Rib fracture pain

A surgical approach

The effort to relieve pain from broken ribs has historically been frustrating for both physicians and patients. Good pain control is vital, not only for comfort but also to ensure that people cough and breathe deeply to prevent pneumonia. Yet most methods for managing pain don't provide lasting relief and can themselves inhibit breathing.

Rib taping, for instance, makes it harder to breathe. And oral narcotics, the mainstay treatment for rib fractures, depress respiration and carry a significant risk of addiction when taken long term. On the other hand, epidural anesthesia, which numbs the nerves that supply the ribs, helps prevent pneumonia but can be used for only five days.

According to Henry J. Schiller, M.D., a trauma and critical care surgeon at Mayo Clinic in Rochester, Minn., better alternatives exist, such as lidocaine patches placed over the ribs and local anesthetic administered using a continuous infusion pump. Still, these options aren't without drawbacks.

Continuous infusion has several advantages over an epidural, including portability, which allows people to go home rather than remain in the hospital. Patients also have a longer pain-free interval — two weeks — before the catheter must be removed. "But then they still have 10 weeks of healing to go," Dr. Schiller says.

Titanium plates stabilize broken ribs

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Fixing fractures

Ultimately, the ideal treatment for rib pain is non-narcotic, provides lasting relief and helps people return to normal activities soon. Dr. Schiller explains that for the past three years, Mayo Clinic has selectively used a surgical procedure that seems to satisfy all these requirements.

"Traditionally, the assumption has been that you don't 'fix' rib fractures, in all senses of that word, because people need to be able to breathe and cough. But for certain patients, we're now using titanium plates designed specifically to stabilize broken ribs."

Some of the plates fit over the bone and attach to it with screws. Other plates, which encircle the ribs from front to back, are better for fragile, osteoporotic bones. This option is especially significant because older adults are at greatly increased risk of morbidity and mortality from broken ribs.

The plates are durable and generally remain in place after the fractures heal. No Mayo Clinic patient has had a problem with infection.

"People return home the day after the procedure. They aren't in pain; they feel wonderful; they go back to work. Any discomfort is easily treated with over-the-counter pain relievers," says Dr. Schiller.

But the procedure, which is expensive and requires a thoracotomy, isn't for everyone. "We're still wrestling with who really needs this procedure," Dr. Schiller points out. "People who do well with pain pills shouldn't have it. But if a person can't cough or breathe deeply or has worsening X-rays, we are likely to offer this option."

Dr. Schiller credits fellow surgeon Brian D. Kim, M.D., with introducing him to rib fracture stabilization. "At first, I laughed at him. But in three years, I've gone from nonbeliever to zealot."