1439 - Ultrasound-Guided Intercostal and Trigger Point Injections to Treat Chronic Post-Traumatic Rib Pain

A 22-year-old female presented with right mid-back pain 1 month after a fall from a horse. The pain, described as constant and stabbing, intensified with shoulder abduction and inhalation. The exam revealed tenderness to palpation just medial to the scapula around ribs 5 and 6 and pain-limited weakness with right shoulder abduction; neurologic exam was otherwise normal. Bedside ultrasound identified a grade 1 right rhomboid major lesion. Initial management with acetaminophen, ibuprofen, and physical therapy provided only partial relief. MRI of the chest wall 6 months post injury revealed healing fracture deformities of the right posterior 4th and 5th ribs with edema and callus formation, and mild adjacent atelectasis.

The patient underwent an ultrasound-guided right intercostal nerve block at ribs 4-6 and trigger point injections of the right trapezius, iliocostalis, external intercostals, rhomboid major, and latissimus dorsi. This procedure provided 90% pain relief immediately and significant sustained pain relief.

Discussions: Posterior rib fractures may be radiographically occult on CT, especially in early stages. MRI offers improved sensitivity for detecting subacute or healing rib fractures. Persistent pain should be further evaluated with a discussion of interventional procedure options. Intercostal nerve blocks combined with trigger point injections provided therapeutic benefit for our patient and allowed our patient to get back to horseback riding relatively pain-free. While intercostal nerve blocks are commonly used for acute rib fractures, there are fewer treatment modalities available for chronic pain related to rib fractures when conservative treatments fail.

Conclusions: Ultrasound-guided intercostal nerve blocks and trigger point injections should be considered when patients present with chronic pain related to rib fractures. These interventional strategies can allow further and more effective management of chronic post-traumatic rib pain.