What is the recommended treatment for rib fractures?

Treatment for Rib Fractures

Begin with scheduled intravenous or oral acetaminophen (every 6 hours) as first-line treatment, add ketorolac or other NSAIDs for moderate-to-severe pain as second-line, and consider regional anesthetic techniques (thoracic epidural, paravertebral blocks, or erector spinae plane blocks) for high-risk patients or inadequate pain control with systemic medications. 1

Risk Stratification (Perform Immediately)

Identify high-risk patients who require aggressive pain management and monitoring:

• Age >60 years - significantly increases complication risk and mortality 1
• SpO2 <90% - indicates respiratory compromise 1
• ≥2-3 rib fractures, flail segment, or pulmonary contusion - predicts complications 1
• Obesity or malnutrition - increases complication risk 1
• Smoking or chronic respiratory disease - impairs respiratory reserve 1
• Anticoagulation therapy - increases bleeding complications 1
• Major trauma mechanism - suggests polytrauma 1

The presence of multiple risk factors exponentially increases likelihood of pneumonia, respiratory failure, and death. 1

Pharmacologic Management Algorithm

Step 1: First-Line Analgesia

• Acetaminophen 1000mg IV or PO every 6 hours - equivalent efficacy between routes in elderly patients 1
• Continue scheduled dosing (not PRN) to maintain baseline analgesia 1

Step 2: Second-Line for Moderate-to-Severe Pain

• Ketorolac 60mg IM/IV (ages 17-64) for breakthrough pain 2
  • Maximum 120mg/day 2
  • Contraindications: aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, active GI bleeding 2
  • Reduce dose by 50% in elderly patients 2
• Alternative NSAIDs if ketorolac contraindicated 1

Step 3: Opioid-Sparing Alternatives

• Low-dose ketamine 0.3mg/kg IV over 15 minutes - comparable efficacy to morphine but with psycho-perceptual side effects 1
• Consider for patients with contraindications to NSAIDs or inadequate response 1

Step 4: Opioids (Use Sparingly)

• Fentanyl preferred over morphine in elderly due to lower respiratory/cognitive depression risk 3
• Reduce dose by ≥50% in elderly patients 3
• Never use as monotherapy - always combine with multimodal approach 3
• Monitor continuously for respiratory depression 3
• Have naloxone immediately available 3

Regional Anesthesia Techniques

Indications for Regional Blocks

Consider regional anesthesia as gold standard for: 1, 2

• High-risk patients (multiple risk factors above)
• Severe pain despite maximal systemic analgesia
• Flail chest or ≥3 displaced fractures
• Contraindications to systemic opioids

Technique Selection (in order of preference)

Thoracic epidural analgesia (TEA) - traditional gold standard 1, 4

• Most effective for severe pain
• Contraindications: anticoagulation, vertebral fractures, hemodynamic instability, patient refusal 5

Paravertebral block (PVB) - excellent alternative to TEA 4, 6

• Similar efficacy to epidural with fewer hemodynamic effects
• Failure rate up to 10% 6
• Suitable when epidural contraindicated

Erector spinae plane (ESP) block - emerging preferred option 6, 5

• Can be performed by trained emergency physicians 1
• Lower risk than neuraxial techniques
• Effective for multiple rib levels
• Feasible in anticoagulated patients 5

Serratus anterior plane (SAP) block - practical alternative 6, 5

• Similar safety profile to ESP
• Good for lateral rib fractures
• Lower complication rates than neuraxial blocks

Intercostal nerve blocks - least effective 6

• Requires concurrent IV medication for adequate analgesia
• Consider only when other blocks unavailable

Surgical Stabilization of Rib Fractures (SSRF)

Indications for Surgery

Strongly consider SSRF for: 1

• Flail chest (≥2 consecutive ribs fractured in ≥2 places each)
• ≥3 severely displaced fractures (>50% displacement on CT)
• Severe refractory pain despite optimal medical management
• Progressive chest wall deformity
• Respiratory failure with pulmonary derangements despite adequate analgesia

Timing is Critical

• Perform within 48-72 hours of injury for optimal outcomes 1
• Early callus formation begins within first week, making surgery technically more difficult after 72 hours 1
• Delayed fixation (>72 hours) associated with longer operative times and increased complications 1

Special Population: Elderly Patients (>60 years)

• Recent evidence suggests elderly may benefit MORE from SSRF than younger patients 1
• Elderly tolerate rib fractures poorly with faster clinical deterioration 1
• Retrospective studies show reduced mortality with SSRF in elderly 1
• However, one guideline suggests conservative management showed benefits in hospital stay and mechanical ventilation duration in elderly 1 - this represents conflicting evidence requiring individualized assessment

Outcomes of SSRF

• Reduces pneumonia, chest deformity, and tracheostomy rates 1
• No statistically significant mortality difference in meta-analysis, but trend toward benefit 1
• Improves return-to-work rates at 3-6 months 1
• Reduces chronic pain and long-term chest wall deformity 1

Non-Pharmacological Adjuncts

• Incentive spirometry - monitor progressive improvement over 2-4 weeks 1
• Cold compresses - apply in conjunction with pharmacotherapy 1
• Pulmonary hygiene protocols - prevent atelectasis and pneumonia 7
• Avoid complete immobilization - encourage controlled movement 1

Common Pitfalls to Avoid

• Using opioids as monotherapy - always employ multimodal approach 3
• Failing to identify high-risk patients early - delays appropriate escalation of care 1
• Inadequate acetaminophen dosing - must be scheduled, not PRN 1
• Delaying regional blocks in appropriate candidates - earlier intervention prevents respiratory complications 1, 4
• Missing surgical window - SSRF after 72 hours has diminished benefits 1
• Underdosing elderly patients with fentanyl - requires 50% dose reduction, not elimination 3
• Combining fentanyl with benzodiazepines - synergistic respiratory depression 3

Expected Recovery Timeline

• Pain improvement: Significant by 4 weeks with appropriate management 1
• Radiographic healing: 6-8 weeks for simple fractures 1
• Functional recovery: 8-12 weeks for simple fractures, up to 6 months for complex injuries 1
• Complete 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