases) and should be avoided. 2

CT chest becomes necessary only if surgical stabilization is being considered, as it provides the detailed displacement measurements needed for operative planning. 1, 3