Care of Rib Injuries

What are rib injuries and who gets them?

The term 'rib injury' usually means rib fracture - that is, a break in one or more of the ribs. Sometimes the ribs are not broken, but there is bruising of ribs or nearby muscles. Rib injuries occur when there is a force to the chest, such as from a fall, road accident or assault. Rib injuries can also be caused by the force of your own muscles. For example, with severe coughing, straining, or heavy sports. This is more likely if there is weakness of the ribs, such as with osteoporosis (thinning of bones) or other disease in the bone.

Children and babies are less likely to fracture ribs because their bones are more elastic. So if a young child or baby has a rib fracture, it is important to know what caused the injury. If there is no clear cause, the possibility of child abuse should be considered.

How are rib injuries diagnosed?

Usually the diagnosis is made from the history (what you tell a doctor about what happened), plus a doctor's examination. Fractured ribs are painful, particularly with movement, deep breaths or coughing. The injured area is tender when pressed.

Rib fractures may (but don't always) show on a chest X-ray. If a rib fracture is suspected, the main purpose of a chest X-ray is to look for complications rather than to diagnose the fracture itself. Therefore, if complications are not suspected and you are otherwise well then you may not need an X-ray. X-rays are not used unless necessary, because of the radiation involved. This especially applies to women who are, or who may be, pregnant.

What is the treatment for rib injuries?

The most important treatment is to have good pain relief

The fracture or bruise usually heals in about four weeks. Good pain relief during this time will help you to breathe and cough properly. Simply 'putting up with the pain' is not a good idea, because it can lead to shallow breathing, lack of coughing and chest infections (see below). Painkillers help to prevent these problems.

Good pain relief is especially important for people who are more prone to chest infections: smokers and people with chronic chest conditions such as COPD or heart failure.

What pain relief should I use?

Three types of painkillers can be used:

• Paracetamol.
• Codeine-type painkillers, known as codeine, codeine phosphate or dihydrocodeine. They come in different strengths, from 8 to 30 milligrams (mg). Sometimes they are combined with paracetamol as co-codamol or co-dydramol.
• Anti-inflammatory painkillers (also known as NSAIDs), such as ibuprofen or diclofenac. (Aspirin is also a NSAID.)

How should I take the painkillers?

For painful rib injuries, it is best to take painkillers regularly; don't wait till pain becomes severe. As the ribs heal, you can gradually cut down on the painkillers. Your doctor or nurse can suggest which painkillers to use, but general advice is:

• For mild to moderate pain, take paracetamol.
• For moderate to severe pain, take paracetamol plus codeine OR paracetamol plus an anti-inflammatory painkiller, OR take all three.

Always follow the dose instructions on the pack, and do not take more than the dose advised on the pack.

Are there any side-effects of the painkillers which I should know about?

Paracetamol is not likely to give you side-effects.

Codeine and dihydrocodeine may cause drowsiness or constipation. For constipation, you can take standard laxatives such as senna tablets, and/or increase the fruit, fibre and fluid in your diet. It is important to treat constipation promptly because straining worsens rib pain. You can continue taking codeine together with enough laxative to relieve the constipation. If you are drowsy do not drive, and if very drowsy you should reduce the codeine dose.

Anti-inflammatory painkillers (such as ibuprofen, diclofenac or aspirin) can cause stomach ulcers or stomach bleeding. Many people can take them without problems, but some people need to be very careful about taking anti-inflammatory painkillers.

• DO NOT take anti-inflammatory painkilers if you are taking anti-clotting medicines such as warfarin, heparin or similar medication.

Discuss with your doctor or nurse before taking anti-inflammatory painkillers if:

• You are aged over 60.
• You have a history of stomach ulcer or stomach bleeding.
• You have asthma, high blood pressure, kidney disease or may be pregnant.
• You are already taking aspirin (including low-dose aspirin) or clopidogrel.
• You are taking these painkillers for long periods, say, for over two weeks continuously.

Your doctor may suggest a different painkiller or a medicine to protect the stomach. Be aware of the symptoms of stomach ulcer or bleeding, which are: pain in the upper part of the abdomen, lethargy and weakness, or black coloured stools (faeces). If you have any of these symptoms see a doctor urgently.

Are there any other treatments?

For severe pain, another option is a 'nerve block' near the injury.

What about work?

Depending on your job and the severity of the injury, you may need time off work.

What are the complications of rib injuries?

Most rib injuries heal well with no problems. Complications can occur if internal organs are damaged by the sharp end of a broken rib.

Pneumothorax

This occurs if the membrane around the lung is damaged. Air enters and forms a pocket of trapped air around the lung, which squashes the lung. The word 'pneumothorax', means air in the thorax. Symptoms include shortness of breath or pain on breathing - sometimes pain near the shoulder. A pneumothorax can show on a chest X-ray. It may need treatment to remove the trapped air under local anaesthetic.

A pneumothorax is usually noticed soon after the injury. However, it can occur later, even several days afterwards. So be alert for symptoms such as shortness of breath, increasing chest pain, or pain that is not near the fracture. Get urgent medical advice if you have any of these symptoms.

Rarely, a dangerous pneumothorax can occur where air is trapped under pressure. It compresses the lungs and causes increasing difficulty breathing. This is called a 'tension pneumothorax' and is a medical emergency. Anyone who has difficulty breathing or who feels more breathless than usual needs immediate medical help.

Air under the skin

A sharp fractured rib can let air from the lung get in underneath the skin. This causes a swollen or bubbly area which may crackle when pressed. It is called 'surgical emphysema'. It will clear up gradually. Surgical emphysema can sometimes be linked to a pneumothorax (see above), and the pneumothorax may need treatment.

Haemothorax

This is similar to a pneumothorax except that there is blood, not air, trapped around the lung. The blood collects at the base of the lung, so may cause shortness of breath or pain in the lower part of the chest. It is treated by draining off the trapped blood under local anaesthetic.

Abdominal injuries

The lower ribs are near the liver, spleen and kidneys. Rib fractures can cause internal damage to these organs. Symptoms are pain in the abdomen or back (rarely pain may travel to the shoulder). If there is internal bleeding then you will feel faint or very unwell. Urgent surgery is needed.

Chest infections

Rib fractures which are painful make it difficult to breathe deeply or cough properly. This can make it difficult to clear mucus in the chest, leading to chest infections. Good pain relief for rib fractures helps prevent chest infections (see under treatment).

Even with good painkillers, some people may get a chest infection following a rib injury. If you have symptoms such as cough, fever, chest pain, shortness of breath or increasing sputum (phlegm), see a doctor urgently.

Complications are more likely if the injury involved a large force, and if the injured person is frail or has other medical problems. If you suspect a complication, get urgent advice.