# Pain management in non-operatively treated patients with multiple single rib fractures: an international comparison

## TL;DR

This study compares pain management and outcomes for patients with multiple rib fractures in two hospitals in the US and the Netherlands.

## Contribution

The study reveals similar clinical outcomes despite differing pain management approaches and patient demographics.

## Key findings

- Despite differences in pain management strategies, outcomes like pain reduction and hospital length of stay were similar between the two hospitals.
- Congestive heart failure and chronic obstructive pulmonary disease were strong predictors of pneumonia in these patients.
- Bilateral and displaced rib fractures were more likely to require ICU admission but had comparable outcomes.

## Abstract

Evidence on non-operative management of multiple single rib fractures remains limited, resulting in institutional treatment variation. This study compared outcomes of different pain management strategies.

A retrospective cohort study at Massachusetts General Hospital (MGH, USA) and Leiden University Medical Center (LUMC, The Netherlands) included patients ≥ 18 years with ≥ 3 single rib fractures between 2018 and 2023. Exclusion criteria included flail chest, surgical fixation, severe extra-thoracic trauma, Glasgow Coma Scale < 15 after 72 h, and transfers. Primary outcomes were pain score change, discharge opioid use, and pulmonary complications. Secondary outcomes included mortality and hospital length of stay (HLOS). Subgroup analysis compared fracture side and displacement, and ICU admission. Forward stepwise logistic regression analysis identified predictors of pneumonia.

545 patients were included (109 at LUMC). LUMC patients were younger (61 vs. 68 years, p < 0.001) with fewer comorbidities but higher injury severity scores (13 vs. 10, p < 0.001). LUMC favored patient-controlled analgesia (22.9% vs. 5.7%, p < 0.001) and less provider-controlled opioids (11.0% vs. 21.3%, p < 0.001). Pain score reduction (4 vs. 4, p = 0.68), discharge opioid use (45 vs. 45 oral morphine equivalents, p = 0.75), HLOS (3 vs. 4 days, p = 0.059), pulmonary complications (3.7% vs. 6.2%, p = 0.31), and mortality (2.8% vs. 1.8%, p = 0.54) were similar. Bilateral and displaced fractures required ICU admission more often but had similar outcomes. Congestive heart failure (OR 14.86, 95%CI 3.24–68.16, p = 0.001) and chronic obstructive pulmonary disease (OR 8.08, 95%CI 1.72–38.03, p = 0.008) independently predicted pneumonia.

Despite differences in patient characteristics and pain management, outcomes were similar. Hospital level treatment heterogeneity may be acceptable when tailored to patient needs, questioning the need for rigid guidelines.