Management of Multiple Rib Fractures

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


  • Fracture displacement:
    • Undisplaced – >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 type:
    • 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 – three of more consecutive ribs with two or more fractures in each rib without clinical paradoxical chest wall movement (i.e. radiographic flail)
  • Flail chest – three or more consecutive ribs with two or more fractures in each rib with clinical paradoxical chest wall movement
  • Ideal Body Weight (IBW):
    • Men: 50 kg + (2.3kg*(height in inches – 60))
    • Women: 45.5 kg + (2.3kg*(height in inches – 60))

Previously Stated Policies:

  • Trauma patients being admitted to SIMU or with ≥ 2 rib fractures should be admitted to trauma service.

Indications for Admission to IMU:

  • Age > 45 with a series of four or more fractures and/or flail segment or chest.(1)
  • Any age with a series of fractures and/or flail segment or chest and:
      • Poor pain control, or
      • Incentive spirometer (IS) volumes ≤ 15 cc/kg IBW, or
    • Oxygen requirement ≥ 5 L/min nasal cannula
    • Volume expansion protocol (VEP) desired every 2-3 hours (every 4 hours can be done on floor; <2 hours 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:

  • Mechanical ventilation
  • VEP < q2 hours
  • 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 a Series of Fractures:

  • Multimodal pain therapy:
  • Volume expansion protocol:
    • Order in Care4: Respiratory Therapy Consult
    • Stepwise progression of therapy employed in the VEP:
      • Incentive spirometry in alert and cooperative patients.  If incentive spirometry goal is not achieved, positive expiratory pressure (PEP) is initiated
      • PEP (EzPAP®, MetaNeb®) is performed if patient is:
        • Unable to perform IS-or-
        • Not meeting incentive spirometry goal or
        • Has persistent or severe atelectasis or
        • Has poor oxygenation
      • Induced deep breathing in patients with a tracheostomy
    • Indications and frequency in the VEP – the RT will assess patient and assign them a RT Triage Score.  The frequency of VEP is based on the RT Triage Score:
        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 q shift if STICU/SIMU status and q 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.”
      • VEP can be done q4 on the floor at the most frequent.  A patient requiring more frequent treatments should be moved to SIMU or STICU.
  • 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 q4 hours during day time.
  • Repeat CXR:
    • Patients with a series of fractures and/or 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 4.(2)
    • If the hemothorax is estimated to be less than 500 cc, observation may be considered.

Surgical stabilization of rib fractures (SSRF)

  • Indications for SSRF at RDTI:
    • Flail segment
    • Flail chest
    • Series of five or more rib fractures
    • One or more rib displaced rib fracture
    • Unstable chest wall
    • Other non-empyema indication for VATS or thoracotomy, especially if fractures preclude stable chest closure
  • Contraindications for SSRF at RDTI:
    • Spine injury which precludes the lateral decubitus position
    • Any skin, subcutaneous, or pleural infection (empyema)
    • Severe TBI with active ICP management
    • Uncorrected coagulopathy
    • Respiratory failure requiring advanced ventilator management, inverse ratio ventilation, or inhaled nitric oxide

Regional analgesia (see APPENDIX A)

  • May provide superior pain control to multimodal pain regimen in patients with a series of rib fractures
  • Consultation with Acute Pain Service is required
  • Consider when:
    • Persistent incentive spirometer volumes < 15 cc/kg 24 hours after admission
    • Progression 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 pain score > 6 requiring continued IV opioids and/or IMU status 24 hours after admission.


Neuraxial techniques:

  • Epidural analgesia (EA)
    • Associated with lower mortality and decreased pulmonary complications in patients older than 60 years(3)
    • Provides pain control that is superior to systemic (intravenous) opioids, enteral analgesics, and intrapleural analgesia(3-8)
    • Technically challenging
    • 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
    • Complications include hypotension, spinal epidural hematoma, spinal cord injury
  • Thoracic paravertebral nerve blockade (TPVB)
    • May provide a comparable improvement in pain control compared to EA(9)
    • Is technically easier to perform than EA
    • Can be used in patients with contraindications to EA
    • 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
  • Intercostal nerve blockade (ICNB)
    • Can provide improved pain control over a limited dermatome distribution(10)
    • Can be performed in patients with contraindications to EA
    • May require multiple injections for sufficient dermatomal coverage, which can increase the risk of local anesthetic toxicity
    • Complications include pneumothorax and vascular puncture
  • Serratus plane block (SPB)
    • Newer technique, not well-studied
    • May provide improved pain control over a larger dermatome distribution than ICNB
    • Can be performed in patients with contraindications to EA
    • Complications include pneumothorax and vascular puncture