# 009 Managing Pain in Elderly Rib Fracture Patients (>65 years)

Fast Facts and Concepts #009 PDF

Authors: Jeremy Juern MD, John Petronovich, Travis Webb, MD, Kathryn Denson MD, Bambi Wessel

Objectives: 

1. Explain the underlying etiology of acute rib fracture pain in elderly patients.
2. List pulmonary complications which may result from poor pain management.
3. Apply the “Pain Plan” for elderly rib fracture patients correctly in patient care.

ACGME Competencies: Patient Care, Medical Knowledge

Context: Hospitalized elderly patients with rib fractures.

Action: Implement an effective pain management protocol for elderly patients hospitalized with rib fractures.

Incidence/Prevalence: Rib fractures are a common injury for patients presenting to emergency departments with blunt thoracic trauma, with approximately 10% of these patients requiring admission to a trauma center. The Medicare Short-term Stay Survey from 2007 identified nearly 353,000 patients admitted with a rib fracture diagnosis code, with the true incidence of rib fractures likely higher as bony fractures within the thorax are often under-detected using traditional radiography (Simon .et al., 2005). Rib fractures are most often sustained during falls, traffic-related events involving motor vehicles and pedestrians, or crush events involving high energy loads. When rib fractures result from major trauma or high energy loads, concurrent injuries to the heart, lungs, liver and spleen are not uncommon.  Mortality rates may range from 3-13% (Carrier et al., 2009), and as high as 18% in patients 65 years and older (Winters, 2009).  Age and the number of rib fractures are the strongest predictors of mortality.

Underlying Science: Elderly patients are at a greater risk for rib fractures due to decreased bone density with age and osteoporosis, and, to a lesser extent, a greater likelihood of metastatic neoplastic  lesions to the bone.  Rib fractures elicit intense pain due to the insertion of inspiratory muscles on the rib bone.  Inspiration causes force and subsequent movement of the bone, aggravating the fracture and eliciting pain.  The patient subsequently limits respiratory tidal volume with a then increased risk of atelectasis, pneumonia, and other pulmonary complications (Bulger et al., 2000).  Adequate pain control is the key in prevention of these complications.

Management Protocol for Rib Fracture Pain: See “Pain Plan” protocol below.  Click image to view full sized Pain Plan.
 

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References:

1. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. Jun 2000; 48(6):1040-6.
2. Carrier FM, Turgeon AF, Nicole PC, Trepanier CA, Fergusson DA, Thauvette D, Lessard MR.  Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials.  Canadian Journal of Anesthesiology 2009; 56(3):230-42.
3. Simon BJ, Chu Q, Emhoff TA, Fiallo VM, Lee KF.  Delayed hemothorax after blunt thoracic trauma: An uncommon entity with significant morbidity.  J Trauma 1998; 45:673-6.
4. Winters BA.  Older adults with traumatic rib fractures: an evidence-based approach to their care.  J Trauma Nurs. Apr 2009; 16(2):93-7.
5. Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-Related ulcer complications. Am J gastroenterology 2009; 104(3):728-38.

Thank you to Jeremy Juern, MD and the Froedtert Trauma Committee, 2011 for the development and usage of the Geriatric Trauma Patient Protocol pain management details.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Jeremy Juern MD, John Petronovich, Travis Webb, MD, Kathryn Denson MD, Bambi Wessel - Fast Fact #9:  Managing Pain in Elderly Rib Fracture Patients (>65 years) , February 2012. Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

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