What is the recommended treatment for fractures of the 11th and 12th ribs?

Treatment of Fractures to the 11th and 12th Rib

Fractures of the 11th and 12th ribs should be managed conservatively with multimodal analgesia, as surgical stabilization does not improve chest wall stability or pain control and should only be considered in highly selected circumstances such as marked displacement causing organ impalement, herniation, vascular impingement, or marked chest wall deformity. 1

Why Conservative Management is Preferred

The 11th and 12th ribs are floating ribs that do not contribute significantly to respiratory mechanics or chest wall stability. 1 Unlike ribs 2-10, surgical repair of these lower ribs does not confer additional benefits in terms of either chest wall stability or pain control, and the necessary tissue trauma to achieve surgical fixation likely does not improve pain levels. 1

The 2024 World Society of Emergency Surgery (WSES) and Chest Wall Injury Society (CWIS) guidelines explicitly state that surgical stabilization of rib fractures (SSRF) should be considered for fractures in ribs 2-10 only, with repair of ribs 11 and 12 reserved for highly selected circumstances. 1

Standard Conservative Treatment Protocol

Multimodal Analgesia Approach

• Administer acetaminophen 1000mg every 6 hours (oral or IV are equivalent in efficacy) as first-line analgesia. 2, 3

• Add NSAIDs such as ketorolac as second-line treatment for breakthrough pain, monitoring for GI upset and avoiding in patients with aspirin/NSAID-induced asthma, pregnancy, or cerebrovascular hemorrhage. 2, 3

• Reserve opioids strictly for breakthrough pain at lowest effective doses and shortest duration to avoid respiratory depression, especially in elderly patients. 2

• Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids if pain remains severe, though expect more psychoperceptual side effects. 2, 3

• Thoracic epidural or paravertebral blocks are gold standard for severe pain or high-risk patients with multiple rib fractures or respiratory compromise. 2, 4, 5

Respiratory Care Protocol

• Perform deep breathing exercises and gentle coughing regularly to clear secretions. 2

• 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

Highly Selected Circumstances for Surgical Consideration

Surgical stabilization of 11th and 12th rib fractures may be considered only when: 1

• Marked displacement causing thoracic or abdominal organ impalement, damage, or herniation
• Marked chest wall deformity causing functional impairment
• Vascular impingement
• Localized refractory pain despite optimal multimodal analgesia including regional blocks

These indications are rare, and the decision requires careful risk-benefit analysis given that the surgical trauma itself may not improve outcomes compared to conservative management. 1

Expected Recovery Timeline

• Pain scores should improve significantly by 4 weeks with appropriate management. 2, 3

• Rib fractures typically heal in 6-8 weeks. 2, 3

• Functional recovery with return to normal activities takes 8-12 weeks for simple fractures. 2, 3

• Complete resolution of pain may take up to 2 years in some patients with multiple displaced fractures. 2, 3

Risk Stratification and Monitoring

High-Risk Features Requiring More Aggressive Pain Management

Assess for high-risk features including: 2, 3

• Age >60 years
• SpO2 <90%
• Presence of 5 consecutive rib fractures
• Obesity or malnutrition
• Smoking or chronic respiratory disease
• Anticoagulation therapy

Warning Signs Requiring Immediate Medical Attention

Watch for complications including: 2, 3

• Worsening dyspnea or respiratory distress
• Fever >38°C
• Productive cough with yellow, green, or bloody sputum
• Progressive oxygen desaturation despite interventions
• Chest pain different from rib pain, especially with shortness of breath

Common Pitfalls to Avoid

• Under-treatment of pain leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia. 2

• Excessive reliance on opioids causes respiratory depression, especially in elderly patients. 2

• Considering surgical stabilization for 11th and 12th rib fractures without the highly specific indications listed above leads to unnecessary surgical morbidity without benefit. 1

• Failing to identify high-risk patients who need more aggressive pain management approaches from the outset. 2, 3