What is the treatment for displaced rib fractures?

Treatment of Displaced Rib Fractures

Displaced rib fractures require surgical stabilization in specific clinical scenarios—particularly flail chest, ≥3 ipsilateral displaced fractures, or respiratory failure—while all other cases should be managed with aggressive multimodal analgesia and respiratory support. 1, 2

Surgical Stabilization Indications

Surgical stabilization of rib fractures (SSRF) is indicated for:

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places with paradoxical chest wall movement) 1, 2, 3
• ≥3 ipsilateral severely displaced fractures in ribs 3-10 1, 2
• Respiratory failure requiring mechanical ventilation despite optimal medical management 1, 2
• Severe refractory pain unresponsive to multimodal analgesia and regional blocks 1, 2
• Chest wall deformity causing functional impairment 2

Surgical Timing

• SSRF should be performed within 48-72 hours of injury for optimal outcomes, as early callous formation begins within the first week and makes fixation technically more difficult 2, 3
• Delaying beyond 72 hours reduces surgical benefits and increases operative times and complications 2

Surgical Technique Considerations

• CT imaging with 3D reconstruction should be obtained before surgery for planning 1
• Ribs 3-8 are most commonly plated, while ribs 1,2,11, and 12 are typically not fixed unless significantly displaced 1, 3
• Precontoured rib-specific plates with locking screws are preferred 3
• Video-assisted thoracoscopy should be performed when possible to control bleeding, evacuate hematomas, and perform intercostal nerve cryoablation 3

Conservative Management for Non-Surgical Candidates

For displaced fractures not meeting surgical criteria, implement aggressive conservative management:

Multimodal Analgesia Protocol

• Start with acetaminophen 1000mg every 6 hours as scheduled first-line therapy (not as-needed dosing) 4, 1, 2
• Add NSAIDs (such as ketorolac) for breakthrough pain, avoiding in patients with aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, or significant renal disease 4, 1
• Reserve opioids strictly for breakthrough pain at lowest effective doses and shortest duration, with dose reduction in elderly patients due to respiratory depression risk 4, 1
• Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an opioid alternative for severe pain, though expect more psychoperceptual side effects 4, 2

Regional Anesthesia for Severe Pain

• Thoracic epidural or paravertebral blocks are the gold standard for severe pain or high-risk patients, reducing opioid consumption and delirium 4, 1, 5, 6
• 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 4, 1, 5

Mandatory Respiratory Care

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

Risk Stratification for Aggressive Management

High-risk patients requiring more intensive monitoring and consideration for SSRF include those with:

• Age >60 years 4, 2
• SpO2 <90% 4, 2
• Presence of 5 consecutive rib fractures or flail segment 4, 2
• Obesity or malnutrition 4, 2
• Smoking or chronic respiratory disease 4, 2
• Anticoagulation therapy 4, 2
• Displacement >50% of rib width on CT 2

Elderly patients (>60 years) deserve special attention as they are less likely to tolerate rib fractures, deteriorate faster, and recent evidence suggests they may benefit more from SSRF compared to younger patients. 2

Monitoring and Follow-Up

• Clinical reassessment within 1-2 weeks to monitor for worsening displacement, complications, and adequate pain control 4
• Immediate attention required for: worsening dyspnea, fever >38°C, productive cough with colored or bloody sputum, progressive oxygen desaturation, or development of pneumothorax/hemothorax 4, 1

Expected Recovery Timeline

• Pain scores should improve significantly by 4 weeks with appropriate management 4, 2
• Rib fractures typically heal in 6-8 weeks 4, 2
• Functional recovery with return to normal activities takes 8-12 weeks 4, 2
• Complete resolution of pain may take up to 2 years in some patients, particularly with displaced fractures 4, 2
• SSRF can shorten recovery time and improve return-to-work rates between 3-6 months compared to non-operative management 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 4, 1
• Excessive reliance on opioids causes respiratory depression, especially in elderly patients 4, 1
• Failing to implement early respiratory physiotherapy results in preventable pulmonary complications 4, 1
• Delaying surgical consultation beyond 72 hours in appropriate candidates reduces SSRF benefits 2, 3
• Failing to identify high-risk patients who need more aggressive pain management and earlier surgical consideration 2