When should inpatient care be considered for patients with rib fracture?

Updated: Jun 13, 2017
  • Author: Sarah L Melendez, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Answer

Patients with isolated rib fractures who are unable to cough and clear secretions adequately should be considered for admission for 24-hour observation. Consider admission for patients with underlying lung disease or decreased pulmonary reserve. A lower threshold for admission of older persons with isolated rib fractures is warranted because of their higher incidence of hypoventilation, hypercapnia, atelectasis, and pneumonia. [20]

Specifically in the age group 65 years and older, consider admission for patients age ≥85 years, or with initial systolic blood pressure < 90 mm Hg, hemothorax, pneumothorax, 3 or more unilateral rib fractures, or pulmonary contusion. [20]  Admission may also allow for observation for occult intra-abdominal organ injury.

Patients being admitted should have good pain control and, if possible, given an incentive spirometer to prevent pulmonary splinting and its resultant complications. [46]  A paravertebral block is only useful for patients with unilateral rib fractures but is associated with a lower rate of systemic hypotension. [47]   [42]

Intercostal nerve blocks provide pain relief without affecting respiratory function, although risks of this procedure include intravascular injection and pneumothorax. The procedure is also limited by the duration of the block and, for patients with multiple rib fractures, the need to perform the procedure at multiple intercostal levels. Intercostal nerve block has been shown to have the advantage of providing dramatically more effective pain control than conventional medications in the initial stage of treatment of patients with thoracic injuries. It is also relatively simple to use; is not associated with neurologic complications due to nausea, vomiting, dizziness, or bleeding; and is not associated with complications from possible misjudgment observed in other measures, such as thoracic epidural injection. [48, 42]


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