Rib fractures

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – analgesia

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1st line –

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 (e.g., methocarbamol) and oral opioids (e.g., oxycodone), with escalation to intravenous opioids (e.g., morphine) 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 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 reduce mortality, ICU or hospital length of stay, length of mechanical ventilation, or pulmonary complications in patients with multiple traumatic rib fractures.[49][50] 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]

Stress fractures, which often occur in athletes, are initially treated with periods of rest, analgesia, and activity modification until symptoms resolve.[44]

Primary options

acetaminophen: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children ≥12 years of age: 325-650 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day (children) or 3200 mg/day (adults)

celecoxib: adults: 100-200 mg orally twice daily

lidocaine topical patch: adults: dose depends on brand of transdermal patch; consult product literature for guidance on dose

gabapentin: adults: 300 mg orally once daily on day 1, followed by 300 mg twice daily on day 2, then 300 mg three times daily, increase gradually according to response, maximum 3600 mg/day

methocarbamol: adults: 1500 mg orally four times daily for 2-3 days, followed by 1000 mg four times daily or 1500 mg three times daily or 750 mg every 4 hours, maximum 8000 mg/day (initial starting dose) or 4500 mg/day (subsequent dose)

Secondary options

oxycodone: children: consult specialist for guidance on dose; adults: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

Tertiary options

morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required, adjust dose according to response

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

acetaminophen

-- AND --

ibuprofen

celecoxib

lidocaine topical patch

gabapentin

methocarbamol

Secondary options

oxycodone

Tertiary options

morphine sulfate

Plus – respiratory physical therapy

Consider – oxygen

Consider – treatment of underlying cause

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Consider –

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

If the patient has a prior history of malignancy, metastatic disease should be suspected. Metastasis from lung, prostate, breast, and liver cancer can involve the ribs, accounting for 12.6% of metastatic lesions.[15] There are numerous primary bone tumors that can present as pathologic rib fractures, including osteochondroma, enchondroma, plasmacytoma, chondrosarcoma, and osteosarcoma; about 37% of 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.

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

with complications

Plus – management of complications

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Plus –

management of complications

Treatment recommended for ALL patients in selected patient group

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].[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].

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 with the appropriate service should not be delayed if any associated injury is encountered.

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.

Consider – mechanical ventilation

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Consider –

mechanical ventilation

Treatment recommended for SOME patients in selected patient group

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, a head injury, severe pulmonary dysfunction, a deteriorating respiratory status, or if immediate surgery is required.[60]

Internal fixation of ribs/flail chest may be considered where there is difficulty weaning the patient from mechanical ventilation, or when thoracotomy is required for other reasons.[61][62][63]

Systematic reviews have reported an 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]

Consider – surgical stabilization

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Consider –

surgical stabilization

Treatment recommended for SOME patients in selected patient group

Surgical stabilization of rib fractures may be considered in patients with flail chest, patients with multiple severely displaced rib fractures, or patients who fail to respond to optimal nonoperative management.[66]

Operative treatment of rib fractures in flail chest is associated with reductions in: the number of days spent on mechanical ventilation; hospital and intensive care length of stay; the rate of pneumonia; the need for tracheostomy; the degree of chest wall deformity; and the cost of treatment.[64][67][69] 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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Rib fractures

Treatment algorithm

all patients

analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

respiratory physical therapy

oxygen

treatment of underlying cause

with complications

management of complications

mechanical ventilation

surgical stabilization