Would you refer a patient with a rib subluxation to orthopedics (ortho)?

Orthopedic Referral for Rib Subluxation

Rib subluxation does not require orthopedic referral in the vast majority of cases, as conservative management with multimodal analgesia and respiratory support is the standard of care. 1, 2

When Orthopedic/Trauma Surgery Referral IS Indicated

Refer to a surgeon experienced in chest wall trauma (typically trauma surgery or thoracic surgery, not general orthopedics) if the patient meets any of these criteria:

• Flail chest (≥2 consecutive ribs each fractured in ≥2 places with paradoxical chest wall movement) 3, 4
• Multiple (≥3) severely displaced rib fractures (displacement >50% of rib width on CT) with respiratory compromise 3, 1
• Severe refractory pain despite multimodal analgesia including regional anesthesia techniques 3, 1
• Respiratory failure requiring mechanical ventilation or inability to wean from ventilator 3
• Significant chest wall deformity affecting lung function or with mechanical instability on palpation 3, 1

Conservative Management Protocol (No Referral Needed)

For isolated rib subluxation or simple rib fractures without the above criteria:

Pain Control

• Acetaminophen 1000mg every 6 hours scheduled (not as needed) as first-line therapy 1, 2
• Add NSAIDs (ketorolac or ibuprofen) for breakthrough pain if no contraindications (avoid in aspirin-induced asthma, pregnancy, cerebrovascular hemorrhage, significant renal disease) 1, 2
• Reserve opioids only for severe breakthrough pain at lowest effective dose 1, 2

Respiratory Support

• Incentive spirometry aiming for >50% predicted volume (>750mL), performed regularly for 2-4 weeks 2, 4
• Teach effective coughing techniques with chest wall support to clear secretions 2, 4
• Monitor respiratory rate - rates >20 breaths/minute indicate respiratory compromise requiring escalation 1, 2

Expected Recovery Timeline

• Rib fractures typically heal in 6-8 weeks, but complete functional recovery takes 8-12 weeks for simple injuries 1, 2
• Pain should show significant improvement by 4 weeks with appropriate management 1, 2

High-Risk Patients Requiring Closer Monitoring

Even without surgical referral, these patients need more aggressive outpatient follow-up or admission consideration:

• Age >60 years (significantly higher morbidity and mortality) 1, 2
• SpO2 <90% on room air 1, 2
• Chronic respiratory disease or smoking history 1, 2
• Anticoagulation therapy 1, 2
• Obesity or malnutrition 1, 2
• Multiple (2-3) rib fractures even without displacement 1, 2

Critical Pitfalls to Avoid

• Don't refer to general orthopedics - rib fracture fixation requires specialized training in chest wall trauma, typically performed by trauma surgeons or thoracic surgeons, not orthopedic surgeons 3
• Don't delay surgical consultation beyond 72 hours if criteria are met - surgical stabilization of rib fractures (SSRF) is most beneficial when performed within 48-72 hours of injury 3, 1, 4
• Don't underestimate elderly patients - they deteriorate faster and may benefit more from SSRF than younger patients 3, 4
• Don't use opioids as first-line therapy - multimodal analgesia with scheduled acetaminophen and NSAIDs provides superior pain control with fewer complications 1, 2

Special Consideration: Slipping Rib Syndrome

If the patient has recurrent subluxation of lower ribs (ribs 8-10) with chronic pain reproduced by the "hooking maneuver" (pulling anteriorly on the rib margin), this represents slipping rib syndrome and may warrant referral to a surgeon experienced in rib stabilization procedures 5. However, this is distinct from acute traumatic rib subluxation and typically presents as chronic pain rather than acute injury.