Feb. 12, 2025
Rib fractures are commonly seen in trauma care, either as standalone injuries or as part of polytrauma, says Brian D. Kim, M.D., a trauma surgeon at Mayo Clinic in Minnesota.
He notes that over the past 20 years, the workup of trauma patients has led to increasing discovery of rib fractures.
"The more you look for rib fractures, the more you find them," he says.
The mechanism of injury in rib fracture varies by U.S. region, yet motor vehicle crashes and falls from ground level or height are common causes nationwide, says Dr. Kim. In the Upper Midwest, additional mechanisms such as all-terrain vehicle and snowmobile crashes cause a significant number of rib fractures, he says. Individuals with osteopenia or osteoporosis have an increased risk of fracturing ribs, which he indicates is expected.
Dr. Kim notes that at times, patients and healthcare professionals attempt to differentiate between a broken or cracked rib, which he believes can lead to confusion. For clarity, he prefers to simply refer to this injury as a rib fracture. Dr. Kim also mentions that a rib injury may involve displacement.
For patients who experience rib fractures, factors that may adversely affect their healing include:
- Tobacco or nicotine use.
- Immunosuppression, due to chemotherapeutics or long-term steroid use.
- Poor glycemic control.
Dr. Kim also says that age and preexistent pain tolerances are key factors affecting rib fracture outcomes.
While Dr. Kim explains he has treated patients with organ damage — such as to the diaphragm or spleen — caused by a floating piece of a fractured rib, he calls this scenario uncommon. More commonly, displaced rib fractures may also be associated with intercostal damage, either muscular, vascular or both.
Crucial actions to care for a patient with a suspected rib fracture
Dr. Kim suggests four key steps to evaluate a patient presenting at a trauma center with a suspected traumatic rib fracture:
- Obtain the history of what occurred, causing the injury.
- Conduct a physical exam.
- Screen the patient with a chest X-ray. If the patient is stable and has no other indications for transfer to a higher level of care, consider a chest CT.
- With the results of imaging, determine whether the patient is a candidate to remain at your facility or requires transfer to a higher level of care.
Pain management and rib fracture
The typical healing time of a nondisplaced rib fracture in an otherwise healthy individual ranges from 6 to 12 weeks. Most fractured ribs heal without surgical intervention. Dr. Kim indicates that a multimodal pain management regimen and commonsense activity reduction can assist with pain relief. While monitoring patients' pain due to rib injury, trauma surgeons also strongly recommend early pulmonary hygiene.
Dr. Kim says that pain management is a bit of an art in that each patient's pain level differs, which is one of the reasons Mayo Clinic Trauma Center uses a multimodal strategy.
A patient with a rib fracture not only experiences pain but also is at risk of pneumonia, as poorly controlled pain can affect respiratory mechanics, says Dr. Kim.
"Patients do not want to breathe as deeply if they experience pain while doing so," he says.
He notes that avoiding deep breaths then leads to poor secretion clearance and low tidal volume breathing.
Dr. Kim says that modern trauma-related rib fracture pain management involves:
Opioid minimization
Trauma centers have moved toward an opioid-minimizing strategy for pain control, and trauma surgeons do not recommend opioids for every patient with a rib fracture. However, Dr. Kim notes there are patients for whom opioids are a necessary component of the analgesic regimen.
Other pain management techniques
If oral medications do not sufficiently control the pain experienced by a patient with one or more rib fractures, a nerve block or a regional anesthetic may be used:
- Erector spinae plane block.
- Intercostal nerve block.
- Serratus anterior plane block.
- Thoracic epidural analgesia.
- Thoracic paravertebral block.
Surgical candidacy for stabilization of rib fractures
Dr. Kim has a strong interest in the management of chest wall injury, including the operative management of fractured ribs. So far, Dr. Kim has been pleased with the results.
"Rib stabilization has been a game-changer," he says.
He notes that prior to the advent of the stabilization procedure, trauma professionals managed all rib fractures with time and analgesia.
"Patients would get pain medications and the assurance that with enough time, the acute pain would get better," he says.
The lack of another available option for rib fracture management led to this singular advice, says Dr. Kim.
However, he points out that only a small subset of patients with rib fractures are surgical candidates.
"Rib stabilization is a growing practice, yet it's the overwhelming minority who need this procedure performed," says Dr. Kim.
Surgical criteria do not necessarily relate to either the number of ribs fractured or their geometry.
"It's not as simple as the more ribs that are broken equals an operation," he says. "On the other hand, one fractured rib does not mean you are not a surgical candidate."
Likewise, the appearance of fractured ribs also is not necessarily a reliable criterion for surgical repair.
"Every decision for an operation is a big one," he says.
Dr. Kim notes that for some patients with rib fractures, stabilizing the ribs and the chest wall helps to control their pain levels and restore the mechanical function of respiration.
Noting that there can be a considerable gray area in how to proceed with rib fracture treatment, he recommends that an experienced trauma surgeon make or advise on this decision.
Professional familiarity with rib stabilization
Although forms of rib stabilization have been available for more than a century, Dr. Kim says some healthcare professionals, patients and their loved ones are unfamiliar with them.
The region in which a patient experiences rib fracture may affect whether rib stabilization is available, says Dr. Kim.
For example, Mayo Clinic has influenced the use of rib stabilization in its health system, integrating the procedure into rib fracture care. And health system professionals are trained to care for a variety of rib injuries.
Although the popularity of rib stabilization in a geographic region influences its use, Dr. Kim indicates that the level of the treating trauma center does not necessarily affect the procedure's availability. Level 1 trauma centers are not the only facilities performing this procedure; rather, its use depends on where a trained surgeon is available with access to the necessary hospital and personnel resources. Dr. Kim notes, for instance, that due to injury patterns and patient responses to treatment, some patients may require prolonged ICU care post-rib stabilization, which is unavailable at all trauma centers.