In a patient with minimally displaced left anterolateral rib 4‑6 fractures who is taking buprenorphine‑naloxone (Suboxone) and alprazolam, is referral to a cardiothoracic surgeon required or will the fractures heal with conservative management?

Management of Minimally Displaced Left Anterolateral Rib 4-6 Fractures

These minimally displaced rib fractures do not require cardiothoracic surgery referral and will heal well with conservative management alone. 1

Why Surgery Is Not Indicated

Surgical stabilization of rib fractures (SSRF) is reserved for specific indications that do not apply to this patient's injury pattern. 1 The 2024 WSES/CWIS guidelines clearly state that SSRF should be considered for:

• Flail chest segments (which this patient does not have) 1
• All displaced ribs when possible in non-flail chest patterns 1
• Severely displaced fractures (defined as no cross-sectional overlap) 1
• Multiple fractures with ≥3 displaced rib fractures 2

The key distinction here is that minimally displaced fractures (defined as >90% cross-sectional overlap or 50-90% overlap for "offset" fractures) do not meet surgical criteria. 1, 3 Your patient's "minimally displaced" fractures fall into the non-displaced or offset category, which are managed conservatively. 3, 2

Ribs 4-6 Location Considerations

Ribs 4-6 in the anterolateral location are among the most commonly plated ribs when surgery IS indicated (ribs 3-8), but only when they are significantly displaced. 1 The anterolateral location means these fractures are accessible surgically, but this accessibility does not change the indication—displacement severity determines surgical candidacy, not anatomic location alone. 1

Conservative Management Protocol

Implement aggressive multimodal analgesia immediately to prevent respiratory complications from pain-related splinting. 3, 4

Pain Management Strategy

• Start scheduled acetaminophen 1000mg every 6 hours around-the-clock as first-line therapy 3, 5
• Add NSAIDs (such as ketorolac) for breakthrough pain, avoiding in patients with contraindications 3
• Reserve opioids strictly for breakthrough pain at lowest effective doses—this is critical given the patient's buprenorphine-naloxone therapy 3, 4

Special Consideration for Buprenorphine-Naloxone Patients

This patient on Suboxone presents a unique challenge for pain management. 6 Buprenorphine is a partial mu-opioid receptor agonist with high receptor affinity, which can block full opioid agonists from binding effectively. 6 If opioids are needed for breakthrough pain, consider:

• Continuing buprenorphine-naloxone and using higher doses of full agonist opioids to overcome receptor blockade
• Consulting pain management or addiction medicine for guidance on temporarily adjusting the buprenorphine regimen
• Strongly consider regional anesthesia techniques instead (see below) 3

Regional Anesthesia Options

For severe pain or high-risk patients, thoracic epidural or paravertebral blocks are the gold standard. 3 Alternatively, erector spinae plane blocks and serratus anterior plane blocks serve as practical alternatives with lower adverse effect profiles. 3, 7

Respiratory Care Protocol (Mandatory)

Inadequate pain control leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia—this is the primary complication to prevent. 3, 2, 5

• Perform deep breathing exercises every 1-2 hours while awake 5
• Use incentive spirometry while sitting, taking slow deep breaths and holding 3-5 seconds before exhaling 3
• Continue incentive spirometry for at least 2-4 weeks 3
• Early mobilization is mandatory to prevent pulmonary complications 3, 2

Risk Stratification

Identify if this patient has high-risk features requiring more aggressive management: 3

• Age >60 years
• SpO2 <90%
• Presence of 5 consecutive rib fractures (this patient has 3)
• Obesity or malnutrition
• Smoking or chronic respiratory disease
• Anticoagulation therapy (note: alprazolam is not an anticoagulant)

Monitoring and Follow-Up

Clinical reassessment within 1-2 weeks is necessary to monitor for worsening displacement, development of complications, and adequate pain control. 3, 2

Watch for complications requiring immediate attention: 3, 5

• Worsening dyspnea or respiratory distress
• Fever >38°C
• Productive cough with yellow, green, or bloody sputum
• Progressive oxygen desaturation despite interventions
• Development of pneumothorax or hemothorax

Expected Healing Timeline

• Pain scores should improve significantly by 4 weeks with appropriate management 3, 5
• Rib fractures typically heal in 6-8 weeks 3, 5
• Functional recovery with return to normal activities takes 8-12 weeks 3, 5
• Complete resolution of pain may take up to 2 years in some patients 3, 5

Critical Pitfalls to Avoid

Under-treatment of pain is the most common error and leads directly to pulmonary complications. 3, 2 The combination of buprenorphine-naloxone and alprazolam requires careful attention—both medications can cause respiratory depression when combined with additional opioids or sedatives. 6 Failing to implement early respiratory physiotherapy results in preventable pulmonary complications. 3