What is the recommended management for a rib fracture?

Management of Rib Fractures

Rib fractures should be managed with scheduled acetaminophen every 6 hours as the foundation, combined with aggressive pulmonary hygiene including incentive spirometry for 2-4 weeks, with early surgical stabilization (within 48-72 hours) considered for patients with flail chest, ≥3 severely displaced fractures, or respiratory failure despite optimal pain control. 1

Initial Pain Management: Multimodal Analgesia Algorithm

First-line: Acetaminophen

• Administer 1000mg every 6 hours on a scheduled basis (not as-needed) 1, 2
• Oral and intravenous routes are equivalent in efficacy 1, 3
• Continue scheduled dosing throughout the acute phase to prevent pain breakthrough 3

Second-line: NSAIDs for inadequate control

• Add NSAIDs (such as ketorolac) when acetaminophen alone fails to control pain 1, 2
• Screen for contraindications: aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, active GI ulcers, severe renal impairment 3
• Monitor for dizziness, GI upset, and increased bleeding risk 3

Third-line: Opioids for breakthrough pain only

• Reserve exclusively for severe breakthrough pain uncontrolled by acetaminophen plus NSAIDs 1, 2
• Use the lowest effective dose for the shortest duration 1, 2
• Reduce doses by 25-50% in elderly patients (>60 years) due to accumulation risk and respiratory depression 1, 3

Alternative: Low-dose ketamine

• Consider 0.3 mg/kg IV over 15 minutes as an opioid alternative 1, 2
• Provides analgesic efficacy comparable to morphine 1, 3
• Expect higher rates of psycho-perceptual adverse effects (dissociation, hallucinations) 1, 3

Regional Anesthesia for High-Risk Patients

Gold standard techniques:

• Thoracic epidural analgesia (TEA) or paravertebral blocks (PVB) should be implemented within 24 hours for patients with multiple rib fractures, severe pain despite multimodal analgesia, or high-risk features 1, 2
• These techniques reduce opioid consumption, delirium in elderly patients, and improve respiratory function 2, 3

Emerging alternatives:

• Erector spinae plane blocks (ESPB) and serratus anterior plane blocks (SAPB) are safe, effective alternatives with lower complication rates 2
• ESPB can be performed by trained emergency physicians, making it practical in trauma settings 2
• Consider these when TEA/PVB are contraindicated or unavailable 2

Contraindications to neuraxial blocks:

• Carefully evaluate bleeding risk in patients on anticoagulation before performing neuraxial or plexus blocks 3
• Hemodynamic instability is an absolute contraindication 1

Respiratory Care Protocol

Incentive spirometry (mandatory):

• Perform while sitting upright, taking slow deep breaths and holding for 3-5 seconds before exhaling 1, 2
• Target >50% predicted volume 1
• Continue for minimum 2-4 weeks to prevent atelectasis and pneumonia 1, 2

Additional pulmonary hygiene:

• Regular deep breathing exercises every 1-2 hours while awake 1, 2
• Gentle coughing exercises to clear secretions 1, 2
• Early mobilization and ambulation as tolerated 1

Monitoring targets:

• Maintain respiratory rate <20 breaths per minute 1
• Keep SpO2 >90% 1, 3

Surgical Stabilization Decision Algorithm

Absolute indications for SSRF (perform within 48-72 hours):

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical movement) 1, 2, 4
• ≥3 ipsilateral severely displaced fractures (>50% rib width displacement on CT) in ribs 3-10 PLUS ≥2 pulmonary derangements despite optimal loco-regional anesthesia 1
• Respiratory failure requiring mechanical ventilation with multiple displaced fractures 1, 2
• Intractable pain despite optimal multimodal analgesia and regional blocks 1, 2

Relative indications:

• Severe chest wall deformity 2, 3
• Multiple displaced fractures in ribs 3-10 (most commonly plated ribs) 3

Absolute contraindications:

• Hemodynamic instability 1
• Severe traumatic brain injury without prospect for neurological recovery 1

Timing is critical:

• Perform SSRF within 48-72 hours for optimal outcomes 1, 2, 3
• Early callous formation begins within the first week, making surgery technically more difficult after 72 hours 3
• Delayed surgery (>72 hours) reduces benefits and increases operative time and complications 3

Benefits of early SSRF:

• Reduces mortality, pneumonia rates, ICU length of stay, duration of mechanical ventilation, and hospitalization costs 1, 4
• Improves pain scores at 2 weeks and 4 weeks 1
• Reduces long-term chronic pain and respiratory compromise up to 2 years post-injury 1, 3
• Better return-to-work rates at 3-6 months 1, 3

Risk Stratification for Aggressive Management

High-risk features requiring intensive monitoring and consideration for SSRF:

• Age >60 years (significantly higher risk of complications and faster deterioration) 1, 2, 3
• SpO2 <90% on presentation 1, 3
• Obesity or malnutrition 1, 3
• 2-3 rib fractures, unstable segment, or pulmonary contusion 1, 3
• Smoking or chronic respiratory disease (COPD, asthma) 1, 3
• Anticoagulation therapy 1, 3
• Major trauma with multiple injuries 1, 3

Special consideration for elderly patients (>60 years):

• Recent evidence suggests elderly patients may benefit MORE from SSRF than younger patients 1, 3
• They are less likely to tolerate rib fractures and deteriorate faster 1, 3
• Several retrospective studies report SSRF in elderly may reduce mortality compared to non-operative management 3
• Early SSRF within 48-72 hours is associated with better in-hospital outcomes in geriatric patients 1, 2

Imaging Strategy

Initial imaging:

• Standard posteroanterior (PA) chest radiograph should be the first test 1, 3
• Detects critical complications (pneumothorax, hemothorax, flail chest) even though it misses up to 50% of rib fractures 1, 3

Advanced imaging:

• CT chest with 3D reconstruction is necessary before SSRF for surgical planning 2, 3
• CT has higher sensitivity for detecting fractures and measuring displacement 1
• Dedicated rib series rarely change management (only 0.23% of cases) and prolong reporting time 1

Key point: Treatment remains the same regardless of whether X-ray detects the fracture, so do not delay management waiting for imaging confirmation 3

Monitoring for Complications

Red flags requiring immediate medical attention:

• Worsening dyspnea or increasing shortness of breath 1, 3
• Fever >38°C (100.4°F) 1, 3
• Productive cough with yellow, green, or bloody sputum 1, 3
• Chest pain different in character from the rib pain 1, 3
• Progressive desaturation despite interventions 1
• Dizziness, fainting, or confusion 3

Regular assessment for:

• Atelectasis, pneumonia, respiratory failure 1, 2
• Pain scores (should improve significantly by 4 weeks) 1, 3
• Respiratory function via incentive spirometry (progressive improvement over 2-4 weeks) 3

Recovery Timeline

Bone healing:

• Rib fractures typically heal in 6-8 weeks 1, 3
• Bone scan activity returns to normal in 79% by 1 year, 93% by 2 years, 100% by 3 years 3

Functional recovery:

• Pain scores improve significantly by 4 weeks with appropriate management 1, 3
• Return to normal activities takes 8-12 weeks for simple fractures 1, 3
• Complex injuries may require up to 6 months for full functional recovery 1, 3
• Complete recovery with resolution of pain may take up to 2 years in some patients, especially with multiple or displaced fractures 1, 3

Impact of SSRF on recovery:

• SSRF performed within 48-72 hours shortens recovery time in selected patients 1, 3
• Better return-to-work rates between 3-6 months compared to non-operative management 1, 3
• Reduces long-term complications including chronic pain (which develops in up to 40% without surgery) and chest wall deformity 1, 3

Critical Pitfalls to Avoid

Undertreatment of pain:

• Leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia 1, 2
• Use scheduled acetaminophen, not as-needed dosing 1, 3

Overreliance on opioids:

• Causes respiratory depression, especially in elderly patients 1, 2
• Increases delirium risk in older adults 2
• Reserve for breakthrough pain only after multimodal analgesia fails 1, 2

Delayed consideration of SSRF:

• Waiting beyond 72 hours reduces surgical benefits and increases complications 1, 3
• Early callous formation makes surgery technically more difficult 3
• Prolonged pain and respiratory compromise result from delayed intervention 1, 2

Failing to identify high-risk patients:

• Elderly patients (>60 years) require more aggressive pain management and earlier SSRF consideration 1, 2, 3
• Multiple risk factors significantly increase complication likelihood 3

Underutilizing regional anesthesia:

• Regional blocks are the gold standard for severe pain and high-risk patients 2, 3
• Particularly important in elderly patients with multiple fractures 3