What is the best course of action for a patient with multiple rib fractures?

Management of Multiple Rib Fractures

Admit the patient to the hospital immediately for close monitoring, multimodal pain management, respiratory support, and evaluation for surgical stabilization within 48-72 hours. 1

Risk Stratification Requiring Admission

Patients with multiple rib fractures are at significantly elevated risk for pulmonary complications, respiratory failure, and mortality, making hospital admission mandatory rather than optional. 1 The following factors compound this risk:

• Age >60 years 1
• SpO2 <90% 1
• Chronic respiratory disease 1
• Obesity 1
• Anticoagulation therapy 1
• Smoking history 1
• ≥3 rib fractures, flail chest, or pulmonary contusion 1

Immediate Diagnostic Workup

Obtain a chest CT scan immediately to accurately assess fracture number, location, displacement magnitude, and evaluate for life-threatening complications including pneumothorax, hemothorax, pulmonary contusion, or flail chest. 2 CT is essential for surgical planning if stabilization is considered. 1

• High-energy mechanisms warrant evaluation for intrathoracic and intra-abdominal injuries even with normal physical examination 1
• Lower rib fractures (ribs 7-12) are associated with abdominal organ injury in 67% of patients with multiple injuries 1
• Multiple rib fractures occur in 46% of patients with blunt aortic injury 1

Multimodal Pain Management Protocol

Start scheduled acetaminophen 1000mg every 6 hours immediately as the foundation of pain control. 1 This is the American College of Surgeons' first-line recommendation. 1

Add NSAIDs (such as ketorolac) for severe pain, unless contraindicated by aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, or significant renal disease. 1

Consider regional anesthetic techniques (thoracic epidural or paravertebral blocks) as the gold standard for severe pain in high-risk patients. 1 These provide superior analgesia compared to systemic medications alone. 3

Reserve opioids only for breakthrough pain at the lowest effective dose and shortest duration, especially in elderly patients due to high risk of respiratory depression. 1 Undertreatment of pain leads to splinting, shallow breathing, and worsening atelectasis, but overreliance on opioids causes respiratory depression. 2

Low-dose ketamine (0.3 mg/kg over 15 minutes) provides morphine-equivalent analgesia with more psychoperceptual effects but avoids respiratory depression. 1

Respiratory Care Requirements

Implement incentive spirometry immediately, aiming for >50% of predicted volume (>750 mL), performed regularly to prevent atelectasis and pneumonia. 1 Continue for at least 2-4 weeks. 1

Teach effective coughing techniques with chest wall support to clear secretions. 1

Combine incentive spirometry with early mobilization (walking and breathing exercises) as part of comprehensive respiratory management. 1 The Anaesthesia society advises against using incentive spirometry alone without multimodal physiotherapy, as studies show no additional benefit without the entire package of early mobilization, breathing exercises, and pain management. 1

Monitor respiratory rate closely—rates >20 breaths per minute indicate respiratory compromise requiring escalation of care. 1

Non-Invasive Ventilation (NIV)

Consider NIV early when patients develop respiratory compromise, as the European Respiratory Society recommends it as first-line respiratory support for multiple rib fractures with acute respiratory failure. 1, 2

NIV reduces:

• Mortality (RR 0.55,95% CI 0.22–1.41) 1
• Intubation rates (OR 0.21,95% CI 0.06–0.74) 1
• Pneumonia incidence (OR 0.29,95% CI 0.13–0.64) 1

Initiate NIV when:

• Respiratory rate >20 breaths per minute 1
• SpO2 <90% despite supplemental oxygen 1
• Incentive spirometry <50% predicted volume 1

Reserve invasive mechanical ventilation for patients who fail NIV trial, present with severe hypoxemia, or have contraindications to NIV. 1 Use low tidal volume ventilation (6 mL/kg predicted body weight) with plateau pressure <30 cm H2O to prevent ventilator-induced lung injury. 1

Surgical Stabilization of Rib Fractures (SSRF)

Evaluate for SSRF within 48-72 hours in all patients with multiple rib fractures, as early intervention provides the strongest evidence for improved outcomes. 1, 2 The World Society of Emergency Surgery strongly recommends this approach. 1

Indications for SSRF:

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places) 1
• ≥3 severely displaced rib fractures 1
• Respiratory failure despite mechanical ventilation or weaning failure 1
• Severe refractory pain non-responsive to multimodal analgesia 1
• Chest wall deformity significantly affecting lung function or showing mechanical instability on palpation 1
• Anterolateral flail segments with displacement 1

Benefits of Early SSRF (≤48-72 hours):

A recent RCT of 403 patients demonstrated that early SSRF decreases:

• Hospital and ICU length of stay 1, 4
• Duration of mechanical ventilation 1, 4
• Pneumonia rates 1, 4
• Tracheostomy requirements 1, 4
• Mortality 1, 4
• Chest deformity 1
• Inflammatory markers 1

SSRF is safe and beneficial in elderly patients despite concerns about operative risk, with studies showing reduced mortality compared to non-operative management in this population. 1 Presence of pulmonary contusion (even severe) is not a contraindication to early SSRF, with recent evidence suggesting benefits regardless of contusion severity. 1

Delayed consideration of SSRF in appropriate candidates with respiratory failure worsens outcomes. 2 Optimal timing is within 72 hours of injury, as delayed surgery significantly reduces benefits. 2

Monitoring and Warning Signs

Patients require immediate escalation of care for:

• Worsening dyspnea or respiratory distress 1, 5
• Increasing chest pain 1
• Fever >38°C (100.4°F) suggesting pneumonia 1, 5
• Progressive desaturation 1
• Dizziness or confusion 1, 5
• Extreme fatigue 1
• Productive cough with yellow, green, or bloody sputum 5
• Significant change in mental status 5

Multidisciplinary Care Setting

Ensure treatment occurs in dedicated centers with multidisciplinary teams experienced in both operative and non-operative management of chest wall trauma. 1 This bundled approach to rib fracture management has been shown to reduce morbidity and improve outcomes. 6, 7

Recovery Timeline

• Rib fractures typically heal in 6-8 weeks 1
• Complete functional recovery takes 8-12 weeks for simple fractures and up to 6 months for complex injuries 1
• Pain should show significant improvement by 4 weeks with appropriate management 1
• Non-union occurs in 1-5% of cases and may require surgical intervention 1
• Chronic pain, deformity, and respiratory compromise can persist for up to 2 years post-injury in some patients 5