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Assessment and management of pain from rib fractures

Created: 14/6/2017
Updated: 25/9/2017

Definition of pain

 An unpleasant sensory and emotional experience associated with potential or actual tissue damage.

Definition of acute pain

Pain that occurs as a result of illness/injury and resolves with healing.

Assessment of acute pain from rib fractures

Patients with multiple rib fractures sustained from high-energy trauma are best evaluated at a trauma centre.


1. History

  • SOCRATES - Nature of injury: significant blunt force trauma
  • Direct correlation between number of ribs fractured and degree of intrathoracic injury [1, 2].

2. Severity score

  • Verbal descriptor scale (VDS): no pain/mild/moderate/severe pain - Numeric rating score (NRS): give pain a score on a scale from 0 to 10
  • Visual analogue scale (VAS): make a mark on a 10 cm line, where 0 = no pain and 10 = the worst pain imaginable
  • Functional activity score: no/mild/significant impairment.
NRS and VAS give more sensitive assessment of pain than VDS [3].


3. Treatment response

  • Treatment methods used
  • Total analgesic consumption
  • Benefits: improvement in pain score, ability to achieve tasks (e.g. physiotherapy)
  • Side effects: nausea, vomiting, constipation, dizziness, confusion.

Management of rib fractures



  • Limited, isolated rib fracture (<3 fractures): outpatient management – oral analgesia + incentive spirometry
  • Hospital admission for any patient with ≥3 rib fractures
  • Consider ICU/HDU admission for elderly patients with ≥6 rib fractures.
There is a significant correlation between the finding of ≥3 rib fractures and serious internal injuries [4, 5].


Main goals of treatment

  • Adequate analgesia
  • Adequate ventilation
  • Stabilisation of chest wall

Pain management

Why is adequate analgesia important?

Poor analgesia:
  • Attempts to minimise chest wall movement
  • Minimal coughing effort: poor secretion clearance
  • Chest wall splinting and alveolar collapse: reduced lung volumes
  • Increased risk of lower respiratory tract infection.
Adequate analgesia:
  • Good cough: good secretion clearance
  • Deep breathing: improved lung volumes
  • Reduced risk of lower respiratory tract infection.
Options for analgesia: 
  • Regional analgesia 
  • Parenteral analgesia 
  • Oral analgesia.
Regional anaesthesia

These techniques may be contraindicated in patients with coagulopathy or multiple trauma (e.g. spinal fractures).

Continuous epidural infusion
  • Thoracic epidural 
  • Associated with a shorter duration of mechanical ventilation [6] 
  • Associated with a reduced incidence of nosocomial pneumonia [6] 
  • Close monitoring required (HDU) 
  • The mortality risk was found to be reduced up to 1 year for patients with ≥3 fractures who had an epidural catheter for analgesia [7].
Paravertebral catheter infusion
  • Unilateral rib fractures 
  • Reduced rate of systemic hypotension 
  • As effective as an epidural for unilateral rib fractures [8, 9].
Intrapleural infusion 
  • Infusion of local anaesthesia into the pleural space 
  • Epidural approach associated with better pain relief [10].
Intercostal nerve block 
  • Limited duration of block 
  • Multiple rib fractures require multiple injections.
Parenteral analgesia

Patient-controlled analgesia with opiates 
  • Timely access to opiates 
  • Reduced risk of excessive sedation
“As needed” (PRN) opiates

Opioid-sparing (paracetamol, non-steroidal anti-inflammatory drug (NSAID), lidocaine)

Oral analgesia 

  • Paracetamol
  • NSAID * caution in patients with coagulopathy ± renal impairment
  • Weak opiates
  • Strong opiates

Operative fixation

Definition of flail chest: fracture of four or more consecutive ribs in two or more places, resulting in paradoxical movement of the chest wall during respiration.

  • Prevent further pulmonary complications 
  • Surgical fixation of rib fractures should be considered as the primary treatment for patients with:
    • Flail segment [9,11, 12]
    • Severe chest wall deformity  pulmonary herniation
    • Symptomatic fracture of ≥3 ribs
    • Failure to wean from mechanical ventilation
    • Chronic pain/disability
  • Use of intermedullary fixation [13–17]


  • Complications:
    • Risk of impingement and chronic pain (proximity to neurovascular bundle)
    • Superficial wound infection
    • Pleural empyema
    • Pleural effusion
    • Osteomyelitis
    • Fixation failure

Other aspects of patient care

Monitoring - Pain score 

  • Pulse oximetry 
  • Spirometry

Fluid management 

  • Judicious fluid resuscitation (limit pulmonary oedema in contused lung) [18]

Deep vein thrombosis (DVT) prophylaxis

  • Trauma patients are high risk for DVT 
  • Coordinate to enable regional blockade

Author: Dr Rebecca Medlock


1. Sirmali M, Türüt H, Topçu S et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24(1): 133–8.
2. Liman ST, Kuzucu A, Tastepe AI et al. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003; 23(3): 374–8.
3. Breivik EK, Bjornsson GA, Skovlund E. A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain 2000; 16(1): 22–8.
4. Easter A. Management of patients with multiple rib fractures. Am J Crit Care 2001; 10(5): 320–7.
5. Sirmali M, Türüt H, Topçu S et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24(1): 133–8.
6. Carrier FM, Turgeon AF, Nicole PC et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2009; 56(3): 230–42.
7. Lyoda A, Satoh N, Yamakawa H et al. Rupture of the descending thoracic aorta caused by blunt chest trauma: report of a case. Surg Today 2003; 33(10): 755–7.
8. Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact Cardiovasc Thorac Surg 2010; 10(1): 92–6.
9. Mohta M, Verma P, Saxena AK et al. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs – A pilot study. J Trauma 2009; 66(4): 1096–101.
10. Karmakar MK, Critchley LA, Ho AM et al. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with unilateral multiple fractured ribs. Chest 2003; 1223(2): 424–31.
11. Luchette FA, Radafshar SM, Kaiser R et al. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma 1994; 36(6): 865–9.
12. Granetzy A, Abd El-Aal M, Emam E, Shalaby A ,Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005; 4: 583–7.
13. Tanaka H, Yukioka T, Yamaguti Y et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002; 52: 727–32.
14. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995; 110: 1676–80.
15. Bottlang M, Long WB, Phelan D et al. Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury 2013; 44: 232–8.
16. Mayberry JC, Terhes JT, Ellis TJ, Wanek S, Mullins RJ. Absorbable plates for rib fracture repair: preliminary experience. J Trauma 2003; 55: 835–9.
17. Marasco SF, Sutalo ID, Bui AV. Mode of failure of rib fixation with absorbable plates: a clinical and numerical modeling study. J Trauma 2010; 68: 1225–33.
18. Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop Relat Res 2000; 371: 216–27

Further reading

Surgical critical care network: surgical fixation of rib fracture guidelines 2013.


You are called to the emergency department to assess a 63-year-old man with known chronic respiratory disease. He has sustained unilateral fractures to his 9th, 10th and 11th ribs but has no other injuries. Paracetamol and codeine phosphate have not provided adequate pain relief.

a) What respiratory problems could result from inadequate pain relief in this patient? (5 marks)
b) How can the effectiveness of his pain relief be assessed? (8 marks)
c) What other methods are available to improve management of this patient’s pain? (7 marks)

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