Rib Fractures

Heal on their own within weeks, and generally require no treatment in and of themselves. The goal in managing these patients is to avoid pulmonary complications that are associated with the significant pain associated with these injuries, and in some cases, mechanical dysfunction (ex. flail chest). When not contraindicated, epidural anesthesia is perhaps the best analgesic option available in this patient population [Shulman M et al. Anesthesiology 61: 569, 1984; Mackersie RC et al. J Trauma 31: 443, 1991; Moon MR et al. Ann Surg 229: 684, 1999; Wu CL et al. J Trauma 47: 564, 1999; Bulger EM et al. Surgery 136: 426, 2004], although a small (n = 30) study of continuous paravertebral blocks suggested that it may be as effective (and associated with less technical difficulty and side effects) as continuous epidural analgesia [Mohta M et al. J Trauma 66: 1096, 2009]. Mechanical ventilation is sometimes necessary in these patients, but should be undertaken with caution, as many of them have pre-existing pulmonary injuries and may be at increased risk of further injury.

Rib fractures should be particularly concerning in patients older than 55 years, as elderly patients with rib fractures have twice the mortality rate of younger patients with the same injuries.

Flail chest injuries are particularly painful and dangerous due to mechanical compromise, but intubation / mechanical ventilation are not necessary mandatory (non-invasive PPV has been used successfully [Antonelli M et al. NEJM 339: 429, 1998]). Many of these patients will have pulmonary contusions, which can lead to shunting and hypoxemia despite adequate ventilation. Because of the inherent risks associated with tracheal intubation in the intensive care unit, consideration should be given to early extubation to CPAP/BiPAP [Beltrame F et al. Monaldi Arch Chest Dis 54: 109, 1999]. Those who are not intubated should be monitored in an ICU setting, at least initially, as they are at increased risk for respiratory failure.