How should a patient with a rib fracture be managed?

Management of Rib Fractures

For most patients with rib fractures, conservative management with multimodal analgesia and aggressive pulmonary hygiene is the standard of care, reserving surgical stabilization for specific high-risk scenarios including flail chest, respiratory failure requiring mechanical ventilation, or intractable pain despite optimal medical management. 1, 2

Initial Diagnostic Approach

• Obtain a standard posteroanterior chest radiograph as the initial imaging study to detect critical complications such as pneumothorax, hemothorax, pulmonary contusion, or flail chest, though this will miss up to 50% of rib fractures themselves. 1, 3

• Do not order dedicated rib series radiographs as they rarely change management (only 0.23% of cases) and prolong reporting time. 3

• Reserve CT chest for surgical planning or when complications are suspected, not for routine isolated rib fractures. 1, 3 If surgical stabilization is being considered, CT with 3D reconstruction should be performed for preoperative planning. 1

• Be vigilant for associated injuries, as over 90% of patients with rib fractures have concomitant injuries, with 32% having hemothorax or pneumothorax and 26% having pulmonary contusion. 4

Pain Management Algorithm

First-line therapy:

• Administer acetaminophen 1000 mg every 6 hours regularly (not as needed) as the foundation of pain control, with IV and oral routes being equivalent. 3, 2

Second-line for severe pain:

• Add NSAIDs such as ibuprofen 600-800 mg every 8 hours or ketorolac 15-30 mg IV every 6 hours after checking for contraindications including renal insufficiency, active bleeding, or peptic ulcer disease. 3, 2

Third-line for breakthrough pain only:

• Reserve opioids (oxycodone 5-10 mg or morphine 2-4 mg IV) for the lowest effective dose and shortest duration, particularly avoiding excessive use in elderly patients due to respiratory depression risk. 3, 2

Advanced pain control options for severe cases:

• Consider thoracic epidural or paravertebral blocks as the gold standard for analgesia in multiple rib fractures, offering superior pain control and reducing opioid consumption and delirium in older patients. 2

• Novel myofascial techniques such as erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB) are safe and effective alternatives that significantly reduce acute pain. 2

• Low-dose ketamine (0.3 mg/kg over 15 minutes) provides analgesic efficacy comparable to morphine with fewer life-threatening events, though with higher rates of psycho-perceptual adverse effects. 2

Respiratory Care Protocol

• Initiate deep breathing exercises and gentle coughing every 2 hours while awake to clear secretions and prevent atelectasis and pneumonia. 3, 2

• Use incentive spirometry while sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling, with a goal of 10 repetitions every hour. 3, 2

• Continue incentive spirometry for at least 2-4 weeks to prevent respiratory complications. 3, 2

• Monitor incentive spirometry volumes closely, as volumes less than 50% predicted despite adequate analgesia indicate significant respiratory impairment requiring escalation of care. 3

Risk Stratification for Complications

High-risk features requiring close monitoring include: 3, 5

• Age >60 years
• SpO2 <90%
• Obesity
• Malnutrition
• Chronic respiratory disease
• Pre-existing pulmonary disease

Understand the severity marker: Rib fractures indicate severe injury where 12% will die from their injuries, one-third will develop pulmonary complications, and one-third will require discharge to an extended care facility. 4

Indications for Surgical Stabilization of Rib Fractures (SSRF)

Consider SSRF for the following specific indications: 1, 2, 5

• Flail chest
• Respiratory failure requiring mechanical ventilation
• Intractable pain despite optimal medical management that prevents adequate respiratory mechanics
• Multiple severely displaced rib fractures with chest wall deformity

Timing of SSRF is critical:

• Perform SSRF within 48-72 hours of injury for optimal outcomes, as early SSRF decreases hospital and ICU length of stay, duration of mechanical ventilation, and hospitalization costs. 1

• Early SSRF (≤48 hours) is associated with decreased levels of inflammatory cytokines and infection markers compared to delayed surgery. 1

• SSRF should target ribs 2-10, with repair of ribs 1,11, and 12 only in highly selected circumstances. 2

• There is no data to suggest that late surgery (7-14 days from injury) confers benefit over conservative management, so this decision should be made case-by-case. 1

Special Considerations for Elderly Patients

• Elderly patients (>60 years) are at significantly higher risk for complications and require more aggressive management with closer monitoring. 3, 5

• Reduce opioid doses in elderly patients due to higher risk of accumulation and respiratory depression. 2

• Early SSRF in geriatric patients is associated with better in-hospital outcomes. 1, 2

Monitoring for Complications

Assess regularly for respiratory complications: 3, 2, 5

• Atelectasis
• Pneumonia
• Respiratory failure
• Delayed pneumothorax or hemothorax (can develop days after initial injury) 6

Instruct patients to seek immediate medical attention for: 2

• Worsening shortness of breath
• Fever above 100.4°F (38°C)
• Productive cough with yellow, green, or bloody sputum
• Chest pain different from the rib pain

For lower rib fractures (ribs 8-12), maintain high suspicion for intra-abdominal organ injury, particularly liver and spleen injuries, as these are significantly more common with lower rib fractures. 7 Patients with more than 6 rib fractures have significantly higher severity of intra-abdominal injuries requiring emergency operations. 7

Expected Recovery Timeline

• Rib fractures typically heal in 6-8 weeks, but complete pain resolution may take up to 2 years in some cases, with pain scores improving significantly by 4 weeks with appropriate management. 3

• Functional recovery with return to normal activities takes 8-12 weeks for simple fractures, with 93% of patients ultimately resuming daily activities without significant disability when managed appropriately. 3

Critical Pitfalls to Avoid

• Never use circumferential rib belts, as they are associated with increased complications including bloody pleural effusion, asymptomatic discoid atelectasis, and do not significantly reduce pain severity. 8

• Undertreatment of pain leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia - this is the most common and dangerous pitfall. 2, 5

• Overreliance on opioids causes respiratory depression, especially in elderly patients, defeating the purpose of pain control. 2, 5

• Delayed consideration of SSRF in appropriate candidates with respiratory failure or flail chest can lead to prolonged pain, respiratory compromise, and worse outcomes. 2, 5

• Failure to recognize that 55% of patients with rib fractures require immediate operation or ICU admission for associated injuries, not the rib fractures themselves. 4