What is the treatment for nondisplaced rib fractures?

Treatment of Nondisplaced Rib Fractures

Nondisplaced rib fractures (defined as >90% cross-sectional overlap on CT) should be managed conservatively with aggressive multimodal analgesia and respiratory support—surgical stabilization is not indicated for isolated nondisplaced fractures. 1

Conservative Management Framework

Pain Control Strategy

Implement multimodal analgesia immediately to prevent respiratory complications from pain-related splinting:

• Start acetaminophen 1000mg every 6 hours (oral or IV are equivalent in efficacy) as first-line therapy 2, 3
• Add NSAIDs (such as ketorolac) for breakthrough pain, avoiding in patients with aspirin/NSAID-induced asthma, pregnancy, or cerebrovascular hemorrhage 2
• Reserve opioids strictly for breakthrough pain at lowest effective doses and shortest duration to avoid respiratory depression, particularly in elderly patients 2, 4
• Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an opioid alternative for severe pain, though expect more psychoperceptual side effects 2

Regional Anesthesia for Severe Pain

For patients with severe refractory pain despite systemic analgesia:

• Thoracic epidural or paravertebral blocks are gold standard for severe pain or high-risk patients 2, 5
• Erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB) serve as practical alternatives with lower adverse effect profiles and can be performed by trained emergency physicians 2, 5
• Intercostal nerve blocks have less analgesic impact and require concurrent intravenous medication to achieve comparable outcomes 5

Respiratory Care Protocol

Aggressive pulmonary hygiene is essential to prevent atelectasis and pneumonia:

• Perform deep breathing exercises and gentle coughing regularly to clear secretions 1, 6
• Use incentive spirometry while sitting, taking slow deep breaths and holding 3-5 seconds before exhaling 2
• Continue incentive spirometry for at least 2-4 weeks 2
• Early mobilization is mandatory to prevent pulmonary complications 1

Risk Stratification

Identify high-risk patients requiring more aggressive management:

• Age >60 years 2
• SpO2 <90% 2
• Presence of 5 consecutive rib fractures 2
• Obesity, malnutrition, smoking 2
• Chronic respiratory disease 2
• Anticoagulation therapy 2

Monitoring and Follow-Up

Clinical reassessment within 1-2 weeks is necessary to monitor for worsening displacement, development of complications, and adequate pain control 1

Watch for complications requiring immediate attention:

• Worsening dyspnea or respiratory distress 2
• Fever >38°C 2
• Productive cough with yellow, green, or bloody sputum 2
• Progressive oxygen desaturation despite interventions 2
• Development of pneumothorax or hemothorax 1

Expected Recovery Timeline

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

When Surgery Is NOT Indicated

Surgical stabilization of rib fractures (SSRF) is reserved for specific indications that do NOT apply to nondisplaced fractures:

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places with paradoxical movement) 2, 7
• ≥3 ipsilateral displaced fractures (>50% rib width displacement) 2, 7
• Severely displaced fractures (no cross-sectional overlap or overlapping ribs) 8
• Respiratory failure requiring mechanical ventilation 2
• Severe refractory pain despite optimal multimodal analgesia including regional blocks 2

Critical Pitfalls to Avoid

Under-treatment of pain leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia—this is the most common and dangerous error 1, 2, 6

Excessive reliance on opioids causes respiratory depression, especially in elderly patients—use multimodal approach instead 2

Failing to implement early respiratory physiotherapy results in preventable pulmonary complications 1, 6