What is the management of rib fractures?

Management of Rib Fractures

Initial Risk Stratification

All patients with rib fractures require immediate risk stratification to determine the appropriate level of care and intensity of pain management. 1

High-risk features requiring hospital admission include: 1, 2

• Age >60 years (27% increased pneumonia risk and 19% increased mortality per rib fracture) 2
• SpO2 <90% on room air 1, 2
• ≥3 rib fractures 1, 2
• Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1
• Pulmonary contusion, pneumothorax, or hemothorax on imaging 2
• Chronic respiratory disease or smoking history 1
• Obesity or malnutrition 1
• Active anticoagulation therapy 1
• Respiratory rate >20 breaths/minute 2

Low-risk patients (young, healthy, isolated single fracture, normal oxygen saturation, no complications) can be managed as outpatients. 2

Multimodal Analgesic Protocol

First-Line: Acetaminophen

Administer acetaminophen 1000mg every 6 hours as scheduled dosing (not as-needed) for all patients with rib fractures. 3, 1 Oral and intravenous formulations are equally effective. 1

Second-Line: NSAIDs

Add NSAIDs (such as ketorolac) for breakthrough pain if acetaminophen alone is insufficient. 3, 1

Contraindications to NSAIDs: 3

• Aspirin/NSAID-induced asthma
• Pregnancy
• Cerebrovascular hemorrhage
• Active GI ulcers or bleeding risk

Third-Line: Opioids

Reserve opioids strictly for severe breakthrough pain at the lowest effective dose and shortest duration. 3 Excessive opioid use causes respiratory depression, particularly in elderly patients, leading to atelectasis and pneumonia. 3

Alternative: Low-Dose Ketamine

Consider ketamine 0.3 mg/kg IV over 15 minutes as an opioid alternative for severe pain, though expect more psychoperceptual side effects. 3, 1

Regional Anesthesia for High-Risk Patients

For patients with severe pain, multiple fractures, or high-risk features, regional anesthetic techniques are superior to systemic opioids alone. 4, 5

Preferred Regional Techniques (in order):

1. Thoracic epidural analgesia (TEA) - Gold standard for severe pain, reduces pneumonia risk by 50% (18% vs 38%) and decreases ventilator days when compared to IV opioids 3, 4
2. Paravertebral block (PVB) - Viable alternative when TEA is contraindicated, though has up to 10% failure rate 6
3. Erector spinae plane block (ESPB) - Can be performed by trained emergency physicians, lower risk profile than neuraxial techniques 6
4. Serratus anterior plane block (SAPB) - Practical alternative with lower adverse effects 6

Surgical Stabilization Indications

Conservative management with multimodal analgesia is the standard for most rib fractures, including fractures of the 11th and 12th ribs. 3

Surgical Stabilization of Rib Fractures (SSRF) Should Be Considered For:

• Flail chest (unstable chest wall) 1
• ≥3 ipsilateral severely displaced fractures in ribs 3-10 with respiratory failure 1
• Severe refractory pain despite optimal multimodal analgesia 1
• Marked chest wall deformity 1
• Thoracic or abdominal organ impalement/herniation from displaced fragments 3

Timing is critical: SSRF must be performed within 48-72 hours of injury for optimal outcomes. 1 Delayed fixation beyond 72 hours reduces benefits and increases operative difficulty due to early callus formation. 1

Special consideration for elderly patients (>60 years): Recent evidence suggests elderly patients may benefit more from SSRF than younger patients, as they deteriorate faster and are less likely to tolerate rib fractures conservatively. 1

Do NOT surgically stabilize 11th and 12th rib fractures unless there is marked displacement causing organ damage, as these floating ribs do not contribute to chest wall stability and surgery provides no benefit. 3

Expected Recovery Timeline

• Pain improvement: Significant reduction by 4 weeks 3, 2
• Bone healing: 6-8 weeks 3, 2
• Return to normal activities: 8-12 weeks for simple fractures 3, 2
• Complete pain resolution: May take up to 2 years in cases with multiple displaced fractures 3, 2

Critical Pitfalls to Avoid

Under-treatment of pain is the most dangerous error - leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia. 3

Over-reliance on opioids - causes respiratory depression, especially in elderly patients, paradoxically worsening outcomes. 3

Considering surgery for 11th/12th rib fractures without specific indications - leads to unnecessary surgical morbidity without benefit. 3

Failing to identify high-risk patients early - delays appropriate escalation to regional anesthesia or surgical intervention. 1

Warning Signs Requiring Immediate Re-evaluation

Patients should return immediately for: 1

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