Oral narcotics are generally reserved for patients with minimal rib fractures who may be managed as outpatients. Patients on intravenous or regional medications may be transitioned to oral agents several days after injury in anticipation of discharge. Nonsteroidal anti-inflammatory drugs may be given in concert with narcotics to reduce the opioid need, although there are no studies specific to rib fracture pain management. NSAID use is limited by bleeding concerns and potential renal toxicity, so it should be avoided in trauma patients with significant early bleeding risk, such as ongoing hemothorax or solid organ injury, and in those with renal insufficiency. A recent case series of intravenous ibuprofen use in patients with rib fractures demonstrated a reduction in the narcotic need [19]. Routine acetaminophen and gabapentin have also been used to augment a multimodal approach to pain management in these patients.

Intravenous narcotics are usually the first method of pain control employed for patients with multiple rib fractures. This route of administration is preferred over subcutaneous or intramuscular injection, as the onset of action is more rapid and more predictable. Patients must be closely monitored for excessive sedation or depression of respiratory drive, especially among the elderly. Patient-controlled analgesia is a good option for patients who are alert as they can control the delivery of the medication, which may provide a more timely response and diminish excessive sedation. Excessive sedation of elderly patients is associated with a significant increased risk of aspiration, which can further compromise pulmonary function. Thus, for patients who are particularly sensitive to narcotics, regional analgesia regimen should be considered.

There are several approaches to the administration of regional anesthetics/narcotics. These include continuous epidural infusion of local anesthetics and/or narcotics, paravertebral or intrapleural infusion of local anesthetic, intermittent intercostal nerve blocks, and continuous local anesthetic infusion in the subcutaneous space following thoracotomy.

The most widely studied approach is the use of epidural catheters for infusion of local anesthetics, with or without narcotics. Previous studies have shown that the use of epidural catheters results in improved pulmonary function tests and better pain scores when compared to intravenous narcotics [20–24]. These studies have generally included all adults and have not focused specifically on the elderly population. In the trial by Bulger et al., patients were randomized to receive intravenous narcotics vs. epidural catheter. There was a significant reduction in the risk of pneumonia and a 2-day reduction in the average duration of mechanical ventilation for the epidural group [23, 25]. A recent multicenter review of the impact of epidural analgesia on outcome for patients with multiple rib fractures demonstrated a significant reduction in the risk of death at 30, 60, and 365 days after injury for those patients managed with an epidural catheter [26].

A recent systematic review of the literature failed to identify a clear impact of epidural analgesia on mortality or ICU length of stay but did suggest a benefit on the duration of mechanical ventilation [24, 27]. Another meta-analysis of five randomized controlled trials of epidural analgesia following rib fracture (223 patients) failed to show clear benefit but highlighted the significant heterogeneity in these studies and the presence of bias [28]. The use of epidural catheters for pain control after severe blunt chest wall injury is a Level 1 recommendation in the 2004 EAST guidelines [29].

Epidural catheter use is limited in some cases due to the many contraindications to catheter placement in patients with multisystem injury. The most common contraindications are associated spine fractures and coagulopathy. In a recent survey of pain service directors at major trauma centers in the USA, it was evident that there remains considerable controversy in this area, and better definition of the absolute and relative contraindications is needed to weigh against the potential benefit of this approach [30]. A common side effect of epidural infusion is systemic hypotension, which thus mandates close monitoring especially in the elderly patient population. One retrospective series noted a higher rate of complications among elderly patients receiving epidural analgesia; however, this analysis was limited due to significant differences in the baseline characteristics between the treatment groups [31].

Several recent studies have evaluated the use of paravertebral infusion of local anesthetics and found this approach to be as effective as epidural infusion [32–35]. This approach is effective only in patients with unilateral rib fractures and was associated with a lower rate of systemic hypotension. The authors also note that placement of these catheters is technically easier than epidural catheters. The sample size for these studies was small, so more work needs to be done in this area.

Another option is the placement of intrapleural catheters for infusion of local anesthetics directly into the pleural space. In some cases these are placed adjacent to a thoracostomy tube. One study, which was placebo controlled, failed to find clear benefit with this approach [36]. Another study which compared intrapleural to epidural analgesia found the epidural approach associated with better pain relief [37].

Intermittent injection of local anesthetics to block the intercostal nerves has been reported as one approach to pain management for these patients. This approach is limited by the duration of the block and thus requires repeated injections to achieve continuous relief. This is very labor intensive, and as a result, this approach has largely been replaced by the continuous infusion strategies noted above. There is also a device available that can be placed in the subcutaneous tissue after thoracotomy for continuous infusion of local anesthetic, but it has not been evaluated in patients who do not require thoracotomy [38].

The second cornerstone of management of patients with multiple rib fractures is to provide close attention to respiratory function and encourage deep breathing through incentive spirometry and coughing to clear secretions. A recent study reported that every 10 % increase in vital capacity in the first 48 h after injury was associated with a 36 % decrease in the development of pulmonary complications [39]. The use of chest physiotherapy may be limited by chest wall pain. The indications for mechanical ventilation are based on the underlying pulmonary physiology and traditional signs of respiratory failure including increased work of breathing, hypercapnia, and hypoxia [40]. In general, adequate attention to pain control is key to reducing pulmonary collapse and thus avoiding intubation. For intubated patients, there was one study that suggested that intermittent recruitment maneuvers may improve oxygenation, but it is not clear if this will affect outcome [41].

The operative stabilization of rib fractures has been controversial, and the procedure has evolved as better technology has become available to stabilize the ribs with a minimally invasive approach. A recent survey of trauma and thoracic surgeons in the USA suggested that the majority felt that rib fracture fixation was appropriate for selected patients, yet only 26 % of these surgeons had performed this procedure [42]. One generally accepted indication is the stabilization of significantly displaced ribs identified at the time of a thoracotomy for other reasons, known as “on the way out fixation.” Other potential indications for primary rib fixation include: flail segment with failure to wean from mechanical ventilation, unstable ribs refractory to conventional pain management, chest wall deformity/defect, and rib fracture nonunion [43].

Several single-center studies have suggested that rib fracture stabilization may facilitate ventilator weaning and thus shorten the duration of mechanical ventilation. There have been two small, randomized trials. Tanaka et al. randomized 37 patients with flail chest, requiring mechanical ventilation to surgical stabilization vs. nonoperative management [44]. Patients in the surgical group spent fewer days on the ventilator, had a lower incidence of pneumonia, and had better pulmonary function at 1 month. Granetzny et al. randomized 40 patients with flail chest to operative stabilization vs. external splinting with adhesive plaster [45]. The operative group had a shorter duration of mechanical ventilation and a lower rate of pneumonia. A case-controlled study by Nirula et al. was consistent with these results [46]. Patients with significant pulmonary contusions are less likely to benefit [47]. A recent systematic review of the literature focusing specifically on patients with a diagnosis of flail chest reported significant benefit from rib fracture fixation [48].

The guideline from the Eastern Association for the Surgery of Trauma recognizes surgical fixation as a Level III recommendation for management of flail chest given the small numbers of patients randomized and the lack of comparison with more recent care pathways for these patients including the use of epidural analgesia [49]. Another area of ongoing investigation involves the potential impact of operative fixation on long-term morbidity for this patient population [50]. There are no studies, which focus specifically on the risks and benefits of rib fracture fixation in the elderly population. These patients may face greater surgical risks due to medical comorbidities, and the poor bone quality may also limit the success of fixation. Further studies are needed to determine the optimal use of this approach in the elderly population.

In summary, elderly patients are not only at greater risk to have chest wall fractures even with minor mechanisms of injury but also suffer from significantly increased risks of morbidity and mortality. As a result, care protocols should focus on a low threshold for hospital and ICU admission and close attention to pain management and respiratory therapy. The role of operative fixation in this population requires further study.