New horizons in rib fracture management in the older adult

Abstract

Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2–5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

Combination of the T7 Unilateral Erector Spinae Plane Block and T10 Bilateral Retrolaminar Blocks in a Patient with Multiple Rib Fractures on the Right and T10–12 Vertebral Compression Fractures: A Case Report

“…The presented case underlines the fact that prompt and adequate analgesia in elderly patients with rib and vertebral fractures is imperative to avoid potentially detrimental pulmonary complications, and can be life-saving in many cases. 2 , 3 Early intervention with adequate pain relief improves patients’ functional capacity by reducing splinting and improving pulmonary function. In fact, Trauma Anesthesiology Society guidelines recommend prompt and effective multimodal analgesia for rib fractures by combining regional anesthesia techniques with pharmacotherapy to relieve the pain, optimize pulmonary function, and reduce opioid-related complications.…”

“…Opioids, on the other hand, are respiratory depressants; they suppress cough and may promote respiratory complications, in addition to interfering with the examination/assessment of other injuries in trauma victims. 3 , 4 …”

“…Considering regional anesthesia, TE analgesia using local anesthetic agents, opioids, or a combination of both has been commonly used to manage pain in patients with rib fractures. 3–5 However, it is technically challenging, with a failure rate of approximately 15%. In patients with multiple injuries, it can mask intra-abdominal injuries and be associated with the loss of bilateral sympathetic tone, causing hypotension.…”

“…In addition, it can result in cardiovascular collapse and cardiac arrest in an inadequately resuscitated patient. 3–5 …”

Trends in incidence rate, health care use, and costs due to rib fractures in the Netherlands

“…Patient and injury characteristics influence the outcome after rib fractures. Increased age, increased number of rib fractures, and presence of concomitant thoracic injuries are associated with poorer outcome including higher pneumonia risk, increased hospital and Intensive Care Unit length of stay (HLOS and ICLOS, respectively), and increased mortality [5,[7][8][9][10][11][12]. While negatively affecting in-hospital outcome, rib fractures are also associated with long-term disability, chronic pain, and reduction of quality of life [13][14][15][16].…”