Recommendations

Key Recommendations

The management of patients with rib fractures is dependent on the age of the patient, number of ribs fractured, and concomitant injuries. A patient with multiple injuries will require evaluation by the appropriate specialists. With chest wall injuries, the main goal is to determine the extent of injuries to the thoracic cage and other organ systems.

Older patients and those with >2 rib fractures are at a higher risk of pulmonary complications such as atelectasis, poor oxygenation, and respiratory compromise.[27] Admission for pain control, pulmonary toilet (mucus and secretion clearance techniques), deep breathing, early mobilization and observation is therefore warranted.[27]​​[42] Because of the increased morbidity and mortality in this subgroup, transfer to a center that has either a pulmonary critical care or a trauma team may be indicated.

Single rib fractures without associated injuries are often managed by pain control, physical therapy, and mobilization. It is important to remember that even single rib fractures can be associated with significant morbidity and mortality, particularly in frail, older patients.[43] Stress fractures, which most often occur in athletes, are initially treated with periods of rest, analgesia, and activity modification until symptoms resolve.[44]

Analgesia

Pain is imperative to treat as it improves pulmonary function and decreases the risk of pulmonary complications such as atelectasis, poor oxygenation, and respiratory compromise as well as reducing the risk of pneumonia, acute respiratory distress syndrome (ARDS), and respiratory failure.[27][45]​​​​​ Individualized multimodal analgesia based on age, level of pain, and extent of the injury is recommended for patients with multiple fractured ribs.​[45][46]​ Start scheduled analgesia as soon as possible with acetaminophen and a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (or, if regional block is likely to be needed, select a cyclo-oxygenase-2 [COX-2] inhibitor such as celecoxib to avoid platelet inhibition).[45]

Other analgesics that may be used include muscle relaxants and oral opioids, with escalation to intravenous opioids and patient-controlled analgesia, as needed (useful for breakthrough pain in particular).[45]​ Increased emphasis on nonopioid options such as NSAIDs, acetaminophen, gabapentin, lidocaine topical patches, and the muscle relaxant methocarbamol (i.e., “multimodal analgesia”) may reduce opioid use.[45][47][48]​​​

A range of analgesia may be used for patients with complicated, multiple, or bilateral rib fractures, including regional nerve blocks (e.g., serratus anterior, paravertebral or intercostal blocks) or thoracic epidural anesthesia.[45]​ There are many options for regional anesthesia, which can be tailored to the patient. Early use of regional anesthesia can avoid the potential complications associated with opioid use.[45] Epidural analgesia improved pain relief compared with other analgesic interventions in one meta-analysis.[27][49]​​ However, further meta-analyses variously report that, compared with other analgesic modalities, epidural anesthesia does not significantly reduce mortality, intensive care unit (ICU) or hospital length of stay, length of mechanical ventilation, or pulmonary complications in patients with multiple traumatic rib fractures.[50][49]​​ A lidocaine topical patch can be an alternative to regional anesthesia.[45][51][52]

Also consider nonpharmacologic alternatives, particularly for uncomplicated rib fractures (e.g., positioning, transcutaneous electrical stimulation, and ice).[45][53]​​​[54]

Oxygen

Administer oxygen as indicated to treat hypoxia.[55]​ Impaired oxygenation can be due to impaired effort of ventilation following chest wall pain or be indicative of underlying pneumothorax, hemothorax, or pulmonary contusion.[27]

Respiratory physical therapy

Rib fractures impair adequate ventilation resulting in atelectasis, poor oxygenation, and respiratory compromise.[27] Early chest physical therapy and mobility are emphasized to improve pulmonary toilet (mucus and secretion clearance techniques). Breathing exercises assessed with incentive spirometry and assisted coughing may help prevent complications.[42][56]

Treatment of underlying cause

Metastasis from lung, prostate, breast, and liver cancer can involve the ribs, accounting for 12.6% of metastatic lesions.[15] Furthermore, there are numerous primary bone tumors that can present as pathologic rib fractures, including osteochondroma, enchondroma, plasmacytoma, chondrosarcoma, and osteosarcoma. About 37% of these lesions are malignant.[16] These should be managed with appropriate specialist referral and treatment.

As age increases, the absolute risk of sustaining a fragility fracture is inversely proportional to the patient's bone mineral density, with about 27% of these fractures occurring in the ribs.[4] Therefore, osteoporosis should be treated if present. 

In children, the presence of rib fractures without associated trauma has the highest probability of being attributable to physical abuse when compared with all other fractures.[14] Among infants younger than 12 months presenting with rib fractures, as many as 82% have sustained these injuries through physical abuse.[2][3]​ A consultation with child protective services should be considered in all children with suspected physical abuse.

Management of complications

Pneumothorax occurs in about 14% to 37% of rib fractures, hemopneumothorax in 20% to 27%, pulmonary contusions in 17%, and a flail chest in up to 6%.[8][9][10]​​ Traumatic injuries to the first rib have a 3% risk of concomitant great-vessel injury.[23]

A tube thoracostomy may be necessary to either decompress a pneumothorax or drain the hemothorax. See  Pneumothorax.

[Figure caption and citation for the preceding image starts]: CT scan showing large left-sided pneumothoraxFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CT scan showing large left-sided pneumothorax[Figure caption and citation for the preceding image starts]: CXR depicting the same pneumothorax as shown on CTFrom the collection of Dr Paul Novakovich; used with permission [Citation ends].CXR depicting the same pneumothorax as shown on CT

Because of the multitude of associated injuries, the treating physician should have a high suspicion for closed-head injuries, solid organ injuries, spine injuries, and extremity fractures. Consultation of the appropriate service should not be delayed if any associated injury is encountered.

Insertion of intercostal drain, open technique: animated demonstration
Insertion of intercostal drain, open technique: animated demonstration

How to insert an intercostal (chest) drain using the open technique. Video demonstrates: tube selection, how to identify the site for drain insertion, how to make the correct incision, how to insert the intercostal drain, how to secure the drain, and postprocedure care.

Mechanical ventilation

Mechanical ventilation may be necessary for unstable patients.[56] Isolated rib fractures rarely require mechanical ventilation unless associated with other injuries, such as pulmonary contusion.[60] For patients with flail chest, mechanical ventilation is only needed if they present with shock, head injury, severe pulmonary dysfunction, or deteriorating respiratory status, or if immediate surgery is required.[60] Internal fixation of ribs/flail chest may be considered in cases failing to wean from the ventilator, or when thoracotomy is required for other reasons.[61][62]​​​[63]​ There is a reported association between operative management of rib fractures in flail chest and reduced ventilator requirements, as well as earlier discharge from intensive care.[62][63][64][65]​​​​ This effect may be less pronounced in the presence of pulmonary contusion.[62]

Surgical stabilization

Surgical stabilization of rib fractures is not required in most patients with simple rib fractures. However, it may be considered in patients with multiple severely displaced rib fractures, or patients who fail to respond to optimal nonoperative management.[66][67] In patients with flail chest, surgical stabilization should be considered on a case-by-case basis.[66][68] It is associated with reductions in:[64][67][68][69]

  • Number of days spent on mechanical ventilation

  • Length of hospital stay

  • Length of intensive care stay

  • Rate of pneumonia

  • Need for tracheostomy

  • Degree of chest wall deformity

  • Cost of treatment.

However, any effect on mortality remains uncertain.[64] In addition, the quality of the evidence upon which these recommendations are based is relatively poor.[66]

While surgical stabilization of fractures is now included within standard treatment, it is not widely practiced and requires ongoing trials in expert centers.

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