Rib injuries
Pain relief is the treatment: it lets patients breathe deeply and cough. Older patients with several fractures do badly.
A 72-year-old woman with COPD tripped at home and fell against the edge of a table. She has pain over the right lower ribs and can't take a deep breath or cough properly. X-ray shows fractures of the 8th, 9th and 10th ribs. SpO₂ 91% on air, RR 24. She takes apixaban for AF. Her daughter wants to take her home.
Can she go home? What are you worried about over the next few days?
- Look for pneumothorax and haemothoraxChest X-ray, ultrasound if trained, examine both sides.
- Lower ribsThink liver (right) and spleen (left): examine the abdomen, check BP.
- Assess riskAge, number of fractures, lung disease, anticoagulants, SpO₂, smoking.
- Analgesia that lets them breathe and coughRegular paracetamol, NSAID if safe, opioid. Nerve blocks for severe pain.
- Breathing exercisesDeep breaths and coughing hourly, holding a pillow against the chest.
- High risk: admitPneumonia is the main killer, days later.
- Low risk: homeAnalgesia, clear advice and return signs.
- Flail segment or paradoxical movement
- Pneumothorax or haemothorax
- SpO₂ below 92% or breathless
- Low BP or abdominal tenderness with lower rib fractures
- Age 65 or over with 2 or more fractures
- Surgical emphysema
- Pneumothorax
- Haemothorax
- Liver or spleen injury
- Pulmonary contusion
- Pneumonia days later
- Thoracic spine fracture
- Under-treated pain
| High risk | Age 65 or over, 3 or more fractures, chronic lung disease, anticoagulants, SpO₂ below 92–95% |
| Flail chest | 2 or more ribs broken in 2 or more places, paradoxical movement: ICU |
| Lower rib fractures (9–12) | Check liver and spleen |
| Paracetamol | 1 g 4 times daily, regularly |
| Ibuprofen | 400 mg 3 times daily with food, if safe |
| Morphine | 5–10 mg orally 4-hourly as needed, or IV titrated in hospital |
| Goal | Able to take a deep breath and cough |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why ribs matter
Rib fractures are painful and, in older people, dangerous. Pain stops deep breathing and coughing, leading to atelectasis, pneumonia and respiratory failure, often 2–4 days after the injury. Good analgesia is the main treatment.
History
- Mechanism: fall, road accident, assault, coughing fit (in osteoporosis).
- Pain on breathing, breathlessness, cough, haemoptysis.
- Age, smoking, COPD or asthma, heart failure.
- Anticoagulants and antiplatelets.
- Abdominal or shoulder tip pain (spleen or liver).
Examination
- ObservationsRR, SpO₂, pulse, BP.
- LookBruising, paradoxical movement (flail), shallow breathing.
- FeelPoint tenderness, crepitus, surgical emphysema.
- Listen and percussReduced breath sounds (pneumothorax, haemothorax), dullness.
- AbdomenUpper quadrant tenderness, signs of bleeding.
- SpineThoracic tenderness.
Who needs admission?
Home with analgesia and breathing advice
- Senior review
- consider observation
- Admit
- strong analgesia, physiotherapy, consider nerve block
The STUMBL score can help estimate risk in blunt chest wall trauma where it is used.
Complications
| Problem | Clues | Action |
|---|---|---|
| Pneumothorax | Reduced breath sounds, surgical emphysema | Chest X-ray; drain if large or symptomatic; tension: decompress |
| Haemothorax | Dullness, low BP | Chest drain, surgical review |
| Flail chest | Segment moving in on breathing in | ICU, analgesia, ventilation support |
| Pulmonary contusion | Worsening oxygenation over 24–48 hours | Oxygen, careful fluids |
| Liver or spleen injury | Lower rib fractures, abdominal tenderness, low BP | CT, surgeons |
| Pneumonia | Fever, cough, rising oxygen need, days later | Antibiotics, physiotherapy |
Pain relief
- Regular paracetamol1 g 4 times daily.
- Add an NSAID if safeIbuprofen 400 mg 3 times daily with food.
- Add an opioidOral morphine or IV in hospital, titrated; watch for sedation in the elderly.
- Still can't breathe or coughNerve blocks (serratus anterior, erector spinae, paravertebral) or epidural by anaesthetists.
Advice for patients going home
- Take painkillers regularly, not just when the pain is bad.
- Take 10 deep breaths and cough every hour while awake, holding a pillow against the chest.
- Don't strap the chest.
- Come back if breathless, coughing up coloured sputum, fever, coughing blood, or the pain stops you breathing.
- Fractures take about 6 weeks to heal; pain improves after 3–4 weeks.
Common mistakes
- Sending an elderly patient home with 3 rib fractures and paracetamol only.
- Strapping the chest.
- Missing a liver or spleen injury with lower rib fractures.
- Not reviewing anticoagulants.
- Under-treating pain because of fear of opioids.
Frequently asked questions
What is the treatment of rib fractures?
Good, regular pain relief so the patient can breathe deeply and cough, breathing exercises, and treatment of complications. High-risk patients are admitted.
Why are rib fractures dangerous in elderly people?
Pain limits breathing and coughing, which leads to pneumonia and respiratory failure, often several days after the injury.
How long do rib fractures take to heal?
About 6 weeks. Pain usually improves after 3–4 weeks.
What is a flail chest?
Two or more ribs broken in two or more places, so a segment of the chest wall moves inwards when the patient breathes in. It needs ICU care.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 72-year-old with COPD on apixaban has 3 rib fractures. What is the best plan?
Answer: Admit. Older age, 3 or more fractures, lung disease and anticoagulants make complications likely.
- Discharge with paracetamol: High risk.
- Strap the chest: Worsens breathing.
- Surgery: Not first.
- Bed rest at home: Pneumonia risk.
2. Fractures of ribs 9–11 on the left should prompt a search for which injury?
Answer: Splenic injury. Lower left rib fractures are associated with spleen injury.
- Cardiac tamponade: Less likely.
- Liver injury: Right side.
- Aortic injury: Upper ribs.
- Brachial plexus injury: Upper ribs.
3. After rib fractures, a patient has a part of the chest wall moving inwards on inspiration. What is this?
Answer: Flail chest. Two or more ribs broken in two or more places cause paradoxical movement; ICU.
- Normal breathing: No.
- Diaphragm palsy: No.
- Surgical emphysema: No.
- Simple pneumothorax: No paradoxical movement.
4. A man had a chest drain for traumatic haemothorax 5 days ago, but chest X-ray shows a persistent loculated opacity and he has fever. What is the best management?
Answer: VATS evacuation. Retained haemothorax (> 300–500 mL residual clot after drainage) risks empyema and fibrothorax. Early VATS (within 3–7 days) evacuates clot and improves outcomes; intrapleural fibrinolytics are an alternative. Late fibrothorax requires decortication.
- Second blind chest drain: A blind drain is ineffective for clot.
- Observe for 6 weeks: Waiting risks fibrothorax and empyema.
- Antibiotics alone: Antibiotics do not remove clot.
5. After a stab wound, a chest drain in the right 5th ICS immediately drains 1600 mL of blood. The patient remains hypotensive. What is needed?
Answer: Thoracotomy. Massive haemothorax: > 1500 mL immediate drainage or > 200 mL/h for 2–4 hours, or ongoing transfusion needs — indications for thoracotomy. Resuscitate with blood products. Most haemothoraces (~85%) are managed with a chest drain alone. Retained haemothorax may need VATS to prevent empyema/fibrothorax.
- Clamp the drain: Clamping the drain does not treat bleeding.
- Second chest drain: A second drain does not control the bleeding.
- Observe drainage for 24 hours: More than 1500 mL drained at once needs thoracotomy, not observation.
6. What volume remains in the lungs at the end of a normal quiet expiration?
Answer: Functional residual capacity. Functional residual capacity (FRC) is the volume left after a normal breath out: expiratory reserve volume plus residual volume (about 2.5 L). At FRC, the inward recoil of the lungs balances the outward recoil of the chest wall. Spirometry cannot measure FRC or RV; helium dilution or body plethysmography is needed.
- Residual volume: The volume left after a maximal expiration.
- Expiratory reserve volume: The extra volume that can be breathed out after a normal expiration.
- Tidal volume: The volume of a normal breath.
- Vital capacity: Maximum breath in to maximum breath out.
7. After a road accident, part of a man's chest wall moves inwards when he breathes in. What injury has he most likely sustained?
Answer: Flail chest. When adjacent ribs are each broken in two places, a free segment moves paradoxically: inwards on inspiration and outwards on expiration. The main danger is the underlying lung contusion and hypoxia. Treat with oxygen, good analgesia and ventilation if needed.
- Single rib fracture: Does not produce paradoxical movement.
- Isolated sternal fracture: Does not cause a free segment by itself.
- Tension pneumothorax: Causes tracheal deviation, absent breath sounds and shock.
- Diaphragmatic rupture: Causes bowel sounds in the chest.
References and dose sources
- NICE NG39 — Major trauma: assessment and initial management
- STUMBL score (blunt chest wall trauma)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.