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Inpatient management of traumatic rib fractures

Babak Sarani, MD, FACS, FCCM
Section Editors
Eileen M Bulger, MD, FACS
Joseph S Friedberg, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Traumatic rib fractures are the consequence of significant forces impacting the chest wall and are most commonly due to blunt injuries (eg, motor vehicle crash, falls, assault), but penetrating injuries (eg, gunshot) can also fracture ribs. Rib fractures are present in 10 percent of all trauma patients and approximately 30 percent of patients with significant chest trauma. The number of fractured ribs also directly correlates with the presence of intrathoracic injury [1,2].

Multiply fractured ribs or flail chest can significantly compromise respiratory function. Pneumonia is often the common pathway to acute respiratory failure resulting from rib fractures, and prevention offers the best means to avoid potentially preventable deaths [3]. The main goal of treatment is to prevent pneumonia and other complications of rib fractures (eg, nonunion), and conservative treatment includes pain control and aggressive supportive pulmonary care to avoid the need for intubation. For some patients in whom these conservative measures are not adequate, rib fracture stabilization may be beneficial.

Although less common, chronic, forceful coughing, as may be seen in patients with severe asthma, cystic fibrosis, or poorly controlled emphysema, can also result in rib fractures [4]. General considerations for single or nontraumatic rib fractures are discussed separately. (See "Initial evaluation and management of rib fractures".)

This topic review will discuss inpatient management of multiple traumatic rib fractures. Specific techniques for surgical stabilization of rib fractures are reviewed separately. (See "Surgical management of severe rib fractures".)


The initial resuscitation, diagnostic evaluation, and management of the patient with blunt or penetrating injury is based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating thoracic trauma is discussed in detail elsewhere.

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Literature review current through: Nov 2017. | This topic last updated: Jul 26, 2017.
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  1. Sirmali M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24:133.
  2. Liman ST, Kuzucu A, Tastepe AI, et al. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003; 23:374.
  3. Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department evaluation and management. Emerg Med Clin North Am 2003; 21:291.
  4. Hanak V, Hartman TE, Ryu JH. Cough-induced rib fractures. Mayo Clin Proc 2005; 80:879.
  5. Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: relationship with pneumonia and mortality. Crit Care Med 2006; 34:1642.
  6. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000; 48:1040.
  7. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery 2005; 138:717.
  8. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994; 37:975.
  9. Lee RB, Bass SM, Morris JA Jr, MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma 1990; 30:689.
  10. Dehghan N, de Mestral C, McKee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462.
  11. Gamblin TC, Dalton ML. Flail chest caused by penetrating trauma: a case report. Curr Surg 2002; 59:418.
  12. Velmahos GC, Vassiliu P, Chan LS, et al. Influence of flail chest on outcome among patients with severe thoracic cage trauma. Int Surg 2002; 87:240.
  13. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg 2009; 33:14.
  14. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med 2009; 27:617.
  15. Pulley BR, Taylor BC, Fowler TT, et al. Utility of three-dimensional computed tomography for the surgical management of rib fractures. J Trauma Acute Care Surg 2015; 78:530.
  16. Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med 2005; 46:232.
  17. Carter RR, Orr NT, Minion DJ, Xenos ES. Aortic injury from posterior rib fracture. Eur J Cardiothorac Surg 2011; 39:138.
  18. Yanagawa Y, Kaneko N, Hagiwara A, et al. Delayed sudden cardiac arrest induced by aortic injury with a posterior fracture of the left rib. Gen Thorac Cardiovasc Surg 2008; 56:91.
  19. Sata S, Yoshida J, Nishida T, Ueno Y. Sharp rib fragment threatening to lacerate the aorta in a patient with flail chest. Gen Thorac Cardiovasc Surg 2007; 55:252.
  20. Hsu YP, Chen RJ, Bullard MJ, et al. Traumatic thoracic aortic injury caused by a sharp edge of left fractured rib on body position change: case report. Changgeng Yi Xue Za Zhi 1998; 21:343.
  21. Marco JV, Gregory JS. Posterior fracture of the left sixth rib causing late aortic laceration: case report. J Trauma 1997; 42:736.
  22. Recinos G, Inaba K, Dubose J, et al. Epidemiology of sternal fractures. Am Surg 2009; 75:401.
  23. Athanassiadi K, Theakos N, Kalantzi N, Gerazounis M. Prognostic factors in flail-chest patients. Eur J Cardiothorac Surg 2010; 38:466.
  24. Jones KM, Reed RL 2nd, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg 2011; 202:598.
  25. Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 2003; 54:478.
  26. Karmy-Jones R, Holevar M, Sullivan RJ, et al. Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury. Can Respir J 2008; 15:255.
  27. Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg 1997; 64:1396.
  28. Morrison CA, Lee TC, Wall MJ Jr, Carrick MM. Use of a trauma service clinical pathway to improve patient outcomes for retained traumatic hemothorax. World J Surg 2009; 33:1851.
  29. Eren S, Esme H, Sehitogullari A, Durkan A. The risk factors and management of posttraumatic empyema in trauma patients. Injury 2008; 39:44.
  30. Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg 2006; 30:1843.
  31. Anavian J, Guthrie ST, Cole PA. Surgical management of multiple painful rib nonunions in patient with a history of severe shoulder girdle trauma: a case report and literature review. J Orthop Trauma 2009; 23:600.
  32. Cacchione RN, Richardson JD, Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma 2000; 48:319.
  33. Gordy S, Fabricant L, Ham B, et al. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014; 207:659.
  34. Fabricant L, Ham B, Mullins R, Mayberry J. Prolonged pain and disability are common after rib fractures. Am J Surg 2013; 205:511.
  35. Kerr-Valentic MA, Arthur M, Mullins RJ, et al. Rib fracture pain and disability: can we do better? J Trauma 2003; 54:1058.
  36. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg 2009; 75:389.
  37. Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg 2008; 20:39.
  38. Todd SR, McNally MM, Holcomb JB, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg 2006; 192:806.
  39. Wilson S, Bin J, Sesperez J, et al. Clinical pathways--can they be used in trauma care. An analysis of their ability to fit the patient. Injury 2001; 32:525.
  40. Yang Y, Young JB, Schermer CR, Utter GH. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg 2014; 207:566.
  41. Vadivelu N, Schermer E, Kodumudi V, et al. Role of ketamine for analgesia in adults and children. J Anaesthesiol Clin Pharmacol 2016; 32:298.
  42. Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82:618.
  43. Galvagno SM Jr, Smith CE, Varon AJ, et al. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg 2016; 81:936.
  44. Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review. Anesth Analg 2004; 99:482.
  45. Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care 2011; 17:323.
  46. Simon BJ, Cushman J, Barraco R, et al. Pain management guidelines for blunt thoracic trauma. J Trauma 2005; 59:1256.
  47. Malekpour M, Hashmi A, Dove J, et al. Analgesic Choice in Management of Rib Fractures: Paravertebral Block or Epidural Analgesia? Anesth Analg 2017; 124:1906.
  48. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004; 136:426.
  49. Mackersie RC, Karagianes TG, Hoyt DB, Davis JW. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma 1991; 31:443.
  50. Moon MR, Luchette FA, Gibson SW, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999; 229:684.
  51. Luchette FA, Radafshar SM, Kaiser R, et al. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma 1994; 36:865.
  52. Shinohara K, Iwama H, Akama Y, Tase C. Interpleural block for patients with multiple rib fractures: comparison with epidural block. J Emerg Med 1994; 12:441.
  53. Ullman DA, Fortune JB, Greenhouse BB, et al. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth 1989; 14:43.
  54. Carrier FM, Turgeon AF, Nicole PC, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2009; 56:230.
  55. Mohta M, Verma P, Saxena AK, et al. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study. J Trauma 2009; 66:1096.
  56. Mackersie RC, Shackford SR, Hoyt DB, Karagianes TG. Continuous epidural fentanyl analgesia: ventilatory function improvement with routine use in treatment of blunt chest injury. J Trauma 1987; 27:1207.
  57. Govindarajan R, Bakalova T, Michael R, Abadir AR. Epidural buprenorphine in management of pain in multiple rib fractures. Acta Anaesthesiol Scand 2002; 46:660.
  58. Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma 1990; 30:799.
  59. Gage A, Rivara F, Wang J, et al. The effect of epidural placement in patients after blunt thoracic trauma. J Trauma Acute Care Surg 2014; 76:39.
  60. Jensen CD, Stark JT, Jacobson LL, et al. Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures. Pain Med 2017; 18:1787.
  61. Bulger EM, Edwards WT, de Pinto M, et al. Indications and Contraindications for Thoracic Epidural Analgesia in Multiply Injured Patients. Acute Pain 2008; 10:15.
  62. Karmakar MK, Critchley LA, Ho AM, et al. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest 2003; 123:424.
  63. Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma 2011; 71:1548.
  64. Short K, Scheeres D, Mlakar J, Dean R. Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial. Am Surg 1996; 62:488.
  65. Carver TW, Milia DJ, Somberg C, et al. Vital capacity helps predict pulmonary complications after rib fractures. J Trauma Acute Care Surg 2015; 79:413.
  66. Shackford SR, Virgilio RW, Peters RM. Early extubation versus prophylactic ventilation in the high risk patient: a comparison of postoperative management in the prevention of respiratory complications. Anesth Analg 1981; 60:76.
  67. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S351.
  68. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014; 208:88.
  69. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg 2012; 215:201.
  70. Battle CE, Hutchings H, James K, Evans PA. The risk factors for the development of complications during the recovery phase following blunt chest wall trauma: a retrospective study. Injury 2013; 44:1171.
  71. Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003; 196:549.
  72. Stawicki SP, Grossman MD, Hoey BA, et al. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc 2004; 52:805.
  73. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012; 43:8.
  74. Émond M, Sirois MJ, Guimont C, et al. Functional Impact of a Minor Thoracic Injury: An Investigation of Age, Delayed Hemothorax, and Rib Fracture Effects. Ann Surg 2015; 262:1115.
  75. Marasco S, Lee G, Summerhayes R, et al. Quality of life after major trauma with multiple rib fractures. Injury 2015; 46:61.