What is the recommended treatment approach for a patient with a rib fracture?

Treatment for Rib Fracture

Start with scheduled acetaminophen 1000mg every 6 hours as the foundation of pain management, add NSAIDs for breakthrough pain, and reserve opioids only for severe refractory pain. 1

Risk Stratification Determines Treatment Intensity

Immediately assess for high-risk features that mandate more aggressive management:

• Age >60 years increases pneumonia risk by 27% and mortality by 19% per rib fracture 1, 2
• SpO2 <90% on room air 1, 2
• Multiple fractures (≥3 ribs) or presence of flail chest 1
• Chronic respiratory disease or active smoking 1
• Anticoagulation therapy 1
• Obesity or malnutrition 1
• Pulmonary contusion, pneumothorax, or hemothorax 2

Patients with any of these features require hospital admission and consideration for regional anesthesia techniques. 1, 2

Multimodal Analgesia Protocol

First-Line: Acetaminophen

• Administer 1000mg every 6 hours on a scheduled basis (not as-needed) 1
• Oral formulation is equivalent to IV for pain control 1
• This provides superior baseline pain control and reduces opioid requirements 1

Second-Line: NSAIDs

• Add ketorolac or other NSAIDs when acetaminophen alone is insufficient 1
• Contraindications to avoid: aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, active GI bleeding 1
• Monitor for GI upset, dizziness, and increased diaphoresis 1

Third-Line: Opioids (Last Resort)

• Reserve exclusively for severe breakthrough pain 1
• Use lowest effective dose for shortest duration 1
• Particularly dangerous in elderly patients due to respiratory depression risk 3

Alternative: Low-Dose Ketamine

• Consider 0.3 mg/kg IV over 15 minutes as opioid alternative 1
• Provides comparable analgesia to morphine 1
• Expect more psycho-perceptual adverse effects 1

Regional Anesthesia for High-Risk or Severe Cases

Thoracic epidural or paravertebral blocks are the gold standard for elderly patients or those with severe pain and multiple fractures. 1, 4

Indications for Regional Techniques:

• Elderly patients (>60 years) with multiple rib fractures 1
• Severe pain inadequately controlled with multimodal systemic analgesia 1
• Flail chest or ≥3 displaced fractures 1
• Respiratory compromise despite adequate systemic analgesia 1

Benefits of Regional Anesthesia:

• Superior pain control with limited contraindications 1
• Improves respiratory function and reduces opioid consumption 1
• Decreases infections and delirium in elderly patients 1
• Reduces mechanical ventilation time and ICU stay 4

Technique Selection:

• Thoracic epidural analgesia (TEA): Most studied, excellent efficacy but contraindicated in anticoagulated patients 4
• Paravertebral block (PVB): Viable alternative to TEA with similar efficacy, 10% failure rate 4
• Erector spinae plane block (ESPB): Can be performed by trained emergency physicians, lower risk profile 4
• Serratus anterior plane block (SAPB): Practical alternative with lower adverse effects 4

Critical caveat: Carefully evaluate bleeding risk before neuraxial or plexus blocks in anticoagulated patients. 1

Surgical Stabilization of Rib Fractures (SSRF)

Indications for Surgery:

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places) 5, 1
• ≥3 ipsilateral severely displaced fractures with respiratory failure 1
• Severe refractory pain despite optimal multimodal analgesia 1
• Chest wall deformity 1

Timing is Critical:

• Perform SSRF within 48-72 hours of injury for optimal outcomes 1
• Early fixation (within 72 hours) shows better outcomes than delayed intervention 1
• Delaying beyond 72 hours reduces benefits and increases operative difficulty 1

Benefits of SSRF:

• Reduces pneumonia, chest deformity, and tracheostomy rates 1
• Shortens mechanical ventilation time (3.7 vs 9.5 days) 6
• Decreases ICU stay (8.2 vs 14.6 days) and total hospitalization (15.3 vs 26.5 days) 6
• Reduces long-term chronic pain and chest wall deformity 1
• Improves return-to-work rates at 3-6 months 1

Special Considerations:

• Elderly patients (>60 years) may benefit MORE from SSRF than younger patients, as they tolerate rib fractures poorly and deteriorate faster 1
• Several retrospective studies show SSRF reduces mortality in elderly patients 1
• Do NOT routinely fix 11th and 12th ribs unless marked displacement causes organ impalement or herniation 3
• Ribs 3-8 are most commonly plated; first, second, eleventh, and twelfth ribs typically not fixed 1

Non-Pharmacological Adjuncts

• Apply ice packs or cold compresses to painful areas 1
• Immobilize extremities when appropriate 1
• Aggressive pulmonary hygiene and chest physiotherapy 5, 7
• Incentive spirometry to prevent atelectasis 7

Expected Recovery Timeline

• Pain scores improve significantly by 4 weeks with appropriate management 1, 3
• Rib fractures heal in 6-8 weeks 1, 3
• Return to normal activities takes 8-12 weeks for simple fractures 1, 3
• Complete pain resolution may take up to 2 years in patients with multiple or displaced fractures 1, 3
• Early callous formation begins within first week, making late surgery technically more difficult 1

Warning Signs Requiring Immediate Evaluation

• Increasing shortness of breath or respiratory distress 1
• Fever >38°C 3
• Productive cough with yellow, green, or bloody sputum 1
• Progressive oxygen desaturation despite interventions 3
• Chest pain different from rib pain, especially with dyspnea 1
• Dizziness, fainting, or confusion 1

Common Pitfalls to Avoid

• Under-treatment of pain leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia 3
• Using opioids as first-line therapy instead of as last resort for breakthrough pain 1
• Underutilizing regional anesthesia in appropriate candidates, particularly elderly patients with multiple fractures 1
• Failing to identify high-risk patients who need aggressive pain management from the outset 1, 3
• Delaying surgical consultation beyond 72 hours in patients with clear SSRF indications 1
• Considering surgery for 11th and 12th rib fractures without highly specific indications (organ impalement, herniation, marked deformity) 3