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
- 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 for anticoagulated patients 5
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 emergency department settings 5
Serratus anterior plane (SAP) block - practical alternative 6, 5
- Similar efficacy to ESP with minimal adverse effects
- Suitable when epidural/PVB contraindicated 5
Intercostal nerve blocks - least effective option 6
- Requires concurrent IV medication for adequate analgesia
- Consider only when other techniques unavailable 6
Non-Pharmacological Measures
- Pulmonary hygiene protocols - incentive spirometry, deep breathing exercises 7
- Early mobilization - prevents atelectasis and pneumonia 7
- Cold compresses - adjunct to pharmacologic therapy 1
- Avoid chest wall immobilization (worsens respiratory mechanics) 1
Surgical Management Indications
Absolute Indications for Surgical Stabilization of Rib Fractures (SSRF)
- Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1
- ≥3 ipsilateral severely displaced fractures with respiratory failure 1
- Severe refractory pain despite maximal medical management 1
- Chest wall deformity 1
Timing Critical for Surgical Outcomes
- Perform within 48-72 hours for optimal results 1
- Early callous formation begins within first week, making surgery technically difficult after 72 hours 1
- Delayed fixation (>72 hours) associated with longer operative times and increased complications 1
Evidence for Surgical Benefits
- Reduces pneumonia, chest deformity, and tracheostomy rates (Cochrane meta-analysis) 1
- No mortality difference between operative and non-operative management overall 1
- Elderly patients may benefit more from SSRF than younger patients, as they deteriorate faster 1
- Improves return-to-work rates at 3-6 months 1
Important Caveat
For elderly patients (>60 years), some evidence suggests conservative management may reduce hospital stay and mechanical ventilation duration, creating equipoise about surgical indications in this population. 1 However, recent retrospective studies show SSRF may reduce mortality in elderly patients specifically. 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
- Not reducing opioid doses in elderly - leads to respiratory depression and delirium 3
- Delaying regional anesthesia consultation in high-risk patients - increases pulmonary complications 1, 2
- Missing surgical window - fixation after 72 hours has diminished benefits 1
- Underestimating elderly patient risk - rib fractures carry significantly higher morbidity/mortality in this population 1
Expected Recovery Timeline
- Pain improvement: significant by 4 weeks with appropriate management 1
- Radiographic healing: 6-8 weeks for bone union 1
- Functional recovery: 8-12 weeks for simple fractures, up to 6 months for complex injuries 1
- Complete recovery: may take up to 2 years in patients with multiple or displaced fractures 1
- Chronic pain: develops in up to 40% of patients, especially with >50% displacement 1