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

Treat the patient’s pain immediately and reassess regularly.[51] Managing pain is imperative as it improves pulmonary function; decreases the risk of pulmonary complications such as atelectasis, poor oxygenation, and respiratory compromise; and can prevent respiratory failure.[57]

Individualise multimodal analgesia based on the patient’s age, their level of pain, and the extent of the injury.[51][57][69][70]

Ensure a range of analgesia is available, including regional nerve blocks (e.g., serratus anterior or erector spinae blocks) or thoracic epidural anaesthesia and nerve blocks, and use an agreed analgesia protocol.[51][57][70]

Epidural analgesia improved pain relief compared with other analgesic interventions in one meta-analysis.[71] However, further meta-analyses variously report that, compared with other analgesic modalities, epidural anaesthesia does not significantly reduce mortality, intensive care unit or hospital length of stay, or pulmonary complications in patients with multiple traumatic rib fractures.[71][72] It is unclear if epidural analgesia has an effect on length of mechanical ventilation.[72]

Start oral analgesics, such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen.[40]

Consider titrated intravenous morphine initially, with a range of follow-up regimens including paracetamol, an NSAID, and an oral opioid, or patient-controlled analgesia, or referral to anaesthetics for epidural anaesthesia or a nerve block.[40][57]

There are many options for regional anaesthesia, which can be tailored to the patient.[40]

A lidocaine topical patch can be an alternative to regional anaesthesia in adults, and may shorten hospital stay, and reduce opioid use.[73][74]

Consider transcutaneous electrical nerve stimulation (TENS) for pain management of uncomplicated rib fractures.

TENS was found in a randomised controlled trial to be more effective than NSAIDs for relieving pain in patients with minor rib fractures following blunt chest trauma.[75]

Many rib fractures are to a single rib and are of low severity, requiring minimal intervention from medical teams. Use pain control, physiotherapy, and mobilisation to manage single rib fractures without associated injuries.

Treat stress fractures, which often occur in athletes, with periods of rest, analgesia, and activity modification until symptoms resolve.[68]

There are scoring systems used to stratify patients and determine treatment. These are often based on the patient’s age and the number of fractures; however, there is no single universally accepted system.[40]

Primary options

paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

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

Consider – oxygen

Plus – chest physiotherapy and respiratory hygiene

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Plus –

chest physiotherapy and respiratory hygiene

Treatment recommended for ALL patients in selected patient group

Arrange chest physiotherapy and encourage mobility to improve mucus and secretion clearance.[51][66]

Deep breathing exercises assessed with incentive spirometry and assisted coughing may help prevent complications.[40][51][66][76]

Consider – treatment of underlying cause

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Consider –

treatment of underlying cause

Additional treatment recommended for SOME patients in selected patient group

Refer patients with rib fracture due to underlying primary bone tumours or metastases to the appropriate specialist.

Metastasis from lung, prostate, breast, and liver cancer can involve the ribs, accounting for 12.6% of metastatic lesions.[27] Furthermore, there are numerous primary bone tumours that can present as pathological rib fractures, including osteochondroma, enchondroma, plasmacytoma, chondrosarcoma, and osteosarcoma. About 37% of these lesions are malignant.[28] Multiple myeloma can present with rib fractures and even with a flail chest.[29][30] Primary bone tumours or metastases should be managed with appropriate specialist referral and treatment.

Identify and treat patients with osteoporosis. See Osteoporosis. 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.[15]

Consider the causes of falls in older adults.[87] These may be inter-related and multifactorial. See Assessment of falls in the elderly.

Non-accidental injury

Suspect child maltreatment if a child has 1 or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[52] Follow your local safeguarding protocol or consult with child protective services. See Child abuse.

The presence of rib fractures without associated trauma has the highest probability of being attributed to non-accidental injury when compared with all other fractures.[44]
In young children, studies have shown rib fractures are a result of child abuse 65% to 100% of the time.[2][3][4][5][6] The probability of abuse in children with intracranial injury and retinal haemorrhage alone is about 33%, but this probability increases to about 98% with the addition of rib fractures.[8][9] Consult with child protective services for children with suspected physical abuse.

Remember to consider an assessment for vulnerable adults, such as those with frailty, dementia, or disability, after a traumatic injury. Take into account known or suspected non-accidental injury.[51] Follow local safeguarding protocol if you have any concerns.

Consider – specialist referral and treatment for patients with complications

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Consider –

specialist referral and treatment for patients with complications

Additional treatment recommended for SOME patients in selected patient group

Management of the patient with rib fractures will depend on the patient’s age, the number of ribs fractured, and concomitant injuries.

In a patient with blunt chest wall trauma, management should be directed by a consultant-led trauma team.

Admit patients with respiratory compromise for pain control, mucus and secretion clearance, deep breathing, early mobilisation, and observation.[42][51][66] Transfer to a centre that has either a pulmonary critical care or trauma team because of the increased morbidity and mortality in this patient group.

Seek advice early on with the appropriate specialist if the patient has complications, such as pneumothorax, haemopneumothorax, pulmonary contusions, pneumonia, and flail chest, or associated injuries, such as significant head injury or intra-abdominal organ injury.

A flail segment, fracture of the sternum or scapula, multiple displaced rib fractures, and fractures of ribs 1 to 3 all suggest a significant amount of force has been transmitted across the thorax, which increases the likelihood of associated injuries and damage to major intrathoracic structures.[40]

See Complications.

Mechanical ventilation

Refer unstable patients to critical care for further treatment and mechanical ventilation. Severity of the injuries may indicate invasive ventilation is required.[40] Isolated rib fractures almost never require mechanical ventilation unless associated with other injuries, such as pulmonary contusion.[77]

For patients with flail chest, mechanical ventilation is needed only if they present with shock, head injury, severe pulmonary dysfunction, or deteriorating respiratory status, or if surgery is required immediately.[77]

Consider internal fixation of ribs or flail chest in patients who fail to wean from the ventilator, or when thoracotomy is required for other reasons.[78]

Surgical stabilisation

Surgical stabilisation of rib fractures is not required in most patients with simple rib fractures. However, it may be indicated in patients with multiple severely displaced rib fractures (flail chest).[64][65]

Consider surgical stabilisation in patients with flail chest on a case-by-case basis.[64][65][56] Suitable patients should be selected by critical care specialists, chest physicians, and thoracic surgeons with appropriate training and experience.[65]

Indications for considering surgical stabilisation include:[40][56]

Severe chest wall injuries, including flail chests
Injuries causing respiratory compromise
Pain control cannot be achieved
Weaning from the ventilator has failed in an intubated patient
The patient is undergoing a thoracotomy for an associated thoracic injury.

A co-existing injury that causes a prolonged period of mechanical ventilation to be necessary is a contraindication to surgical stabilisation.[40] Patients who are haemodynamically unstable should not undergo surgical stabilisation of rib fractures.[56]

There is a lack of evidence on the timing of surgery and the methods used.[40]

More information: surgical stabilisation

In the UK, the National Institute for Health and Care Excellence states that evidence on insertion of metal rib reinforcements to stabilise a flail chest wall is limited but consistently shows efficacy, and that there are no safety concerns in the context of patients who have had severe trauma with impaired pulmonary function.[65]

Surgical stabilisation is associated with reductions in:[56][65][81][82][83][84]

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.

A small randomised trial has shown better rates of return to employment following surgical fixation compared with non-operative management.[85]

A Bayesian meta-analysis of 18,018 patients across 39 studies found that surgical stabilisation of rib fracture was associated with lower pulmonary complications and mortality for adults with traumatic rib fractures, compared with non-operative management.[86]

However, any effect on mortality remains uncertain.[81] In addition, the quality of the evidence upon which these recommendations are based is relatively poor.[64]

The procedure should be undertaken by surgeons and anaesthetists experienced in the management of chest injuries and fracture surgery.

Postoperative care should be on a specialist thoracic surgery ward, if not critical care, with continued input from specialist nursing, physiotherapy, pain management, and surgical teams.

Surgical stabilisation of fractures is now included within standard treatment and requires ongoing trials in expert centres.

Use of this content is subject to our disclaimer

Rib fractures

all patients

analgesia

Primary options

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

Primary options

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

Primary options

oxygen

chest physiotherapy and respiratory hygiene

treatment of underlying cause

Non-accidental injury

specialist referral and treatment for patients with complications

Mechanical ventilation

Surgical stabilisation

More information: surgical stabilisation

Rib fractures

Treatment algorithm

all patients

analgesia

Primary options

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

Primary options

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

Primary options

oxygen

chest physiotherapy and respiratory hygiene

treatment of underlying cause

Non-accidental injury

specialist referral and treatment for patients with complications

Mechanical ventilation

Surgical stabilisation

More information: surgical stabilisation