Management of Multiple Rib Fractures

Original Date: 12/2013 | Supersedes: 06/2019 | Last Review Date: 06/2023
Purpose: To standardize treatment of multiple rib fractures including flail chest

Taxonomy¹:

- Fracture displacement:
  - Undisplaced or nondisplaced: >90% contact between the fracture cortical surfaces
  - Offset: some cortical contact between fracture surfaces, but less than 90%
  - Displaced: no cortical contact between fracture surfaces

Fracture characterization:
- Simple: single fracture line across the rib with no fragmentation or comminution
- Wedge: a wedge fracture has a second fracture line that does not span the whole width of the rib
- Complex: at least two fracture lines with one or more fragments that span the width of the rib
Series of fractures: fractures on neighboring ribs
Anatomic locations of rib fractures:
- Anterior: anterior to the anterior axillary line (vertical line from the intersection of the posterior border of the pectoralis major and the second rib)
- Lateral: between anterior and posterior axillary lines
- Posterior: posterior to the posterior axillary line (vertical line through the tip of the scapula)
Flail segment: A series of three or more ribs with two or more fracture lines in each rib seen on cross-sectional imaging without the clinical finding of paradoxical chest wall movement (e., radiographic finding)
Flail chest: A series of three or more ribs with two or more fracture lines in each rib plus clinical paradoxical chest wall movement
Ideal Body Weight (IBW):
- Men: 50 kg + (2.3 × (height in inches – 60))
- Women: 45.5 kg + (2.3 × (height in inches – 60))

Indications for Admission to IMU:

Any age with multiple rib fractures and/or flail segment and:
- Poor pain control, or
- Incentive spirometer (IS) volumes ≤ 8 mL/kg IBW, or
- Oxygen requirement ≥ 6 L/min nasal cannula
- Volume expansion protocol (VEP) desired Q2H or Q3H (Q4H can be done on floor; <Q2H should be done in STICU)
When the above indications are no longer met, the patient may be transferred to floor.

Indications for Admission to ICU:

Flail chest injury
Invasive positive pressure ventilation
Non-invasive positive pressure ventilation (NIPPV):
- Requiring more support than CPAP or BiPAP at 8 cmH₂O PEEP or 60% FiO₂
- Requiring CPAP or BiPAP > 12 hours regardless of settings
- Requiring more support than Vapotherm 30 L/min 60% FiO₂
VEP desired Q1H
When the above indications are no longer met, the patient may be transferred to a lower level of care.

Initial Management for All Patients Admitted with Rib Fractures:

Multimodal oral pain medication therapy
Volume expansion protocol (VEP):
- Order in EMR: Respiratory Therapy Consult
- Stepwise progression of therapy employed in the VEP:
  - Incentive spirometry in alert and cooperative patients. If the incentive spirometry goal is not achieved, positive expiratory pressure (PEP) is initiated.
  - Positive airway pressure, positive expiratory pressure, or intrapulmonary percussive ventilation devices may be added if patient:
    - Is unable to perform incentive spirometry, or
    - Is not meeting incentive spirometry goal, or
    - Has persistent or severe atelectasis, or
    - Has hypoxemia
  - Induced deep breathing in patients with a tracheostomy
- Indications and frequency in the VEP – the RT will assess patient and assign them an RT Triage Score. The frequency of VEP is based on the RT Triage Score ²

RT Triage Score	VEP Frequency
22-32	q4 hours and q2 hours prn
15-21	QID and q4 hour prn
8-14	TID and q4 hour prn
0-7	BID and q4 hour prn
Tracheotomies	q4 hour and q2 hour prn

- Patients who meet incentive spirometry goals are discharged from the VEP.
- Patients with ≥2 rib fractures, a pulmonary contusion, a chest tube, or abdominal/thoracic surgery who meet incentive spirometry goals are seen once per shift if STICU/SIMU status and once every 48 hours if floor status.
- If you think patient with adequate incentive spirometry requires more frequent therapy than the VEP calls for, you may order “VEP q _ hour despite IS for __ hours duration.”
Physical activity:
- If able, patient should be out of bed for majority of day (in chair and ambulating).
- For patients who cannot get out of bed, the stationary hand bike may be used.
  - Bike therapy should be used every 4 hours during daytime.
Repeat CXR:
- Patients with a pneumothorax, a series of fractures, or a flail segment should have a repeat CXR performed 24 hours after admission.
- If the 72-hour CXR shows any opacity concerning for a retained hemothorax, a non-contrast CT chest should immediately be obtained.
- Clinical judgment should guide the decision to go for video assisted thoracoscopic surgery (VATS) and evacuation of hemothorax. Ideally, the VATS would occur on hospital day 3 or 4³
- If the hemothorax is estimated to be less than 500 cc, observation may be considered.

Surgical stabilization of rib fractures (SSRF) (see APPENDIX A)

SSRF in clinical flail chest or unstable chest wall injury:
- SSRF is recommended in patients with a clinical flail chest or unstable chest wall injury and respiratory failure requiring mechanical ventilation.
- SSRF is conditionally recommended in patients with a clinical flail chest or other unstable chest wall injury not requiring mechanical ventilation.
SSRF in non-flail chest injuries:
- SSRF is conditionally recommended against in patients without a clinical flail chest or unstable chest wall injury, especially in the absence of mechanical ventilation.
SSRF in symptomatic non-union:
- No recommendation is offered for SSRF in patients with chronic pain from a rib fracture non-union.

Regional analgesia (see APPENDIX B)

May provide superior pain control to multimodal pain regimen alone in patients with rib fractures.
Consultation with Acute Pain Service is required (Spectralink 4-9762).
Consider when:
- Persistent incentive spirometer volumes < 15 mL/kg 24 hours after admission
- Deterioration from spontaneous breathing to invasive mechanical ventilation or non-invasive positive pressure ventilation (NIPPV) within 48 hours of admission
- Increasing FiO₂ requirement within 48 hours of admission
- Inability to wean from mechanical ventilation within 48 hours
- Persistent numeric pain score > 6 requiring continued IV opioids and/or IMU status 24 hours after admission.

APPENDIX A. Literature Review for SSRF

Search	Database	Search Term	Limits	Total Yield: # of Articles	# Excluded Articles	# Included Articles
1	PubMed	((rib fractures[Title/Abstract] OR flail chest[Title/Abstract] OR chest wall injury[Title/Abstract]) AND (surgery[Title/Abstract] OR surgical[Title/Abstract] OR fixation[Title/Abstract] OR SSRF[Title/Abstract])) AND (randomized[Title/Abstract])	None	58	52	6
2	PubMed	((rib fractures[Title/Abstract] OR chest wall injury[Title/Abstract]) AND (non union[Title/Abstract]) AND (surgery[Title/Abstract] OR surgical[Title/Abstract] OR fixation[Title/Abstract] OR SSRF[Title/Abstract]))	None	9	9	0
Reasons for Exclusion: Did not compare SSRF to a non-surgical control (44) Not a randomized controlled trial (17)

Included Studies

Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002 Apr;52(4):727-32; discussion 732. doi: 10.1097/00005373-200204000-00020. PMID: 11956391.
Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005 Dec;4(6):583-7. doi: 10.1510/icvts.2005.111807. Epub 2005 Sep 15. PMID: 17670487.
Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, Fitzgerald M. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013 May;216(5):924-32. doi: 10.1016/j.jamcollsurg.2012.12.024. Epub 2013 Feb 13. PMID: 23415550.
Liu T, Liu P, Chen J, Xie J, Yang F, Liao Y. A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. J Surg Res. 2019 Oct;242:223-230. doi: 10.1016/j.jss.2019.04.005. Epub 2019 May 14. PMID: 31100568.
Marasco SF, Balogh ZJ, Wullschleger ME, Hsu J, Patel B, Fitzgerald M, Martin K, Summerhayes R, Bailey M. Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial. J Trauma Acute Care Surg. 2022 Jun 1;92(6):1047-1053. doi: 10.1097/TA.0000000000003549. Epub 2022 Jan 25. PMID: 35081599.
Dehghan N, Nauth A, Schemitsch E, Vicente M, Jenkinson R, Kreder H, McKee M; Canadian Orthopaedic Trauma Society and the Unstable Chest Wall RCT Study Investigators. Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial. JAMA Surg. 2022 Nov 1;157(11):983-990. doi: 10.1001/jamasurg.2022.4299. PMID: 36129720; PMCID: PMC9494266.
Meyer DE, Harvin JA, Vincent L, Motley K, Wandling MW, Puzio TJ, Moore LJ, Cotton BA, Wade CE, Kao LS. Randomized controlled trial of surgical rib fixation to non-operative management in severe chest wall injury. Ann Surg. 2023 Sep 1;278(3):357-365. doi: 10.1097/SLA.0000000000005950. Epub 2023 Jun 15. PMID: 37317861; PMCID: PMC10527348.

Summary of Evidence for SSRF:

SSRF in clinical flail chest and unstable chest wall injuries

Four randomized controlled trials comparing SSRF to non-operative management have been conducted in patients with flail chest.^4,5,6,7 All patients enrolled in these four trials had a clinical flail chest injury and nearly all had respiratory failure requiring mechanical ventilation.

The first trail enrolled 37 patients with “severe” flail chest (e., flail chest injury of ≥6 ribs) and randomized them to either SSRF with Judet struts or usual care with positive pressure ventilation (called “internal pneumatic stabilization” in the trial).⁴ Patients were allocated on HD#5. No power calculation or prespecified primary endpoints. SSRF patients had decreased incidence of pneumonia on day 21 (4 [22%] vs. 17 [90%], p < 0.05), decreased duration of mechanical ventilation (10.8 [±3.4] days vs. 18.3 [±7.4] days, p < 0.05), decreased ICU length of stay (16.5 [±7.4] days vs. 26.8 [±13.2] days, p < 0.05), and decreased incidence of tracheostomy at day 21 (3 [17%] vs. 15 [79%], p < 0.05). For quality of life outcomes, fewer patients in the SSRF group reported “chest tightness” (6 [33%] vs. 16 [84%], p < 0.05), “thoracic cage pain” (7 [39%] vs. 17 [89%], p < 0.05), and “dyspnea on effort” (5 [28%] vs. 12 [63%], p < 0.05) at 12 months after injury. SSRF patients were also more likely to be back at work at 6 months after injury (11 [61%] vs. 1 [5%], p < 0.01). While this difference was no longer observed at 12 months, more people in the SSRF group were back to high activity jobs (13 [72%] vs. 3 [16%], p < 0.01).
The second trial enrolled 40 patients and allocated them at 36 hours to SSRF with K wires or “strapping and packing” (an adhesive plaster dressing designed to provide external fixation of the flail segment).⁵ No power calculation or prespecified primary endpoints. Standard deviations and interquartile ranges for length of stay outcomes were not provided. SSRF patients had fewer ventilator days (2 days vs. 12 days, p < 0.001) and a shorter ICU length of stay (9.6 days vs. 14.6 days, p < 0.001) and hospital length of stay (11.7 days vs. 23.1 days, p < 0.001). SSRF patients also had improved incentive spirometry measurements (FVC, TLC, and FEF₇₅) at 2 months after injury.
The third trial enrolled 46 patients and allocated them at 48 hours to usual care with positive pressure ventilation or SSRF using bioabsorbable plates.⁶ The study was powered to the primary outcomes of ventilator days and ICU length of stay. SSRF patients had a decreased ICU length of stay (324 [238-380] hours vs. 448 [323-647] hours, p = 0.03) and decreased incidence of tracheostomy (9 [23%] vs. 16 [70%], p = 0.04). However, there were no differences in spirometry results at 3 months or quality of life measured by the Short Form 36 at 6 months after injury.
The fourth trial enrolled 50 patients with flail chest and ISS ≥16 and randomized them to either usual care or SSRF.⁷ The study was powered to a primary outcome of ventilator days, though only 80% of the patients enrolled required mechanical ventilation. Patients in the SSRF group had fewer ventilator days (7 [6-10 days] vs. 9 [7-12] days, p = 0.012) and a shorter ICU length of stay (10 [7-12] days vs. 12 [9-15] days, p = 0.032), though these benefits were driven primarily by the subgroup of patients with pulmonary contusions. The SSRF group also had a lower incidence of ARDS (7 [28%] vs. 15 [60%], p = 0.045)

A fifth study enrolled patients with clinical flail chest as well as “unstable chest wall” injuries (any one of the following: >100% displacement of 3 or more ribs, loss of thoracic volume [>25% volume loss of involved lobe(s)], overriding of ≥3 rib fractures by at least 15 mm each, or ≥3 rib fractures associated with intra-parenchymal injury).^[i] This multicenter trial enrolled 207 patients at 15 level 1 trauma centers in the US and Canada and allocated them to SSRF or usual care within 72 hours of injury. The study was powered to a primary outcome of ventilator-free days in the first 28 days after injuries. Patients in the SSRF group had more ventilator-free days (mean difference 2.1 days, 95% CI -0.3 to 4.5 days, p = 0.09), though the difference did not meet statistical significance. Mortality was also lower in the operative group (0 [0%] vs. 6 [6%], p = 0.01), however only half as many patients in the SSRF group required mechanical ventilation after randomization. Tests of interaction for the pre-specified subgroup of patients requiring mechanical ventilation at the time of randomization showed greater potential benefit in patients that were ventilated and no benefit in patients who were not ventilated.

SSRF in non-flail injuries

Two randomized controlled trials comparing SSRF to usual care have been conducted in the non-clinical flail chest population.^9,10

The first trial enrolled 124 patients with ≥3 consecutive rib fractures and either refractory pain or bicortical displacement at four Australian Level 1 trauma centers.⁹ Patients were allocated to either SSRF or usual care within 48 hours of arrival to the hospital. The study was powered to a primary endpoint of Pain Rating Index (PRI) at 3 months following injury as assessed by the McGill Pain Questionnaire (higher PRI equating to worse pain). At 3 months the median PRI in SSRF patients was nearly double that of usual care patients (7.7 [1.7-19.8] vs. 3.6 [0.7-15.3], p = 0.17), though this did not reach statistical significance. At 6 months, PRI remained higher in the SSRF group, this time reaching statistical significance (2.6 [0-17.1] vs. 0 [0-5.7], p = 0.04). Despite this, more patients in the SSRF group were back to work at 6 months (23 [66%] vs. 14 [37%], p = 0.01). Inpatient opioid exposure and quality of life (measured by the Short Form 12) at 3 and 6 months were similar between groups.
The second trial enrolled 84 patients at a single center with a “severe chest wall injury” (defined as any one of: ≥5 consecutive rib fractures, ≥1 bicortically displaced fracture, or radiographic flail segment).¹⁰ Patients were randomized to either SSRF or usual care at a median of 48 hours and stratified by unit of admission as a proxy for injury severity. The study was powered to a primary outcome of hospital length of stay, but the final enrollment was underpowered for the primary outcome. Regardless, SSRF patients experienced a greater hospital length of stay (9 [6-20] days vs. 6 [3-11] days, p = 0.005). After adjusting for the stratification variable, hospital length of stay remained greater in the SSRF group (RR 1.46, 95% CI 1.17-1.83). Daily opioid exposure was similar between groups, as was the incidence of opioid prescription at discharge. Quality of life at 1 month (measured by the EQ-5D-5L) was worse for the SSRF group in the Mobility (3 [2-3] vs. 2 [1-2], p = 0.012) and Self-Care (3 [2-3] vs. 2 [1-2], p = 0.034) dimensions, though these differences were no longer observed at 3 and 6 months.

SSRF in symptomatic non-union

No randomized controlled trials or cohort studies of SSRF in patients with chronic pain from non-union of a rib fracture could be identified. Several case reports have been published, all of which favor the use of SSRF in this population.

APPENDIX B. Regional analgesia for rib fractures.

Neuraxial techniques:

May be contraindicated in patients with unstable spine or pelvic fractures or those whose injuries preclude positioning for the procedure.
Cannot be performed within 12 hours of enoxaparin administration, even at prophylactic doses, per the American Society of Regional Anesthesia guidelines.¹¹
Epidural analgesia
- The randomized controlled trials supporting epidural analgesia are complicated by poor methodology, small sample sizes, and high risk of bias.
- Epidural analgesia may provide pain control that is superior to systemic opioids, but this has not been conclusively demonstrated by the randomized trial data.
- Technically challenging
- Complications include hypotension, spinal epidural hematoma, spinal cord injury.
Thoracic paravertebral nerve blockade (TPVB)
- May provide comparable pain control to epidural analgesia.
- Is technically easier to perform than epidural analgesia.
- Can be used in patients with contraindications to epidural analgesia.
- Complications include inadvertent epidural, intrathecal, or intrapleural injection, pneumothorax, hypotension, and vascular puncture.

Non-neuraxial regional techniques:

Technically easier to perform.
Not associated with hypotension.
Can be performed in patients with contraindications to neuraxial analgesia.
Intercostal nerve blockade (ICNB)
- Can provide improved pain control over a limited dermatome distribution.
- May require multiple injections for sufficient dermatomal coverage, which can increase the risk of procedure-related complication or local anesthetic toxicity.
- Complications include pneumothorax and vascular puncture.
Myofascial plane blockade (g., serratus anterior plane blockade, erector spinae plane blockade)
- Newer techniques, not well-studied.
- May provide improved pain control over a larger dermatome distribution than ICNB.
- Complications include pneumothorax and vascular puncture.

Literature Review for Regional Analgesia in Multiple Rib Fractures

Search	Database	Search Term	Limits	Total Yield: # of Articles	# Excluded Articles	# Included Articles
1	PubMed	((rib fractures[Title/Abstract] OR flail chest[Title/Abstract] OR chest wall[Title/Abstract]) AND (analgesia[Title/Abstract] OR thoracic epidural[Title/Abstract] OR intercostal[Title/Abstract] OR intrapleural[Title/Abstract] OR myofascial[Title/Abstract])) AND (randomized[Title/Abstract] OR randomly[Title/Abstract])	None	97	78	18
2	Reference Search	N/A	N/A	2	1	1
Reasons for Exclusion: Not rib fractures: 58 Not a randomized controlled trial: 9 Not regional analgesia: 12 Full text not available: 1
Article full text not available: Luchette FA, Radafshar SM, Kaiser R, Flynn W, Hassett JM. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma. 1994 Jun;36(6):865-9; discussion 869-70. doi: 10.1097/00005373-199406000-00018. PMID: 8015010.

Included Studies:

Ullman DA, Fortune JB, Greenhouse BB, Wimpy RE, Kennedy TM. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth. 1989 Jan-Feb;14(1):43-7. PMID: 2486586.
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 Apr;31(4):443-9; discussion 449-51. PMID: 1902264.
Gabram SG, Schwartz RJ, Jacobs LM, Lawrence D, Murphy MA, Morrow JS, Hopkins JS, Knauft RF. Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial. World J Surg. 1995 May-Jun;19(3):388-93. doi: 10.1007/BF00299166. PMID: 7638994.
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 Jun;62(6):488-93. PMID: 8651535.
Moon MR, Luchette FA, Gibson SW, Crews J, Sudarshan G, Hurst JM, Davis K Jr, Johannigman JA, Frame SB, Fischer JE. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg. 1999 May;229(5):684-91; discussion 691-2. doi: 10.1097/00000658-199905000-00011. PMID: 10235527; PMCID: PMC1420813.
Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004 Aug;136(2):426-30. doi: 10.1016/j.surg.2004.05.019. PMID: 15300210.
Hakim SM, Latif FS, Anis SG. Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: a randomized open-label trial. J Anesth. 2012 Dec;26(6):836-44. doi: 10.1007/s00540-012-1424-4. Epub 2012 Jun 7. PMID: 22674157.
Ge YY, Wang XZ, Yuan N, Yuan LY, Ma WH, Hu Y. [Effect of ultrasound guided patient-controlled paravertebral block on pulmonary function in patients with multiple fractured ribs]. Zhonghua Wai Ke Za Zhi. 2016 Dec 1;54(12):924-928. Chinese. doi: 10.3760/cma.j.issn.0529-5815.2016.12.010. PMID: 27916036.
Yeying G, Liyong Y, Yuebo C, Yu Z, Guangao Y, Weihu M, Liujun Z. Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures. J Int Med Res. 2017 Dec;45(6):2085-2091. doi: 10.1177/0300060517710068. Epub 2017 Jun 21. PMID: 28635359; PMCID: PMC5805206.
Agamohammdi D, Montazer M, Hoseini M, Haghdoost M, Farzin H. A Comparison of Continuous Thoracic Epidural Analgesia with Bupivacaine Versus Bupivacaine and Dexmedetomidine for Pain Control in Patients with Multiple Rib Fractures. Anesth Pain Med. 2018 Apr 25;8(2):e60805. doi: 10.5812/aapm.60805. PMID: 30009148; PMCID: PMC6035480.
Tekşen Ş, Öksüz G, Öksüz H, Sayan M, Arslan M, Urfalıoğlu A, Gişi G, Bilal B. Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial. Am J Emerg Med. 2021 Mar;41:16-20. doi: 10.1016/j.ajem.2020.12.041. Epub 2020 Dec 23. PMID: 33383266.
Zhao Y, Tao Y, Zheng S, Cai N, Cheng L, Xie H, Wang G. Effects of erector spinae plane block and retrolaminar block on analgesia for multiple rib fractures: a randomized, double-blinded clinical trial. Braz J Anesthesiol. 2022 Jan-Feb;72(1):115-121. doi: 10.1016/j.bjane.2021.04.004. Epub 2021 Apr 22. PMID: 33895221; PMCID: PMC9373659.
Leasia KN, Ciarallo C, Prins JTH, Preslaski C, Perkins-Pride E, Hardin K, Cralley A, Burlew CC, Coleman JJ, Cohen MJ, Lawless R, Platnick KB, Moore EE, Pieracci FM. A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2021 Nov 1;91(5):872-878. doi: 10.1097/TA.0000000000003264. PMID: 33951024.
El Malla DA, Helal RAEF, Zidan TAM, El Mourad MB. The Effect of Erector Spinae Block versus Serratus Plane Block on Pain Scores and Diaphragmatic Excursion in Multiple Rib Fractures. A Prospective Randomized Trial. Pain Med. 2022 Mar 2;23(3):448-455. doi: 10.1093/pm/pnab214. PMID: 34240173.
Wallen TE, Singer KE, Makley AT, Athota KP, Janowak CF, Hanseman D, Salvator A, Droege ME, Strilka R, Droege CA, Goodman MD. Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial. J Trauma Acute Care Surg. 2022 Feb 1;92(2):266-276. doi: 10.1097/TA.0000000000003462. PMID: 34789700.
Elawamy A, Morsy MR, Ahmed MAY. Comparison of Thoracic Erector Spinae Plane Block With Thoracic Paravertebral Block for Pain Management in Patients With Unilateral Multiple Fractured Ribs. Pain Physician. 2022 Sep;25(6):483-490. PMID: 36122257.
Nasr-Esfahani M, Kolahdouzan M, Pourazari P, Yazdani E. Comparing the Effectiveness of Bupivacaine Administration through Chest Tube and Intercostal Blockage in Patients with Rib Fractures. Adv Biomed Res. 2022 Aug 26;11:66. doi: 10.4103/abr.abr_50_21. PMID: 36325169; PMCID: PMC9621344.
Armin E, Movahedi M, Najafzadeh MJ, Honarmand A, Rukerd MRZ, Mirafzal A. COMPARISON OF ULTRASOUND-GUIDED ERECTOR SPINAE PLANE BLOCK WITH INTERCOSTAL NERVE BLOCK FOR TRAUMA-ASSOCIATED CHEST WALL PAIN. J Emerg Med. 2022 Oct;63(4):520-527. doi: 10.1016/j.jemermed.2022.09.018. PMID: 36462798.

Summary of Evidence for Regional Analgesia in Multiple Rib Fractures

Thoracic Epidural Analgesia

Four randomized controlled trials have compared thoracic epidural analgesia to systemic pain medications.^12,13,14,15

The first study was a pilot trial of trauma patients admitted to the ICU with “multiple rib and pelvic fractures, but without head injuries.”¹² Patients were randomized to either continuous + PRN intravenous morphine or epidural opioids. The trial was not powered to a primary endpoint. The epidural group had a shorter duration of mechanical ventilation (3.07 [±1.3] days vs. 18.23 [±18.1] days, p < 0.05), shorter ICU LOS (5.93 [±1.4] days vs. 18.69 [±5.2] days, p < 0.05), and shorter hospital LOS (14.85 [±2.2] days vs. 47.69 [±14.7] days, p < 0.05). Incidence of tracheostomy was decreased in the epidural group (6.7% vs. 38.5%, p < 0.05). However, the lack of clarity regarding inclusion and exclusion criteria and the screening process used is a significant limitation. Additionally, the sheer magnitude of the difference between the groups (epidural group spent 2 fewer weeks on the ventilator and in the ICU and 4 fewer weeks in the hospital) raises concern for selection bias.
The second trial enrolled trauma patients with ≥3 rib fractures or flail chest/sternum (n = 32).¹³ Patients were randomized to epidural analgesia with fentanyl or intravenous fentanyl within 24 hours of presentation. The trial was not powered to a primary outcome. Vital capacity was improved in both groups after initiating the allocated pain control regimen, but the groups were not compared to one another. Tidal volume, respiratory rate, and minute volume were not improved in either group. PaCO2 increased and PaO2 decreased in the intravenous fentanyl group. These values did not change in the epidural group, and the two groups were not compared to one another. Hospital LOS was the same in both groups. The trial is limited by selection of less meaningful outcome measures and the manner in which they were compared (favoring before/after comparisons within each randomization group to comparisons between the randomization groups). Although the authors conclude that epidural analgesia should be the preferred method of pain management in patients with multiple rib fractures, this conclusion does not appear to be supported by the data provided in their study.
The third trial enrolled trauma patients with ≥3 rib fractures, a flail segment, pulmonary contusion, or sternal fracture (n = 24).¹⁴ Patients were randomized to either patient-controlled epidural analgesics (0.25% bupivacaine + morphine) or patient-controlled intravenous opioids (morphine). The trial was not powered to a primary outcome. 34 patients were initially enrolled but 10 withdrew. Reasons for withdrawal were not provided. Visual Analog Score was improved for the epidural group at 24h (scores not provided, p < 0.05) and 72h (3.8 vs. ???, p < 0.05). Maximum inspiratory force was greater for the epidural group at 72h (data not provided, p < 0.05). Tidal volume was also better for the epidural group at 72h (590 mL vs. 327 mL, p < 0.05). Plasma cytokine levels were similar at all time points, except IL-8 which was lower in the epidural group at 48h and 72h (data not provided, p < 0.05). Urinary catecholamines were similar at all time points. Given the lack of detail regarding methodology, failure to consider confounders, and failure to discuss why 29% of the enrolled patients withdrew from the study, the study results should be regarded with caution.
The fourth trial enrolled trauma patients with >3 rib fractures (n = 46). ¹⁵ Patients were randomly assigned to epidural analgesia or intravenous opioids. The trial was powered to a primary outcome of pneumonia within the first 28 days using the CDC definition. Incidence of pneumonia was greater in the systemic opioids group, but this difference did not reach statistical significance (9 [38%] vs. 4 [18%], p = 0.15). Duration of mechanical ventilation, ICU length of stay, and hospital length of stay were similar between groups. Multivariable regression models were then performed to adjust for confounders (generally not a recommended analytic strategy in a randomized controlled trial). However, the authors report an increased odds of pneumonia for the IV opioid group (OR 6.0 [95% CI 1.0-35], p = 0.05) and an increase in ventilator days for the IV opioid group (RR 2.0 [95% CI 1.6-2.6], p < 0.001). There were no differences in mortality or LOS.

One randomized controlled trial compared thoracic epidural to lumbar epidural.¹⁶ The trial randomized 55 patients with isolated blunt thoracic trauma admitted to the ICU to thoracic epidural analgesia (placed at the T5-T6 or T6-T7 intercostal space) or lumbar epidural analgesia (placed at the L2-L3 or L3-L4 intercostal space). The study was powered to a primary endpoint of incidence of mechanical ventilation or incidence of pneumonia. Visual Analog pain scores were similar between groups, as was the daily opioid exposure. Incidence of pneumonia, incidence of mechanical ventilation, and duration of mechanical ventilation were also similar between groups.

One randomized controlled trial compared thoracic epidural with bupivacaine alone to thoracic epidural with bupivacaine plus dexmedetomidine.¹⁷ The trial randomized 64 patients with multiple rib fractures and “respiratory symptoms.” The catheter was maintained for three days in all patients and removed on day 4. Timing of allocation was not specified. The study was powered to a primary outcome of Visual Analog pain score. Visual Analog Scores were lower in the bupivacaine + dexmedetomidine group on day 2 (5.55 (±2.45) vs. 6.85 (±3.54), p < 0.001), day 3 (2.89 [±0.99] vs. 4.90 [±1.44], p < 0.001), and day 4 (1.05 [±0.78] vs. 2.67 [±0.67], p < 0.001). Some arterial blood gas measurements demonstrated statistically significant differences between the groups that were not clinically meaningful (e.g., PaO2 71.56 [±10.64] vs. 78.01 [±6.1], p = 0.002).

Paravertebral Nerve Blockade

Two randomized controlled trials have compared paravertebral nerve blockade to systemic pain medications.^{18, 19}

The first study was a randomized controlled trial of American Society of Anesthesiology class 2 or 3 trauma patients with ≥1 rib fracture who underwent surgical stabilization of the fractured ribs (n = 60).¹⁸ Patients were randomized to post-operative patient-controlled paravertebral nerve blockade or patient-controlled intravenous opioids. The study was not powered to a primary outcome. PaO2 measurements and P:F ratios were clinically and statistically better in the paravertebral nerve blockade group at all timepoints (30 minutes, 60 minutes, 24 hours, 48 hours, and 72 hours). FEV₁ was also improved in the paravertebral nerve blockade group at 72 hours (2.9 [±4] L vs. 2.2 [±0.5] L, p < 0.01).
The second study was a randomized controlled trial of trauma patients with ≥3 unilateral rib fractures (n = 90).¹⁹ Patients were randomized to either patient-controlled paravertebral nerve blockade with ropivacaine or patient-controlled intravenous opioids with sufentanil. The trial was powered to a primary outcome of pain score measured by visual analog scale. VAS scores were lower in the paravertebral group at 60 min after induction of analgesia (3.9 vs 4.9, p < 0.05 [95% CI not provided]) and at 24 hours (3.4 vs 4.1, p < 0.05 [95% CI not provided]). VAS scores were the same in both groups at 48 and 72 hours. FVC, FEV₁/FVC, and peak expiratory flow rates were improved in the epidural group at 1 hour and 72 hours (p < 0.05). There was no difference in mortality.

One randomized controlled trial compared paravertebral nerve blockade to thoracic epidural analgesia.²⁰ The trial randomized adult trauma patients with ≥3 consecutive unilateral rib fractures (n = 30) to either thoracic epidural analgesia with bupivacaine or paravertebral nerve blockade with bupivacaine. Timing of allocation was not specified. The trial was not powered to a primary outcome. Both thoracic epidural and paravertebral nerve blockade showed similar decreases in Visual Analog Scores from baseline at 30 minutes, 24 hours, and 72 hours. P:F ratio was similar between groups at 30 minutes and 24 hours but greater in the paravertebral group at 72 hours (mean difference not reported, p = 0.018). Inpatient opioid exposure, ICU length of stay, and hospital stay were slightly greater in the paravertebral group, though these did not reach statistical significance. Twice as many patients in the epidural group experienced hypotension (6 [40%] vs. 1 [7%], p = 0.04).

Intercostal Nerve Blockade

One randomized controlled trial compared intercostal nerve blockade to systemic pain medications.²¹ The trial was a single center double-blinded study that enrolled adult trauma patients with ≥2 rib fractures and inability to achieve > 50% predicted inspiratory capacity on incentive spirometry. Patients were randomized to either intercostal injection with liposomal bupivacaine or peri-intercostal subcutaneous injection with 0.9% sodium chloride (the proceduralist was not blinded). The trial was powered to a primary endpoint of total inpatient opioid exposure in morphine milligram equivalents (MME). However, the study was stopped short of its planned enrollment (powered to n = 200; actual n = 100). Although there was a significant decrease in MME exposure in both groups over time, there were no differences between groups. In tests of interaction for patients with ≤ 6 fractures, 7-12 fractures, or ≥ 13 fractures, there was no differential treatment effect. Numeric pain rating scores were also similar between groups at all time points. Incentive spirometry volumes were greater in the bupivacaine group on day 1 and day 2 but not day 3.

One randomized controlled trial compared single shot intercostal nerve blockade to “continuous intercostal nerve blockade” with an indwelling catheter.²² This single center trial enrolled adult trauma patients with rib fractures undergoing planned SSRF (n = 34). Patients were randomized to either intercostal nerve blockade with an admixture of 0.25% bupivacaine plus liposomal bupivacaine or placement of an infusion catheter beneath the scapula for infusion of 0.125% bupivacaine (both done at the time of SSRF). However, the catheter position beneath the scapula is of questionable efficacy, since local anesthetic infused in this location would not effectively block either the intercostal nerves or any recognized myofascial plane. The trial was powered to a primary endpoint of Sequential Clinical Assessment of Respiratory Function (SCARF) score measured at 10:00 AM daily. Median SCARF scores on post-operative days 1-5 were similar between groups. Median daily opioid exposure was lower in the intercostal group on post-operative days 1-4, but the differences were not statistically significant.

One randomized controlled trial compared intercostal nerve blockade to intrapleural analgesia.²³ The trial enrolled non-intubated adult trauma patients with rib fractures and “disturbed ABG parameters” who required a chest tube (n = 30). Patients were randomized to either intercostal nerve blockade with bupivacaine at the time of chest tube insertion or intrapleural analgesia with bupivacaine through the chest tube once it was placed. The trial was not powered to a primary endpoint. PaO₂ was higher and HCO₃ was lower in the intercostal nerve blockade group, though these differences were not clinically meaningful. Mean numeric pain scores were decreased in the intercostal nerve blockade group (1.68 [±0.02] vs. 6.29 [±2.9], p = 0.001). Mean opioid exposure in the 12 hours following the procedure was greater in the intrapleural group (4.1 [±1.1] mg vs. 1.65 [±0.48] mg, p = 0.001).

Intrapleural Analgesia

Two randomized controlled trials have compared intrapleural analgesia to systemic pain medications.^{24, 25}

The first study was a randomized controlled trial of trauma patients with ≥1 rib fracture (n = 42) who presented within 12 hours of injury with FVC <70% of predicted.²⁴ Patients were randomly assigned to intrapleural analgesia (IPA) or systemic opioids using an even/odd distribution based on the sequentially assigned admission number (this is not a preferred methodology). The trial was not powered to a primary outcome. Change in FVC was greater in the IPA group in the most severely impaired subset of patients (initial mean FVC <20% predicted), however it does not appear that this was a pre-specified subgroup and was not stratified in the randomization. Adverse outcomes, including PNA, were the same between groups.
The second study was a randomized control trial of adult trauma patients with a blunt chest wall injury (n = 16) who were randomized to intrapleural infusions of either saline or an admixture of lidocaine and bupivacaine.²⁵ The study was not powered to a primary endpoint. Inpatient opioid exposure and spirometry measurements (FVC and FEV₁) were similar between groups.

Myofascial Plane Blockade

One randomized controlled trial compared serratus plane blockade to systemic pain medications.²⁶ The single center trial enrolled adult trauma patients with rib fractures and a numeric pain score of ≥ 4 (n = 60). Patients were randomized to either serratus anterior plane blockade with 0.25% bupivacaine plus patient-controlled systemic analgesia with intravenous tramadol (demand only; no continuous infusion) or patient-controlled analgesia alone. The trial was powered to a primary outcome of tramadol exposure in the first 24 hours. Tramadol exposure was decreased in the serratus plane group (98.33 [±74.13] mg vs. 148.30 [±87.68] mg, p = 0.02). Numeric pain scores were also lower in the serratus plane group at 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, and 24 hours.

Four randomized trials have compared erector spinae plane blockade (ESPB) to other regional analgesia techniques.^{27, 28, 29, 30}

One trial compared ESPB to retrolaminar blockade.²⁷ This single-center double-blinded trial enrolled adult trauma patients with 3-6 unilateral rib fractures undergoing planned SSRF (n = 80). Patients were randomized to either ESPB or retrolaminar blockade (both using ropivacaine after the induction of general anesthesia and prior to the start of SSRF). The trial was powered to a primary outcome of intraoperative remifentanil exposure. The anesthesiologist, patient, and outcomes assessors were blinded to the treatment group. Remifentanil exposure was decreased in the retrolaminar group (392.8 [±118.7] µg vs. 501.7 [±190.0] µg, p < 0.01). Post-operatively, there was no difference in opioid exposure. Visual analog pain scores were lower in the retrolaminar group at 2, 4, and 12 hours, but the differences were not clinically meaningful (mean differences 0.7 points, 0.6 points, 0.5 points, and 0.5 points, all p < 0.05). PaCO₂ was decreased and diaphragmatic excursion was increased in the retrolaminar group, though the differences were not clinically meaningful.
One trial compared ESPB to serratus anterior plane blockade.²⁸ This single-center double-blinded trial enrolled adult trauma patients with rib fractures and an ASA score of 1 or 2 admitted to the ICU (n = 50). Patients were randomized to either ESPB (with 0.25% bupivacaine) and sham SAPB or SAPB (with 0.25% bupivacaine) and sham ESPB. The trial was powered to a primary endpoint of Numeric Pain Score (NPS). The patient and outcomes assessors were blinded to the allocation group. NPS was lower in the ESPB group at 6 hours (1 [1-2] vs. 2 [2-2.5], p <0.001), 12 hours (3 [2-3] vs. 3 [3-4], p = 0.002), and 24 hours (4 [3-4] vs. 4 [3.5-5], p = 0.048), however the differences were not clinically meaningful. Tramadol exposure in the first 24 hours was also decreased in the ESPB group (50 [50-100] mg vs. 100 [75-150] mg, p = 0.004). Diaphragmatic excursion was improved in the ESPB group at 2, 6, 12, and 24 hours after the block, but the differences were not clinically meaningful.
One trial compared ESPB to paravertebral nerve blockade.²⁹ This single-center trial enrolled adult trauma patients with multiple unilateral rib fractures and Visual Analog pain scores (VAS) ≥ 7 (n = 60). Patients were randomized to either ESPB or paravertebral nerve blockade using an admixture of 0.5% bupivacaine and dexamethasone. Both patients and clinicians were reported to be blinded to the allocation group, but details about the blinding strategies were not provided. The trial was powered to a primary endpoint of opioid exposure in the first 24 hours. Opioid exposure in the first 24 hours, the time from blockade to the need for the first rescue dose of opioids, and the incidence of rescue opioids were similar between groups. VAS measured at 30 minutes, 3 hours, 6 hours, 12 hours, 18 hours, and 24 hours were also similar. More patients in the paravertebral group experienced hypotension (6 [20%] vs. 0 [0%], p = 0.024).
One trial compared ESPB to intercostal nerve blockade.³⁰ The trial enrolled adult trauma patients with either blunt or penetrating thoracic trauma (n = 50). The presence of rib fractures was not necessary for inclusion. Patients were randomized to either ESPB or intercostal nerve blockade with 1% lidocaine. The trial was powered to a primary endpoint of Numeric Pain Score (NPS) at 60 minutes after blockade. NPS was lower in the ESPB group at 20 minutes (5.2 [±1.2] 6.1 [±1.3], p = 0.04) and 60 minutes (4.1 [±1.0] vs. 5.4 [±1.2], p = 0.001), and decrease in NPS from baseline was greater at 20 minutes (-2.7 [±1.5] vs. -1.2 [±0.9], p = 0.001) and 60 minutes (-3.9 [±1.5] vs. -1 [±0.9], p < 0.001).

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