How do you manage a T12 false rib fracture?

Management of T12 False Rib Fracture

T12 rib fractures should be managed conservatively with aggressive multimodal analgesia and pulmonary hygiene, as surgical stabilization of ribs 11 and 12 does not improve outcomes and should only be considered in exceptional circumstances such as marked displacement causing organ impalement, herniation, or vascular impingement. 1

Why T12 Fractures Are Managed Differently

The T12 rib is a "false rib" (ribs 8-12) that does not directly attach to the sternum and has minimal contribution to respiratory mechanics compared to ribs 3-10. 1 The 2024 World Society of Emergency Surgery (WSES) guidelines explicitly state that repair of ribs 11 and 12 does not confer additional benefits in terms of chest wall stability or pain control. 1 Surgical stabilization should be reserved for ribs 2-10, where fixation meaningfully impacts respiratory function and chest wall mechanics. 1

Conservative Management Protocol

Multimodal Analgesia

• Administer acetaminophen 1000mg every 6 hours as the foundation of pain control. 2
• Add NSAIDs (ibuprofen 400-600mg every 6-8 hours or ketorolac) for severe pain. 2
• Reserve opioids only for breakthrough pain at the lowest effective dose for the shortest duration to avoid respiratory depression. 2
• Consider regional anesthesia techniques such as erector spinae plane blocks (ESPB) or serratus anterior plane blocks (SAPB) if pain is refractory to oral medications, as these significantly reduce acute pain and opioid consumption. 1, 2

Pulmonary Hygiene

• Perform deep breathing exercises and gentle coughing exercises every 2 hours while awake to clear secretions. 2
• Use incentive spirometry while sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling, continuing for at least 2-4 weeks. 2
• Initiate early mobilization and chest physiotherapy to prevent atelectasis and pneumonia. 3

Monitoring for Complications

Respiratory Surveillance

• Assess for atelectasis, pneumonia, and respiratory failure through serial clinical examination and pulse oximetry. 2
• Monitor for worsening shortness of breath, fever above 100.4°F (38°C), productive cough with colored or bloody sputum, or chest pain different from the rib pain. 2

Special Considerations for Elderly Patients

• Reduce opioid doses in elderly patients due to higher risk of accumulation and respiratory depression. 2
• Maintain heightened vigilance for complications, as elderly patients with rib fractures have significantly higher mortality rates. 1

Exceptional Circumstances for Surgical Consideration

Surgical stabilization of T12 fractures should only be considered when: 1

• Marked displacement causes thoracic or abdominal organ impalement, damage, or herniation
• Marked chest wall deformity is present
• Vascular impingement occurs
• Localized refractory pain persists despite optimal multimodal analgesia

Critical Pitfalls to Avoid

• Undertreatment of pain leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia. 2
• Overreliance on opioids causes respiratory depression, particularly in elderly patients. 2
• Pursuing surgical stabilization for isolated T12 fractures without exceptional indications exposes patients to unnecessary operative risk without proven benefit. 1

The evidence is clear that lower rib fractures (11 and 12) do not benefit from surgical repair in typical circumstances, making conservative management with aggressive pain control and respiratory support the standard of care. 1