Anaesthetic and surgical management of rib fractures

Learning objectives.

By reading this article, you should be able to:

• •Detail the pathophysiology of rib fractures and the associated morbidity and mortality.
• •Describe an initial strategy for analgesia for patients with rib fractures.
• •Outline the evidence base for surgical fixation of rib fractures.
• •Explain the proposed long-term benefits and the perioperative anaesthetic management of rib fracture fixation.

Key points.

• •Rib fractures are a significant health burden in terms of morbidity and mortality, especially in the elderly.
• •The most important aspects of management are multimodal analgesia, including regional anaesthesia and ventilatory support.
• •Scoring systems do not reliably predict failure of conservative treatment, but may help to guide requirements for analgesia.
• •The National Institute for Health and Care Excellence guidance recommends surgical fixation of rib fractures in flail chest injuries; emerging evidence suggests it should also be considered in multiple fractures.
• •It may not be necessary to fix all fractures present, but fractures of ribs 4–9 tend to generate the most pain.

Background

Rib fractures represent a substantial health burden; one in five patients admitted after trauma will have at least one rib fracture, and mortality directly correlates with the number of fractures. Chest injuries contribute to 25% of deaths after trauma, and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of work.¹

In the UK, rib fractures are most commonly the result of blunt chest wall trauma. Younger adults tend to sustain high-impact blows, such as in motor vehicle collisions, whilst the elderly usually suffer fragility fractures, for example after a fall from standing height. Both are associated with significant morbidity and mortality for different reasons. Other less common causes of rib fracture include penetrating trauma, stress fractures (chronic coughing and athletes), pathological fractures (primary or secondary bone lesions), fractures secondary to radiotherapy and non-accidental injuries in children.

Patterns of rib injury

Anatomy

There are 12 pairs of ribs, all of which articulate posteriorly with the respective thoracic vertebra and transverse processes. Ribs 1–7 are true ribs in that they articulate anteriorly directly with the sternum via costal cartilages. Ribs 8–10 are false ribs as their attachment to the sternum is not direct, and ribs 11 and 12 are floating as they have no anterior connection. The inferior aspect of the rib is grooved to accommodate the neurovascular bundle, comprising the intercostal vein, artery and nerve. The neurovascular bundle can be variably located posteriorly. Travelling laterally and anteriorly, the bundle is increasingly likely to sit in the groove.

The most common ribs to fracture are ribs 4–10. The first three ribs are relatively protected by the clavicle and shoulder girdle, so require a significant amount of force is required to fracture these ribs. The lower floating ribs 11 and 12 are more mobile and less likely to fracture. Traumatic fractures tend to occur at the site of impact or at the weakest point, usually the posterolateral curve.²

Rib fractures can be described by

• (i)Number of ribs broken
• (ii)Unilateral or bilateral injuries
• (iii)Position on the rib (anterior, lateral or posterior)
• (iv)Displaced or undisplaced
• (v)The presence or absence of a flail segment (can be determined both radiologically and clinically)

Flail chest

Radiologically, a flail segment is the presence of three contiguous ribs fractured in two or more places. Clinically, a flail chest is paradoxical chest wall movement in a patient who is breathing spontaneously. This is a more variable phenomenon; it can occur in a patient with one rib fractured in two places, or sometimes not be present even in a patient with a significant radiological flail. Both clinical and radiological definitions of flail chest signify increased severity of injury; the presence of a flail chest injury is associated with a mortality rate of up to 35%.²

Complications of rib fractures and associated patterns of trauma

Rib fractures can have immediate adverse effects on ventilation as a result of significant damage or distortion to the thorax in uni- or bilateral injuries. Displaced fractures can tear pleura and lung and damage intercostal vessels, causing pneumothorax with or without haemothorax. These early complications require prompt detection and management. Significant deformity of the chest wall will cause altered pulmonary mechanics, including reducing total lung capacity, altering dynamic compliance and ventilation perfusion matching.

In the hours and days after injury, blossoming contusions (expanding, haemorrhaging or both) with or without the consequences of inadequate analgesia can exacerbate ventilatory failure. Pain from fractures limits chest wall excursion resulting in reduced tidal volumes and the inability to effectively cough, leading to atelectasis and sputum retention. This increases the likelihood of pneumonia and accounts for the majority of the delayed mortality after chest wall trauma. Pneumonia occurs in around a third of those over 65 yrs of age after rib fractures and is associated with an increased likelihood of death; in some studies, elderly patients were reported to have double the morbidity and mortality of patients under the age of 65 yrs.³

Rib fractures from blunt trauma are invariably associated with underlying lung contusion.^1,2 Damage to the alveolar capillary membrane complex leads to bleeding into the lung tissue and subsequent oedema. This often impairs gas exchange from intra-pulmonary shunting and reduced lung compliance. The net effect is hypoxaemia, hypercarbia and an increased work of breathing. Contusions are often apparent on initial CT scans, but may not become evident on chest X-ray (CXR) until 24 h after the injury and tend to resolve after 7–14 days with supportive management.⁴

Certain injury patterns should raise suspicion of significant intrathoracic injury. Flail segment, sternal fracture, scapula fracture, posterior sternoclavicular dislocation, multiple displaced rib fractures and fractures of ribs 1–3 all suggest a significant amount of force has been transmitted across the thorax. Their presence increases the likelihood of associated injuries, such as severe lung contusions and damage to other major intrathoracic structures, such as thoracic aortic dissections; tracheobronchial disruption; myocardial, valvular or pericardial damage; and, rarely, oesophageal trauma.3, 4, 5 Fractures of ribs 10–12 are more likely to be associated with injuries to the liver, spleen and kidneys.

Several factors have consistently been shown to correlate with adverse outcomes and increased likelihood of death after rib fractures. The most significant are age over 65 yrs; comorbidities, especially respiratory and cardiovascular diseases; more than three broken ribs; and development of pneumonia.⁶

Rib fractures in the elderly

Whilst the energy forces involved in rib fractures in the elderly are usually lower than in younger patients, the outcomes are worse. The increased frequency of fractures at lower forces is attributable to osteoporosis, frailty and reduced muscle mass, all of which occur with advanced age. Both morbidity and mortality are doubled in patients aged over 65 yrs, and each additional broken rib further increases the risk of mortality and complications.^3,6

Assessment of pain can be challenging in the elderly, for example in those less able to communicate because of cognitive deficits. Ageing itself is also associated with changes in pain perception and altered pharmacokinetics and dynamics. Consequently, analgesic regimens are more often inadequate or associated with adverse effects in the elderly.

Rib fracture scoring systems and risk stratification

There is currently no universally accepted assessment tool for patients with rib fractures to guide risk stratification and treatment. Several scoring systems have been developed internationally to attempt to stratify patients at risk of complications. Most common are the rib fracture score, chest trauma score (CTS) and RibScore.

Rib fracture score simply considers the details of the rib fractures and the patient's age. Rib fracture score is calculated as breaks (number of total fractures of the ribs) multiplied by the number of sides affected (×1 for single-sided fractures; ×2 for bilateral fractures) plus an age factor (51–60=1; 61–70=2; 71–80=3; >80=4).⁷ Unfortunately, it is a poor discriminant for both respiratory morbidity (pneumonia and requirement for tracheostomy) and mortality; as such, it is not useful as a single predictor of outcome.⁵

Chest trauma score aims to stratify those patients most at risk of death or complications in the first 24 h. Chest trauma score is calculated by a sum of points from age (<45=1; 45–65=2; >65=3), number of fractured ribs (<3=1; 3–5=2; >5=3) plus 2 extra points if fractures are bilateral and pulmonary contusion points defined by radiologist (mild=1; severe=2; bilateral=3). Studies have confirmed a link between high CTS score and morbidity and mortality. Chest trauma score most accurately predicts pneumonia in the elderly, which is a common cause of mortality in that subgroup.⁸

RibScore is predominantly a radiographic score placing emphasis on severity of thoracic injuries. It delineates radiologically severe from mild chest trauma, but is not as good at predicting patient morbidity and mortality. RibScore gives a score of 0 or 1 depending on the presence or absence of the following injuries: six or more ribs fractured, bilateral rib fractures, occurrence of flail chest, more than three displaced rib fractures, first rib fractured and fractures present in all three segmental locations (anterior, lateral and posterior).⁹

Outcomes based on scores from different scoring tools vary depending on whether they are applied to geriatric or non-geriatric populations, even though they are weighted for patient age. The scores also only consider specific thoracic components of any injury. For example, the scores do not correlate well with injury severity score (ISS) and mortality across all patient groups.⁵

The most significant risk factors for mortality appear to be increasing age, number of rib fractures, pre-existing chronic lung disease, use of anticoagulants before injury and oxygen saturation at presentation. A UK-based group has used these risk factors to develop and validate an alternative score (STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients [STUMBL]), which may more accurately predict morbidity and mortality in UK populations. This is the tool currently adopted in our organisation; the area under the receiver operator curve (ROC) is 0.97 (Table 1).^10,11

Table 1.

STUMBL chest scoring system. Scores: 1–10 (mild), 10–30 (moderate) and >30 (severe)

STUMBL chest scoring system
+1 per 10 yrs over 10
+2 per 5% reduction in oxygen saturations <95% breathing room air
+3 per individual fracture (two fractures on one rib=+6)
+4 anticoagulant or antiplatelet drugs
+5 chronic lung disease

Management of patients with rib fractures

Diagnosis

After an injury, the most sensitive imaging modality is CT; this will confirm the number and site of fractures and detect flail segments, underlying intrathoracic injury and pulmonary contusions. Chest X-ray alone will miss up to 50% of fractures.⁴

Ventilatory management

Supplementary oxygen will often be required to treat hypoxia and may facilitate the safe use of various sedating analgesics. Patients developing more significant hypoxia with or without hypercarbia may benefit from high-flow nasal cannulae or non-invasive ventilation (NIV). These devices, used in conjunction with good-quality (often regional) anaesthesia, have been demonstrated to be associated with reduced intubation rates and mortality.¹² Certain patients may have contraindications to NIV, such as base of skull fractures, reduced levels of consciousness or pneumothorax before chest drain insertion. Invasive ventilation will be required if the thoracic injuries are sufficiently severe or the extrathoracic injuries dictate airway or ventilatory control.

Positive-pressure ventilation provides pneumatic stabilisation of the chest wall, and assisted ventilation both limits atelectasis and reduces work of breathing. Bronchopleural fistula with an air leak via intercostal drains should not be considered a contraindication to positive-pressure ventilation, as long as major airway injury has been excluded. This is also the case in the context of simple pneumothorax, where conservative management may be appropriate even if positive-pressure ventilation is required.¹³ Physiotherapy also plays a vital role; incentive spirometry and assisted coughing may both help prevent complications.

Analgesia

The cornerstone of good supportive care is effective multimodal analgesia to reduce the incidence of pulmonary complications. A specific rib fracture pathway, including a stepwise approach to analgesia, and regular reviews from a team of specialists, including medical, nursing, pain management, and physiotherapy, may reduce complications and mortality.¹⁴ Our experience is that cohorting rib fracture patients is associated with improved outcomes. Cohorting allows the multidisciplinary team to gain familiarity with analgesia; early mobilisation; and specific physiotherapy, including routine incentive spirometry. Analgesia must be initiated in a timely fashion soon after presentation to the emergency department. Figure 1 highlights the rib fracture pathway used in our trust. We utilise the STUMBL scoring system to stratify severity and guide analgesia (Table 1).¹⁵

Fig 1.

University Hospitals Plymouth isolated blunt chest trauma tool. QDS - four times daily, BD - twice daily, PRN - as required, OD - once daily, ACT - acute care team, UHP - University Hospitals Plymouth, MTC - Major trauma centre, SpR - specialist registrar, ICU - intensive care unit, HDU - high dependency unit, IBW - ideal body weight.

Oral analgesics, including paracetamol and non-steroidal anti-inflammatory drugs, should be started unless contraindicated. Our institution favours regional techniques over i.v. opioids where possible. Local anaesthesia catheter-based techniques have been demonstrated to provide superior pain relief and a lower incidence of pulmonary complications when compared with systemic opioids in the context of rib fractures, although there is no proven effect on mortality.¹⁶ More severely injured patients and those at higher risk of complications attributable to comorbidities should be transferred to a high-dependency area that can provide non-invasive respiratory support.

Options for providing regional anaesthesia of the chest wall have increased in recent years, and the choice of regional anaesthetic technique should be tailored to the patient (Fig. 2).

Fig 2.

University Hospitals Plymouth regional anaesthesia decision aid for rib fracture management. SAP -serratus anterior plane block, ESP - erector spinae plane block.

Traditionally, epidural analgesia has been the regional anaesthetic technique with the best evidence of efficacy in rib fractures. Meta-analysis has shown that thoracic epidural provides superior analgesia to paravertebral block, intercostal block and i.v. analgesia.¹⁶ However, concerns around spinal neurological damage and the cardiovascular consequences have led to a decrease in epidural use in this setting over the years. Paravertebral, erector spinae plane (ESP) blocks and serratus anterior plane blocks may all be as efficacious as epidurals in appropriate patients. There are also fewer and less serious complications associated with these blocks when compared with epidurals, especially when considering the widespread use of anticoagulants in the general population. These blocks are increasingly being used despite a lack of evidence base.¹⁶ The ESP block was first described in 2016. Local anaesthetic (LA) is injected under ultrasound (US) guidance deep to the erector spinae muscles (iliocostalis, longissimus and costalis). Literature surrounding ESP in rib fractures is limited given its novelty, but some studies have suggested that ESP is a highly effective technique for rib fractures, and locally, it is our regional catheter technique of choice in this scenario given its simplicity and good safety profile.¹⁷ Serratus anterior plane blocks may also be beneficial in anterior rib fractures.¹⁸ Table 2 highlights the differences in regional techniques. Details of how to perform the specific blocks are beyond the scope of this article, but have been covered elsewhere.¹⁹

Table 2.

Comparison of regional anaesthetic techniques and i.v. opioids in rib fracture management. ED, emergency department; Epi, epidural; ESP, erector spinae plane block; ICB, intercostal block; LA, local anaesthetic; LOS, length of stay; PCA, patient-controlled analgesia; PVB, paravertebral block; SPB, serratus anterior plane block

Type of analgesia	Features	Evidence for use
Epi	•Unilateral or bilateral fractures •Contraindicated in coagulopathy, systemic sepsis •Complications: reduced MAP, urinary retention, unintentional motor block, reduced mobility, spinal cord trauma/infection/haematoma	•Provides the most effective analgesia in meta-analysis comparing Epi, PVB, ICB and i.v.; no mortality benefits; some studies suggest Epi may increase LOS. •May be technically difficult; positioning may be problematic
PVB	•Unilateral fractures: bilateral insertion for bilateral analgesia •Less sympathetic block than Epi; no urinary retention •Safer than Epi in the presence of anticoagulants	•As effective as epidural in terms of respiratory complications and duration of artificial ventilation or stay in ICU
ICB	•Requires multiple injections of LA at the level of the fracture and one level above and below •Unilateral analgesia •May not be suitable for multiple fractures as volume of LA required may exceed safe dose •Can be performed landmark or using US •Risk of pneumothorax	•Has not traditionally been a popular choice of analgesia for rib fractures •May improve respiratory function compared with no regional technique
ESP	•Provides analgesia in unilateral fractures; may be inserted bilaterally •Analgesia to anterior and posterior hemithorax; LA will spread three segments above and four below site of injection •Can be performed sitting or lateral •Technically easier than PVB, ICB and Epi; can potentially be inserted in ED •Minimal changes in MAP •Lower risk of complications in the anticoagulated patient	•Some studies have shown improved spirometry values post-block insertion in rib fracture patients •Novel technique; evidence comparing with more traditional regional techniques is currently lacking •Retrospective cohort study showed improved pain scores and spirometry values with reduced opioid consumption associated with ESP catheter insertion •RCT needed
SPB	•Unilateral fractures; provides analgesia to anterior chest wall •Can be inserted bilaterally •Blocks lateral branches of intercostal nerves •May be performed supine and in anticoagulated patients •Only effective in fractures of anterior two-thirds of hemithorax •May be useful in multiple injured patients with anterior fractures	•Efficacy limited to case reports and observational studies •No comparison studies with other techniques at present
I.V. opioids	•Indicated in severe pain, where LA regional technique not possible or contraindicated •Can provide analgesia for multiple injuries •PCA not suitable in unconscious patients or those unable to press button •May cause hypotension and respiratory depression	•Inferior analgesia to epidural, paravertebral and intercostal blocks in meta-analysis

Surgical fixation of rib fractures

Surgical fixation of rib fractures first gained popularity in the 1940s and 1950s, but it was known to be associated with significant failure and a high incidence of complications. Since the 1950s, the management of rib fractures changed with the introduction of newer ventilation strategies, improvements in mechanical ventilator technology, and the introduction of percutaneous tracheostomy to facilitate weaning. A conservative approach with prolonged positive-pressure ventilation became normal practice.

More recently, new surgical devices have been developed for surgical fixation, and as understanding of adverse pulmonary mechanics imposed by fractured ribs has increased, fixation of the most severe fractures has come back into vogue.²⁰

Indications

The only current indication for surgical fixation with a strong evidence base and recommended by the National Institute for Health and Care Excellence is for patients with flail chest injuries requiring mechanical ventilation.

Open reduction and internal fixation (ORIF) of flail chest has been demonstrated to be associated with a reduced incidence of pneumonia, tracheostomy, length of hospital stay, ventilation requirement and reduced mortality.²¹ Varied interpretation of the term 'flail chest' may in part account for the difference in practice observed throughout the UK.

Despite a lack of robust evidence, severely displaced non-flail fractures with resultant respiratory compromise, significant chest wall deformity, chronic non-union and failure to wean from mechanical ventilation are all considered by the surgical author (AM) as valid indications for fixation. Patients with rib fractures requiring a thoracotomy for other reasons (e.g. severe haemothorax) often have their rib fractures surgically repaired simultaneously.

Other areas lacking an evidence base include timing of surgery and methods of fixation; thus, national provision of this service is surgeon and centre dependent.^21,22 Local data suggest that if surgery is delayed beyond 3 days of the injury, the durations of ICU and hospital stay are disproportionately prolonged, so it seems likely that early fixation is optimal. UK data from the Trauma Audit and Research Network suggest that early surgical fixation of rib fractures reduces mortality when compared with historical cohort data. There is little benefit to surgical fixation beyond 10 days post-injury because of the high likelihood of suitable patients having already developed pneumonia.²³

At our centre, the current indications for surgical fixations are

• (i)Likelihood of respiratory compromise (symptomatic fractures of three or more consecutive ribs, flail segment, significant comorbidities or STUMBL score >21)
• (ii)Difficult pain management in non-intubated patients despite appropriate use of analgesic drugs and regional techniques
• (iii)Intubated patients in whom weaning from artificial ventilation fails
• (iv)Thoracotomy being undertaken for associated thoracic injury
• (v)Patients with severe anterolateral flail chest or severe chest wall deformity with or without pulmonary herniation

Many patients with multiple relatively undisplaced rib fractures (and no associated complications) will be managed initially without surgery. A number of these patients will go on to develop pneumonic complications. Currently, there is no validated method to predict which patients would have benefitted from surgical fixation. Deteriorating incentive spirometry values may be indicative of impending respiratory failure, but a threshold value for consideration of fixation has not been established.²⁴ Trials are currently underway to assess the impact of surgical fixation on multiple rib fractures without flail; the ORIF trial running in the UK and the FixCon trial in the USA are evaluating the impact of surgical fixation of rib fractures on short- and long-term outcomes, including cost–benefit analyses.^25,26 A recently undertaken study has found that surgical fixation of three or more displaced fractures without flail leads to reduced pain scores at 2 weeks, reduced opiate consumption and improved quality of life, suggesting that fixation of non-flail fractures may be beneficial.²⁷

Contraindications

Any coexisting injury that may necessitate a prolonged period of mechanical ventilation should be considered a contraindication to surgical rib fixation. This includes significant neurosurgical trauma and severe lung contusions. The reasons for this are that surgical fixation of fractures will not liberate the patient from mechanical ventilation and that perioperative one-lung ventilation may cause hypoxia and hypercarbia, both of which may exacerbate raised intracranial pressure and neurological injuries. The presence of infection with empyema and a contaminated field is considered a relative contraindication because of the potential risk of prosthetic infection.

Methods of surgical fixation

In some centres, orthopaedic surgeons deliver the service, whereas in other units thoracic surgeons take the lead. There is no evidence that one model provides improved outcomes. In thoracic surgical centres, video-assisted thoracoscopic surgery assessment of the pleural space can be used to identify any underlying visceral injury, aid evacuation of haemothorax and perform pleural irrigation.

Fixation of the ribs is different to a number of orthopaedic operations in that postoperative immobility is not an option. The most commonly used plating systems involve titanium plates fixed to the outside surface of the rib and secured with cortical locking screws. This means that the pleural cavity is not always breached and there may be no requirement for postoperative pleural drainage. However, haemothorax is extremely common, and untreated represents a risk for the development of empyema, so in most thoracic surgery units a drain will be placed. Bone grafting is occasionally required if significant bony defects are present.

Which fractures to fix?

It is not necessary to fix all fractures present. Ribs 4–9 generate the most pain as they provide the majority of chest wall stability. The decision should be individualised, based on extent of displacement, flail chest and clinical examination of the patient. Some studies have suggested that partial stabilisation of flail chest is acceptable if exposure of all fracture sites will cause significant postoperative pain or be technically difficult.²⁸

Before any fixation, a recent CT 3-D reconstruction can aid operative planning (Fig. 3). Rib fractures can become displaced over time when compared with the initial trauma CT as a result of continual intercostal and diaphragm movement. Individual fractures are reduced and stabilised using preformed or moulded plates and clamps; a calliper is used to estimate the width of the rib, and so to determine the length of bi-cortical screw required. Figure 4 shows the plates visible on CXR postoperatively.

Fig 3.

CT 3-D reconstruction of multiple rib fractures, used as part of preoperative planning. The postoperative CXR of the same patient can be seen in Figure 4.

Fig 4.

Postoperative CXR after surgical fixation of rib fractures.

Surgical complications

Specific surgical complications are rarely described in the literature. Infection, recurrent haemothorax and pneumothorax secondary to underlying pulmonary injury can occur. Prosthetic failure is also rarely described.

Anaesthetic management for surgery

Preoperative assessment

This should encompass routine anaesthetic checks and a detailed review of the mechanism of injury, associated intra- and extrathoracic injuries and whether these have been treated or managed conservatively. Any concomitant injury to the spine or pelvis may result in restrictions on the patient's movement, which may make positioning difficult or impossible. Detailed assessment of respiratory and cardiovascular function is needed. The degree of respiratory support, presence of chest drains and the presence of persistent pneumothorax or surgical emphysema are all important. In addition to a routine ECG, an echocardiogram is advised if significant myocardial contusion is suspected. Recent blood results should be reviewed with particular attention paid to clotting tests and transfused blood products.

Intraoperative management

Most commonly, surgical access requires the patient to be laterally positioned. Occasionally supine or prone positioning may be required. Most surgeons favour one-lung ventilation intraoperatively, and so a double-lumen tracheal tube or bronchial blocker will often be needed. Standard intraoperative monitoring is required; invasive arterial monitoring may also be indicated in patients with significant other injuries or comorbidities that may predispose to haemodynamic instability or problematic oxygenation. Appropriate pressure area care is important. The duration of surgery depends on the number of fractures to be fixed and the ease of exposure and reduction of these fractures. Specific steps to monitor the patient's temperature and avoid hypothermia will be required for prolonged operations.

Postoperative management

The ability to wake up the patient and wean from invasive ventilatory support depends on the extent of any underlying lung contusions, extrathoracic injuries and cardiorespiratory abnormalities. Less severely injured patients without significant underlying contusions who were not sedated and ventilated before the procedure should not require routine postoperative ventilation. More severely injured patients will require admission to or transfer back to critical care postoperatively. These patients will require an individualised approach to extubation, and some of these patients may require a further period of ventilation. Postoperative analgesia should follow a similar approach to elective thoracic procedures and include LA infusions. In our centre, routine practice is to insert erector spinae blocks either uni- or bilaterally depending on injury. Performing this after surgical fixation of rib fractures usually results in resolution of pain and mechanical impedance to ventilation, thereby facilitating weaning and successful extubation.

Long-term outcomes

Rib fractures are associated with significant morbidity and mortality. At 2 yrs after an injury, two-thirds of patients are reported to have ongoing pain issues and a third will not have returned to their usual employment before the injury, often because of chronic pain or non-union of fractures.²⁹

Reassuringly, studies of patients who underwent surgical fixation for both flail chest and multiple fractures demonstrated reduced incidence of pneumonia, reduced length of stay and a greater likelihood of returning to work in this group.²⁹ There is a current UK trial underway, Outcomes After Chest Trauma Score, investigating patient-reported outcomes in the UK-based population. Applying the findings of this study may help demonstrate which patients may benefit from surgical rib fracture fixation.

Summary

Rib fractures represent a significant health burden, especially in the elderly. Long-term effects are often underestimated and may be improved with surgical fixation. Good multimodal analgesia instituted shortly after presentation to a hospital is key; assessment of the severity of pain should guide analgesia and prompt consideration of regional LA techniques. Surgical fixation of rib fractures may become more common given the emerging evidence suggesting a benefit. Anaesthetists can expect to become increasingly involved in the management of these patients. We may be asked to provide pain management, including provision of regional techniques, and provide perioperative and in some cases postoperative care for these patients, some of whom may have undergone surgical fixation. A good understanding of the pathophysiology of these important injuries is vital to improve patients' care.

Declaration of interests

The authors declare that they have no conflicts of interest.

Acknowledgements

The authors thank Ross Vanstone, Mark Rockett and Robin Berry for permission to reproduce the University Hospitals Plymouth chest trauma analgesic pathway, and Ross Vanstone for guidance in writing the analgesia section.

MCQs

The associated MCQs (to support CME/CPD activity) are accessible at www.bjaed.org/cme/home by subscribers to BJA Education.

Biographies

Ashleigh Williams MRCP FRCA FFICM is a specialty registrar in intensive care and anaesthetics at Derriford Hospital, Plymouth.

Colin Bigham BSc MRCP FRCA FFICM is a consultant in anaesthesia and intensive care medicine at Derriford Hospital. His special interests include echocardiography and ultrasound.

Adrian Marchbank BSc FRCS (CTh) is a consultant in cardiothoracic surgery at Derriford Hospital. His special interests include surgery for lung cancer, arterial revascularisation, mitral valve repair and off-pump coronary artery surgery. He is also the Caldicott Guardian for the Trust.

Matrix codes: 1D02, 2G01, 3G00