To whom should I refer a patient with a rib subluxation, particularly one with severe displacement, multiple fractures, or respiratory compromise, and a possible history of chronic respiratory disease?

Referral for Rib Subluxation/Fracture

Refer patients with rib subluxation or fractures to a trauma surgeon or thoracic surgeon experienced in surgical stabilization of rib fractures (SSRF), particularly when severe displacement, multiple fractures (≥3 consecutive ribs), flail chest, respiratory compromise, or chronic respiratory disease are present. 1

Immediate Referral Indications (Within 24-48 Hours)

Refer urgently to trauma surgery or thoracic surgery for:

• Flail chest (≥3 consecutive ribs fractured in ≥2 places with paradoxical chest wall movement) 1, 2, 3
• ≥3 severely displaced rib fractures (≥50% rib width displacement on CT) 1, 2
• Respiratory compromise despite optimal pain management (SpO2 <90%, respiratory rate >20/min, incentive spirometry <50% predicted) 2, 4, 3
• Multiple consecutive rib fractures (≥4 ribs) with pulmonary contusion 2, 4
• Bilateral rib fractures 1
• Marked chest wall deformity causing thoracic volume restriction 1
• Vascular impingement or organ impalement/herniation 1
• Refractory pain non-responsive to multimodal analgesia including regional blocks 1, 3

Specialist Selection

The optimal referral is to a dedicated trauma center with a multidisciplinary team experienced in both operative and non-operative chest wall trauma management. 4, 3 This typically includes:

• Trauma surgeons with SSRF training 1
• Thoracic surgeons experienced in rib plating 5, 6, 7
• Acute care surgeons at Level I or II trauma centers 5

Additional Specialist Considerations

For patients with chronic respiratory disease (COPD, asthma, interstitial lung disease):

• Pulmonology consultation should occur concurrently with surgical evaluation, as these patients have significantly higher risk of respiratory failure and pneumonia 1, 4
• Pain management/anesthesiology for regional anesthetic techniques (thoracic epidural, paravertebral blocks) which are gold standard for severe pain 4, 3

For lower rib fractures (ribs 7-12) with multiple injuries:

• Consider general surgery consultation as 67% of these patients have associated abdominal organ injury requiring contrast-enhanced CT evaluation 1

Timing of Surgical Evaluation

SSRF should be performed within 48-72 hours when indicated, as this timing significantly reduces pneumonia, mechanical ventilation duration, ICU stay, and mortality compared to delayed surgery. 1, 2, 4, 3, 5 Early referral (within 24 hours of presentation) allows adequate time for preoperative planning and optimization.

Critical Pitfalls to Avoid

• Delaying surgical consultation beyond 72 hours in patients meeting SSRF criteria significantly reduces benefits and increases pneumonia risk 2, 4
• Assuming elderly patients are not surgical candidates - SSRF is safe and beneficial in elderly patients despite operative risk concerns, with reduced mortality compared to non-operative management 4
• Considering pulmonary contusion a contraindication - even severe contusion is not a contraindication to early SSRF, with recent evidence showing benefits regardless of contusion severity 4
• Referring only patients with flail chest - non-flail patterns with ≥3 displaced fractures, bilateral fractures, or respiratory compromise also benefit from SSRF 1, 2

Ribs Most Commonly Requiring Surgical Stabilization

Ribs 3-8 are most commonly plated, as fractures of ribs 6-8 strongly contribute to decreased thoracic volumes and are most straightforward to expose. 1 Ribs 1,11, and 12 are only stabilized in highly selected cases of marked displacement causing vascular or organ damage. 1, 3