What is the appropriate management for a rib fracture?

Management of Rib Fractures

Immediate Pain Control: The Foundation of Treatment

Administer acetaminophen 1000mg every 6 hours regularly (not as needed) as first-line therapy, with oral and intravenous routes being equally effective. 1, 2

• Add NSAIDs (such as ketorolac) as second-line for severe pain if no contraindications exist (avoid in aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, renal disease, or active GI ulcers). 1, 2

• Reserve opioids exclusively for breakthrough pain at the lowest effective dose and shortest duration—undertreatment of pain leads to splinting, shallow breathing, atelectasis, and pneumonia, while overuse causes respiratory depression, especially in elderly patients. 1, 3

• Consider low-dose ketamine (0.3 mg/kg over 15 minutes) as an opioid alternative with comparable efficacy to morphine, though it produces more psychoperceptual side effects. 1, 2

Regional Anesthesia for High-Risk or Severe Cases

Implement thoracic epidural or paravertebral blocks within 24 hours for patients with multiple rib fractures, severe pain despite multimodal analgesia, or high-risk features—these techniques are the gold standard and superior to systemic opioids. 1, 2, 4, 5

• Regional anesthesia reduces opioid consumption, improves respiratory function, and decreases infections and delirium in elderly patients. 2

• Carefully evaluate bleeding risk before neuraxial blocks in anticoagulated patients. 2

• Ultrasound-guided erector spinae plane block is effective for posterior rib fractures when epidural or paravertebral blocks are unavailable. 4

Aggressive Respiratory Care

Perform incentive spirometry while sitting, taking slow deep breaths and holding for 3-5 seconds, continuing for at least 2-4 weeks to maintain volume >50% predicted and respiratory rate <20 breaths/minute. 1, 6

• Encourage deep breathing exercises and gentle coughing regularly to eliminate secretions. 1, 6, 7

• Apply ice or cold compresses to the painful area as an adjunct to pharmacological therapy. 2

• Provide supplemental oxygen to maintain SpO2 >90%. 3

Risk Stratification: Identify High-Risk Patients

Patients requiring more aggressive management include those with: 1, 2

• Age >60 years (each rib fracture increases pneumonia risk by 27% and mortality by 19% in elderly patients) 1, 8
• SpO2 <90% 1, 2
• 2-3 rib fractures, unstable segment, or pulmonary contusion 1, 2
• Obesity or malnutrition 1, 2
• Smoking or chronic respiratory disease 1, 2
• Anticoagulation therapy 1, 2
• Major trauma 1, 2

Imaging Strategy

Obtain a standard PA chest radiograph initially to detect life-threatening complications (pneumothorax, hemothorax, flail chest), recognizing it will miss up to 50% of rib fractures—but this does not change management in uncomplicated cases. 1, 2, 3

• Dedicated rib series add minimal value, changing management in only 0.23% of patients. 1

• Order chest CT with 3D reconstruction for all patients being considered for surgical stabilization, as it provides precise information on fracture number, location, and displacement magnitude. 1, 3

Surgical Stabilization: Timing Is Critical

Consider surgical stabilization of rib fractures (SSRF) within 48-72 hours (ideally within 48 hours) for: 1, 3

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places) 1, 2
• ≥3 ipsilateral severely displaced fractures (>50% rib width displacement on CT) in ribs 3-10 with respiratory failure or ≥2 pulmonary derangements despite optimal analgesia 1
• Intractable pain despite optimal medical management 1
• Chest wall deformity 2

Delaying surgery beyond 72 hours markedly reduces benefits, resulting in prolonged pain, longer operative times, increased complications, and greater likelihood of long-term respiratory compromise. 1, 3

• Early callous formation begins within the first week, making surgery technically more difficult after 72 hours. 2

• SSRF reduces mortality, pneumonia rates, ICU length of stay, mechanical ventilation duration, and hospitalization costs compared to non-operative management. 1, 3

• Elderly patients (>60 years) may benefit more from SSRF than younger patients, as they tolerate rib fractures poorly and deteriorate faster—early SSRF is associated with better in-hospital outcomes in this population. 1, 2

• Absolute contraindications: hemodynamic instability and severe traumatic brain injury without prospect for neurological recovery. 1

Recovery Timeline and Long-Term Outcomes

Rib fractures typically heal in 6-8 weeks, but complete functional recovery takes 8-12 weeks for simple fractures and up to 6 months for complex injuries, with chronic pain and respiratory compromise persisting up to 2 years in some patients. 1, 2, 8

• Pain scores improve significantly by 4 weeks with appropriate management. 1, 2

• SSRF performed within 48-72 hours improves return-to-work rates at 3-6 months and reduces long-term chronic pain and chest wall deformity. 1, 2

• Only 59% of patients return to work at 6 months, highlighting the significant long-term morbidity. 8

Warning Signs Requiring Immediate Evaluation

Seek urgent medical attention for: 1, 2, 3

• Worsening dyspnea or progressive desaturation despite interventions 1, 3
• Fever >38°C 1
• Productive cough with yellow, green, or bloody sputum 1
• Chest pain different from rib pain 1
• Dizziness, fainting, or confusion 2

Common Pitfalls to Avoid

• Undertreatment of pain is the most critical error—it leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia. 1, 3

• Excessive reliance on opioids causes respiratory depression, particularly in elderly patients. 1, 3

• Late consideration of SSRF in appropriate candidates leads to prolonged pain and respiratory compromise. 1, 3

• Failing to identify high-risk patients who need regional anesthesia techniques. 1, 2

• Ignoring the tripod position as a sign of respiratory distress requiring immediate intervention. 3