Is rest and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) management sufficient for rib fracture, considering chronic steroid use and osteoporosis risk?

From the Guidelines

For rib fracture management, rest and NSAIDs (such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) are the standard treatment. The patient should limit activities that cause pain and use ice packs for 15-20 minutes several times daily to reduce inflammation. Deep breathing exercises are important despite discomfort to prevent pneumonia.

Key Considerations

• Regarding the rheumatologist referral, chronic steroid use can indeed cause osteoporosis, which increases fracture risk 1.
• The correct spelling is "osteoporosis" (not osteoprosis) and "rheumatologist" (not rhematologist).
• The rheumatologist should evaluate bone density and may recommend calcium (1000-1200mg daily), vitamin D (800-1000 IU daily), and possibly bisphosphonates like alendronate to prevent further bone loss 1.
• Steroids reduce calcium absorption and increase bone resorption, making bone protection measures essential for patients on long-term steroid therapy.

Additional Recommendations

• Patients on long-term steroids should have a repeat bone densitometry at 1 year, and if stable, repeated at two to three-year intervals, but if declining, repeated annually 1.
• High-risk threshold for intervention is T score -1.5, (or a FRAX 10 year 20% risk for major osteoporotic fracture) 1.
• Intravenous zoledronic acid given annually may be used first line where there is evidence of malabsorption or increased risk of gastrointestinal side effect from oral bisphosphonate use 1.

Surgical Stabilization of Rib Fractures

• Surgical stabilization of rib fractures (SSRF) is a treatment option for severe chest wall injuries, including flail chest or multiple and displaced rib fractures 1.
• SSRF can improve patient outcomes and reduce morbidity and mortality, but its use is not uniformly considered in trauma centers 1.

From the Research

Management of Rib Fractures

• The management of rib fractures typically involves a multimodal approach to pain management, including the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and other pharmacologic agents 2, 3, 4.
• Rest is also a common recommendation for patients with rib fractures, as it can help reduce pain and promote healing.
• The use of chronic steroids can be a concern, as it may increase the risk of osteoporosis and subsequent fractures 2.

Pain Management Options

• NSAIDs, such as ibuprofen, have been shown to be effective in reducing narcotic requirements and length of stay in patients with traumatic rib fractures 4.
• Other pain management options, including regional anaesthetic techniques such as thoracic epidurals and erector spinae blocks, may be considered for patients with significant chest trauma or those at high risk of pulmonary complications 3, 5.
• Multimodal analgesia, including the use of acetaminophen, gabapentinoids, ketamine, lidocaine, and dexmedetomidine, may also be used to manage pain in patients with rib fractures 2.

Considerations for Chronic Steroid Use

• Chronic steroid use can increase the risk of osteoporosis, which can lead to an increased risk of fractures 2.
• Patients on chronic steroids should be monitored closely for signs of osteoporosis and fractures, and alternative treatments should be considered when possible.
• The use of NSAIDs and other pain management options should be carefully considered in patients on chronic steroids, as they may interact with steroids or exacerbate underlying conditions 2, 3, 4.