Whether early operative rib fixation is of benefit to reduce acute and chronic pain remains to be determined. ![]() Continuous intercostal nerve blockade with local anesthetic is available as a bedside procedure and has applicability and benefit for a broader range of patients. Epidural catheter analgesia can be an effective modality in patients at risk for respiratory deterioration secondary to pain, but injured patients frequently have contraindications preventing insertion. But because of chronic misuse potential and central desensitization concerns, pain researchers and clinicians are increasingly recommending that opioids be used only in combination with other analgesic modalities such as acetaminophen, nonsteroidal anti-inflammatory medication (NSAID), the anticonvulsants gabapentin and pregabalin, and the topical lidocaine patch. Opioids, oral or intravenous, are traditional first-line therapy for acute rib fracture pain. Thus, pain management in the early post-injury setting is likely paramount to obtaining a more favorable recovery. Interestingly, the number of fractures and the bilaterality of fractures were not predictive. A recent prospective study of rib fracture patients found that pain and disability at 8 weeks post injury could be predicted by the pain intensity within the first few days after injury. There is mounting evidence that a patient’s perception of pain in the early post-injury period is associated with chronic pain development. In this review, we detail the important physiologic principles which guide effective management of blunt thoracic injury and provide insight into new approaches being developed. The tendency of pulmonary contusions to “blossom” prior to beginning a trajectory of resolution puts the patient at risk for respiratory deterioration over the subsequent 2 to 3 days. ![]() The severity also ranges from mild to severe. Pulmonary contusion often accompanies blunt thoracic trauma with or without rib fractures. Trauma patients with multiple fractured ribs demonstrate a clinically significant reduction in quality of life out to 24 months with less than half the thoracic trauma group returning to a good level of functioning at that time. Acute management, however, may not address the potential long-term morbidity of such injuries. Despite this, the management for the vast majority of rib fracture injuries remains supportive only, with analgesia, chest physiotherapy, and, when required, respiratory support being mainstays of care. Aside from the acute impact of rib fracture injury, long-term pain, disability and deformity also frequently occur. Rib fracture injuries extend across a broad spectrum of severity ranging from a single fractured rib that may be sustained in a fall to multiple fractured ribs that result in a flail chest with respiratory failure. ![]() Emerging or unclarified strategies include the importance of acute pain control of rib fractures to alleviate the development of chronic pain, the role of rib fracture operative reduction/internal fixation (ORIF) in severe chest wall trauma, and the use of surfactant and dual lung ventilation for severe pulmonary contusion. In this review, we describe the development of current principles of management of rib fractures, flail chest, and pulmonary contusion. Pulmonary lacerations, pneumatoceles, and even lobar infarction can occur. Pulmonary contusion often accompanies blunt chest wall trauma and when diffuse will result in respiratory failure regardless of other injuries. Flail chest, along with chest wall deformity, the most severe of chest wall injuries, is associated with significant acute morbidity and mortality. Rib fractures are notoriously painful and can lead to prolonged hospitalization, contribute to the development of pneumonia and respiratory failure, and delay outpatient recuperation significantly. Blunt chest trauma accounts for a significant proportion of debilitating and life-threatening injuries.
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