Acute pain management of rib fractures: a narrative review

Abstract

BACKGROUND: Rib fractures are common conditions often associated with significant complications, including respiratory failure, pneumonia, prolonged hospitalisation, and chronic pain. Adequate pain management is crucial to improve outcomes and reduce morbidity in these patients. Despite the wide adoption of multimodal analgesia, the optimal combination of analgesic strategies remains uncertain. OBJECTIVE: To review and synthesize current evidence on analgesic strategies for acute pain management in patients with rib fractures. METHODS: We conducted a narrative review by searching scientific literature on PubMed and Scopus to identify randomised controlled trials (RCTs) on analgesia for rib fractures from blunt trauma. Included studies assessed pharmacologic, non-pharmacologic and regional anaesthesia interventions. Studies describing surgical treatment of multiple rib fractures or addressing analgesia for non-traumatic causes of rib fractures (e.g. neoplasms) or study design other than RCTs were excluded. Forty-seven RCTs met the inclusion criteria. RESULTS: Opioids remain the most studied class of analgesics in the context of rib fracture. While effective for acute pain relief, they pose significant risks, especially in the elderly population. Non-opioid agents - especially non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol -are effective components of opioid-sparing strategies. Thoracic epidural and paravertebral blocks offer superior analgesia and respiratory benefits but are associated with a steep learning curve, are time-consuming, and carry a significant risk of procedural complications. Emerging regional anaesthesia techniques, such as the erector spinae plane (ESP) and serratus anterior plane (SAP) blocks, demonstrated promising results due to their ease of administration and favourable safety profiles. Non-pharmacologic approaches, including cryotherapy, transcutaneous electrical nerve stimulation (TENS), and kinesiotaping, represent additional pain relief options, although evidence remains limited. CONCLUSIONS: Multimodal analgesia - combining pharmacologic, non-pharmacologic and regional anaesthesia approaches -is considered the most effective strategy to guarantee pain relief in patients with multiple rib fractures. However, substantial heterogeneity remains in the regimens employed. Further research is needed to standardize multimodal analgesic protocols and to assess their impact on long-term, patient-centred outcomes.

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