From the Guidelines
Rib fracture splinting is not recommended as a standard treatment for rib fractures. Instead, optimal pain management is the cornerstone of treatment, typically involving a multimodal approach with NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily), acetaminophen (1000mg every 6 hours), and if needed, opioids such as oxycodone (5-10mg every 4-6 hours) for breakthrough pain 1. Regional anesthesia techniques like intercostal nerve blocks or thoracic epidural analgesia may be beneficial for severe pain. Physical splinting with external devices or wraps should be avoided as they restrict chest wall movement, potentially leading to atelectasis, pneumonia, and respiratory compromise. The natural splinting that occurs from pain-induced shallow breathing is already problematic, and additional external restriction worsens outcomes.
Some key points to consider in the management of rib fractures include:
- Early mobilization and pulmonary hygiene are essential to prevent complications like pneumonia 1
- Surgical stabilization of rib fractures (SSRF) may be considered in patients with flail chest or severe chest wall injuries, as it has been shown to reduce the duration of mechanical ventilation, pneumonia rates, and ICU stay 1
- The use of ketamine as an alternative to opioids for pain management in elderly patients with rib fractures may be considered, as it has been shown to have fewer side effects and similar efficacy 1
- A multimodal analgesic approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and tramadol, may be effective in managing pain in elderly patients with rib fractures 1
Overall, the goal of treatment for rib fractures is to optimize pain management, prevent complications, and improve outcomes, with a focus on individualized care and consideration of the patient's specific needs and circumstances.
From the Research
Rib Fracture Splinting
- Rib fracture splinting is a common and painful injury that can lead to significant morbidity and mortality, especially in the elderly 2.
- The primary endpoint of care for rib fractures is to reduce morbidity and mortality through risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach 2.
- Rib fracture splinting can limit a patient's ability to take a deep breath, leading to atelectasis, poor secretion removal, and ultimately pneumonia 3.
- Pneumonia is a common pathway to respiratory failure in patients with rib fractures, and each rib fracture increases the risk of developing pneumonia by 27% and the risk of dying by 19% in the elderly 3.
Management of Rib Fracture Splinting
- Adequate pain control, rapid mobilization, and meticulous respiratory care are essential in preventing complications in patients with multiple rib fractures 4.
- A multimodal analgesic approach, including pharmacologic and regional analgesia, can help reduce morbidity and mortality associated with rib fractures 2.
- Epidural analgesia has been shown to provide superior pain relief and reduce the risk of subsequent pneumonia in patients with multiple rib fractures 5.
- Thoracic nerve blocks, such as erector spinae block, serratus anterior plane nerve block, and intercostal nerve block, can be performed safely in an emergency department setting and provide excellent anesthesia for rib fractures and thoracic trauma 6.
Complications of Rib Fracture Splinting
- Delayed morbidity for patients with rib fractures is often a result of hypoventilation leading to atelectasis, pneumonia, and respiratory failure 4.
- Rib fractures can have long-term implications, with only 59% of patients returning to work at 6 months 3.
- The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria, but when feasible, it is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures 5.