What is the plan of care for an adult patient with no significant past medical history and a rib fracture?

Management of Rib Fractures

Multimodal Analgesia as Foundation

Administer acetaminophen 1000mg every 6 hours around-the-clock as first-line therapy, not as-needed dosing, since scheduled administration provides superior pain control compared to PRN dosing. 1, 2

• Oral and intravenous acetaminophen are equally effective for pain control in rib fracture patients, so use the oral route unless the patient cannot tolerate PO intake 2
• Add NSAIDs (such as ketorolac or ibuprofen) as second-line therapy for severe pain inadequately controlled by acetaminophen alone 1, 2
• Reserve opioids exclusively for breakthrough pain at the lowest effective dose for the shortest duration to avoid respiratory depression, which is the primary pathway to complications 1, 2
• In elderly patients, reduce opioid doses further due to higher risk of accumulation and respiratory depression 1

Common Pitfall to Avoid

Undertreatment of pain leads directly to splinting behavior, shallow breathing, poor cough effort, atelectasis, and ultimately pneumonia—the most common pathway to respiratory failure and death in rib fracture patients 1, 3

Aggressive Respiratory Care

Implement incentive spirometry immediately with specific technique: sit upright, take slow deep breaths, hold for 3-5 seconds, then exhale slowly. 1

• Continue incentive spirometry for at least 2-4 weeks to prevent respiratory complications 1
• Perform regular deep breathing exercises and gentle coughing exercises to clear secretions 1
• Monitor oxygen saturation closely, as SpO2 <90% is a significant risk factor for complications requiring escalation of care 2

Risk Stratification for Complications

Identify high-risk patients who need more intensive monitoring and consideration for advanced interventions 2:

• Age >60 years (each rib fracture increases pneumonia risk by 27% and mortality by 19% in elderly patients) 3
• ≥3 rib fractures or presence of flail chest 2
• SpO2 <90% on presentation 2
• Chronic respiratory disease or active smoking 2
• Anticoagulation therapy 2
• Obesity or malnutrition 2
• Pulmonary contusion on imaging 2

Advanced Pain Control for High-Risk Patients

For elderly patients or those with ≥3 fractures and severe pain despite multimodal analgesia, strongly consider thoracic epidural or paravertebral nerve blocks as the gold standard intervention. 1, 2

• Regional anesthesia techniques reduce opioid consumption, decrease delirium in older patients, and improve respiratory function 1
• Novel alternatives include erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB), which are safe and effective with significantly reduced acute pain 1
• Low-dose ketamine (0.3 mg/kg over 15 minutes) provides analgesia comparable to morphine with fewer life-threatening events, though with higher psycho-perceptual side effects 1, 2

Surgical Stabilization Indications

Consider surgical stabilization of rib fractures (SSRF) within 48-72 hours for specific indications, as outcomes deteriorate significantly with delayed intervention beyond 72 hours. 1, 2

Absolute Indications for SSRF:

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical movement) 1, 2
• Respiratory failure requiring mechanical ventilation despite optimal medical management 1
• Intractable pain despite multimodal analgesia and regional blocks 1, 2

Relative Indications:

• ≥3 ipsilateral severely displaced fractures (>50% displacement) in ribs 3-10 1, 2
• Significant chest wall deformity 2

Evidence for SSRF:

A Cochrane meta-analysis found no mortality difference between operative and non-operative management, but SSRF significantly reduced pneumonia, chest deformity, and tracheostomy rates 2. The benefit is greatest when performed within 72 hours, particularly in elderly patients who deteriorate faster and are less likely to tolerate conservative management. 2

Technical Considerations:

• Obtain CT imaging with 3D reconstruction before SSRF for surgical planning 1
• Repair ribs 2-10; ribs 1,11, and 12 only in highly selected circumstances 1

Monitoring for Complications

Assess daily for respiratory complications, which represent the primary cause of morbidity and mortality in rib fracture patients. 1

Red Flags Requiring Immediate Evaluation:

• Worsening shortness of breath despite interventions 1
• Fever >100.4°F (38°C) suggesting pneumonia 1
• Productive cough with yellow, green, or bloody sputum 1
• New or different chest pain distinct from rib pain 1
• Increasing oxygen requirement or SpO2 <90% 2

Expected Recovery Timeline

Rib fractures typically heal within 6-8 weeks, but complete functional recovery may take 8-12 weeks for simple fractures and up to 6 months for complex injuries. 2

• Pain scores should improve significantly by 4 weeks with appropriate management 2
• Long-term morbidity including chronic pain and reduced quality of life can persist up to 2 years, particularly with displaced fractures (>50% displacement) 2
• Only 59% of patients return to work at 6 months, highlighting the significant public health impact 3
• SSRF performed early can shorten recovery time and improve return-to-work rates between 3-6 months compared to conservative management 2

Special Considerations for Elderly Patients

Elderly patients (>60 years) require more aggressive management from the outset, as they are at significantly higher risk for complications and deteriorate faster than younger patients. 1, 2

• Early SSRF in geriatric patients is associated with better in-hospital outcomes compared to conservative management 1
• Several retrospective studies report that SSRF in the elderly may reduce mortality compared to non-operative management 2
• Reduce opioid doses due to higher risk of accumulation and respiratory depression 1
• Consider regional anesthesia techniques earlier in the treatment algorithm 1, 2