What are the treatment approaches for displaced versus non-displaced rib fractures?

Treatment for Displaced versus Non-Displaced Rib Fractures

Displaced rib fractures (≥50% displacement or no cross-sectional overlap) require surgical stabilization of rib fractures (SSRF) when there are ≥3 severely displaced fractures in ribs 3-10, particularly if accompanied by respiratory compromise, while non-displaced fractures (>90% cross-sectional overlap) are managed non-operatively with multimodal analgesia and pulmonary hygiene. 1

Classification of Rib Fracture Displacement

The 2024 WSES/CWIS guidelines established a standardized displacement classification system based on cross-sectional overlap on CT imaging: 1

• Non-displaced: >90% cross-sectional overlap
• Offset: 50-90% cross-sectional overlap
• Displaced: >0 to <50% cross-sectional overlap
• Severely displaced: No cross-sectional overlap or overlapping ribs

This classification system directly guides treatment decisions and improves communication between providers. 1

Treatment Approach for Non-Displaced Fractures

Non-operative management is the standard for non-displaced rib fractures, consisting of: 2

• Multimodal analgesia: Regular acetaminophen every 6 hours, supplemented with NSAIDs for severe pain 2
• Opioids: Reserved only for breakthrough pain at the lowest effective dose for the shortest duration to avoid respiratory depression 2
• Pulmonary hygiene: Regular deep breathing exercises, gentle coughing to clear secretions, and incentive spirometry while sitting upright (holding breaths for 3-5 seconds) for at least 2-4 weeks 2
• Chest physiotherapy and pleural drainage as needed 2

Critical Pitfall to Avoid

Undertreatment of pain leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia—the most common complication pathway in non-displaced fractures. 2, 3

Treatment Approach for Displaced Fractures

SSRF should be performed for displaced rib fractures meeting specific criteria, ideally within 48-72 hours of injury: 4

Absolute Indications for SSRF:

1. Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical movement): Recent RCT data showed 0% mortality with SSRF versus 6% with non-operative management in mechanically ventilated patients 1, 4

2. ≥3 severely displaced rib fractures (>50% rib width displacement or no cross-sectional overlap) in ribs 3-10 1, 4

3. ≥3 displaced rib fractures (ribs 3-10) PLUS ≥2 pulmonary derangements despite optimal loco-regional anesthesia: 1, 4

   • Respiratory rate >20 breaths/minute
   • Incentive spirometry <50% predicted
   • Numeric pain score >5/10
   • Poor cough

Evidence Supporting SSRF for Displaced Fractures:

The Denghan 2024 multicenter RCT demonstrated that SSRF for unstable chest wall injuries (≥3 fractures with severe displacement >100% or overriding by ≥15mm) resulted in: 1

• Decreased mortality (0% vs 6%; p=0.01)
• Improved ventilator-free days
• Decreased hospitalization length

The Pieracci multicenter trial showed SSRF for ≥3 displaced fractures (≥50% displacement) without flail chest resulted in: 1

• Lower pleural space complication rates
• Lower pain scores and respiratory disability at 2 weeks
• Improved quality of life

Multiple meta-analyses confirmed SSRF benefits including reduced pneumonia rates, decreased ICU length of stay, shorter mechanical ventilation duration, lower mortality, decreased tracheostomy rates, less chest wall deformity, and reduced dyspnea. 1

Critical Timing Considerations

SSRF must be performed within 48-72 hours of injury for optimal outcomes, with the strongest evidence supporting intervention within the first 72 hours. 4 Delaying surgical decision beyond 72 hours significantly reduces benefits. 4

Important caveat: Rib fracture displacement worsens over time—a 2021 study demonstrated that fractures become significantly more displaced on repeat imaging, with a 10.1% missed fracture rate on initial CT. 5 This means initial "offset" fractures may progress to "displaced" or "severely displaced" categories, requiring reassessment if symptoms worsen. 5

Technical Surgical Approach

When SSRF is indicated: 4, 6

• Pre-operative imaging: CT with 3D reconstruction is mandatory for surgical planning 4, 6
• Target ribs: Ribs 2-10 (ribs 3-8 most commonly plated); avoid ribs 1,11, and 12 except in highly selected circumstances 4, 6
• Fixation method: Titanium precontoured rib-specific plates with threaded holes and self-tapping locking screws 6
• Avoid: Pelvic fixation plates (outdated technique) 1, 4
• Surgical approach: Lateral approach for majority of fractures; muscle-sparing technique preferred 6
• Adjuncts: Polymer cable cerclage for longitudinal fractures, fractures near spine, osteoporotic ribs, and cartilage injuries 6

Perioperative ultrasound localization of fracture sites optimizes surgical efficiency, reducing incision length (9 vs 15.5 cm), operative time (120 vs 174 minutes), and post-operative opioid requirements. 7

Special Population: Elderly Patients

Elderly patients (>60 years) warrant particularly aggressive consideration for early SSRF as they deteriorate faster and are less likely to tolerate rib fractures. 4, 3 Early SSRF within 48-72 hours should be strongly considered for elderly patients meeting surgical criteria. 4 Opioid doses must be reduced in elderly patients due to higher risk of accumulation and respiratory depression. 2

Expected Outcomes with SSRF

Compared to non-operative management, SSRF provides: 1, 4

• Reduced mortality in mechanically ventilated patients
• Decreased pneumonia rates
• Lower pleural space complications
• Shorter ventilator duration and faster weaning
• Improved pain scores at 2 weeks
• Better return-to-work rates at 3-6 months
• Reduced long-term chronic pain and chest wall deformity

Contraindications to SSRF

Hemodynamically unstable patients should not undergo SSRF. 1 Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. 8 The role of severe pulmonary contusion remains controversial—SSRF benefits were not observed in patients with concomitant severe pulmonary contusion regarding mechanical ventilator time and ICU stay. 1

Algorithm for Decision-Making

For non-displaced fractures (>90% overlap):

• Non-operative management with multimodal analgesia and pulmonary hygiene 2
• Monitor for respiratory complications (atelectasis, pneumonia, respiratory failure) 2, 3
• Consider repeat CT if symptoms worsen (displacement may progress) 5

For offset fractures (50-90% overlap):

• Initial non-operative management 1
• Close monitoring for respiratory derangements
• Consider SSRF if ≥2 pulmonary derangements develop despite optimal analgesia 1, 4

For displaced/severely displaced fractures (<50% overlap or no overlap):

• If ≥3 fractures in ribs 3-10: SSRF within 48-72 hours 4
• If flail chest: SSRF within 48-72 hours (absolute indication) 4
• If respiratory failure requiring mechanical ventilation: SSRF within 48-72 hours 4
• If elderly (>60 years): Lower threshold for SSRF 4

Common pitfall: Failing to obtain CT with 3D reconstruction before surgery compromises surgical planning and should never be omitted. 4