How should rib fractures be treated, including analgesia, respiratory support, monitoring, admission criteria, and indications for surgical fixation?

Treatment of Rib Fractures

All patients with rib fractures should receive scheduled acetaminophen 1000 mg every 6 hours as the foundation of pain management, combined with aggressive respiratory physiotherapy, and early surgical stabilization (SSRF) should be performed within 48–72 hours for patients with flail chest, ≥3 severely displaced fractures, or respiratory failure despite optimal analgesia. 1

Multimodal Analgesia: The Cornerstone of Management

First-Line: Scheduled Acetaminophen

• Administer acetaminophen 1000 mg orally or intravenously every 6 hours on a scheduled basis—not as-needed—as this provides superior pain control compared to PRN dosing 1, 2
• Oral and intravenous formulations are equivalent in efficacy, so choose based on patient tolerance 1, 2

Second-Line: NSAIDs for Inadequate Control

• Add NSAIDs (such as ketorolac 60 mg IV/IM for patients 17–64 years, or oral NSAIDs) when acetaminophen alone fails to achieve adequate analgesia 1, 2
• Avoid NSAIDs in patients with renal impairment, active GI ulcers, aspirin-induced asthma, or pregnancy 1, 2
• Co-prescribe a proton-pump inhibitor when giving NSAIDs to elderly patients to reduce GI bleeding risk 1

Third-Line: Tramadol for Moderate Pain

• Tramadol 50–100 mg every 4–6 hours (maximum 400 mg/day, 300 mg/day if >75 years) is appropriate when acetaminophen plus NSAIDs are insufficient or NSAIDs are contraindicated 1
• Tramadol is contraindicated in patients with seizure history, uncontrolled depression, or concurrent use of other CNS depressants 1
• Tramadol provides combined μ-opioid agonism with serotonin-norepinephrine reuptake inhibition, offering less respiratory depression than traditional opioids 1

Reserve Opioids for Breakthrough Pain Only

• Use stronger opioids (morphine, fentanyl) exclusively for severe breakthrough pain unresponsive to the above regimen, at the lowest effective dose for the shortest duration 1, 2
• Elderly patients are at significantly higher risk of respiratory depression and oversedation with opioids 1, 2

Regional Anesthesia: Gold Standard for Severe Pain

• Thoracic epidural analgesia (TEA) or paravertebral blocks (PVB) are the gold standard for patients with severe pain, multiple fractures, or high-risk features 1, 2
• These techniques should be implemented within 24 hours of presentation when available 1
• Regional anesthesia reduces opioid consumption, improves respiratory function, decreases pneumonia and delirium rates, and shortens ICU stay 1, 2
• PVB is preferred over TEA in anticoagulated patients due to lower bleeding risk 1

Respiratory Support and Pulmonary Hygiene

Active Respiratory Interventions

• Perform deep breathing exercises and gentle coughing regularly to eliminate secretions 1
• Use incentive spirometry while sitting upright, taking slow deep breaths and holding for 3–5 seconds before exhaling 1
• Continue incentive spirometry for at least 2–4 weeks to prevent atelectasis and pneumonia 1
• Target incentive spirometry >50% predicted volume and maintain respiratory rate <20 breaths/minute 1

Adjunctive Measures

• Apply ice packs or cold compresses to the painful area alongside pharmacological therapy 1, 2
• Early mobilization is critical to prevent respiratory complications 3

Surgical Stabilization of Rib Fractures (SSRF)

Indications for SSRF

SSRF should be considered for: 4, 1

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical movement)
• ≥3 ipsilateral severely displaced fractures (>50% rib width displacement on CT) in ribs 3–10
• Multiple displaced fractures with respiratory failure or ≥2 pulmonary derangements despite optimal locoregional anesthesia
• Intractable pain despite maximal medical management
• Severe chest wall deformity

Timing is Critical

• SSRF must be performed within 48–72 hours of injury for optimal outcomes 1, 5
• Surgery within this window reduces mortality, pneumonia rates, ICU length of stay, mechanical ventilation duration, and hospitalization costs 1, 5
• Delaying SSRF beyond 72 hours markedly reduces benefits, resulting in prolonged pain, longer operative times, higher pneumonia rates, and increased long-term respiratory compromise 1, 5
• Early callous formation begins within the first week, making surgery technically more difficult after 72 hours 1

Absolute Contraindications to SSRF

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

Pre-operative Requirements

• Chest CT with three-dimensional reconstruction is mandatory before SSRF to provide precise information on fracture number, location, and displacement magnitude 1, 5

Benefits of SSRF

When performed within 72 hours, SSRF provides: 1, 5, 6, 7

• Reduced pneumonia rates (OR 0.20)
• Decreased ICU length of stay
• Shorter mechanical ventilation duration
• Lower tracheostomy rates
• Improved pain scores at 2 weeks and 4 weeks
• Reduced long-term chronic pain and respiratory compromise up to 2 years post-injury
• Better return-to-work rates at 3–6 months

Risk Stratification and Admission Criteria

High-Risk Features Requiring Aggressive Management

Patients with the following factors need more intensive monitoring and lower threshold for SSRF: 1, 2

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

Special Considerations in Elderly Patients

• Elderly patients (>60 years) are at significantly higher risk of complications and faster clinical deterioration 1, 2
• Recent evidence suggests elderly patients may benefit more from SSRF than younger patients 1
• Several retrospective studies report that SSRF in the elderly may reduce mortality compared to non-operative management 1
• Reduce opioid doses in elderly patients due to higher risk of accumulation and respiratory depression 1

Monitoring for Complications

Signs Requiring Immediate Medical Attention

Evaluate urgently for: 1, 5

• Worsening dyspnea or increasing oxygen requirements
• Fever >38°C
• Productive cough with yellow, green, or bloody sputum
• Chest pain different in character from rib pain
• Progressive desaturation despite interventions
• Tripod positioning (suggests respiratory distress)

Common Complications to Monitor

• Pneumothorax or hemothorax (obtain immediate chest X-ray if desaturation occurs) 5
• Atelectasis 1, 3
• Pneumonia (common pathway to respiratory failure) 1, 3, 8
• Respiratory failure requiring mechanical ventilation 1

Imaging Strategy

Initial Diagnostic Approach

• Standard posteroanterior (PA) chest radiograph is the first-line imaging modality to identify critical complications such as pneumothorax, hemothorax, pulmonary contusion, and flail chest 1, 2
• Plain chest X-ray misses up to 50% of rib fractures themselves, but this does not typically alter management in uncomplicated cases 1, 2
• Dedicated rib series rarely add information that changes management (only 0.23% of cases) and prolong reporting time 1

When to Obtain CT

• Chest CT is reserved for patients being considered for SSRF or when complications are suspected—it is not recommended for routine diagnosis 1, 5
• CT with three-dimensional reconstruction is mandatory before any surgical planning 1, 5

Recovery Timeline

Expected Healing Phases

• Rib fractures typically heal in 6–8 weeks, but complete recovery with resolution of pain and return to normal function can take up to 2 years, especially with multiple or displaced fractures 1, 2
• Pain scores improve significantly by 4 weeks with appropriate management 1
• Functional recovery with return to normal activities takes 8–12 weeks for simple fractures and up to 6 months for complex injuries 1
• SSRF performed within 48–72 hours can shorten recovery time in selected patients, with better return-to-work rates at 3–6 months 1
• Long-term morbidity including chronic pain, deformity, and respiratory compromise can persist for up to 2 years in some patients 1

Factors Prolonging Healing

• Displacement >50% of rib width significantly prolongs healing and increases long-term pain 1
• Osteoporosis or chronic systemic steroid therapy delays bone healing 1
• Non-union occurs in approximately 1–5% of cases and may require surgical intervention 1

Critical Pitfalls to Avoid

Pain Management Errors

• Under-treatment of pain leads to splinting, shallow breathing, poor cough, atelectasis, and pneumonia—this is the most common and dangerous error 1, 5, 3
• Excessive reliance on opioids causes respiratory depression, especially in elderly patients 1, 2
• Failing to use scheduled acetaminophen as the foundation (not PRN dosing) 1
• Not considering regional anesthesia in appropriate high-risk candidates 1

Surgical Timing Errors

• Late consideration of SSRF in appropriate candidates leads to prolonged pain, respiratory compromise, and loss of surgical benefits 1, 5
• Delaying surgery beyond 72 hours significantly worsens outcomes 1, 5

Risk Assessment Errors

• Failing to identify high-risk patients (elderly, multiple fractures, comorbidities) who need more aggressive management 1, 2
• Not recognizing that elderly patients deteriorate faster and may benefit more from early SSRF 1