Rib injuries usually heal themselves in a few weeks. Good painkillers
are important so that you can breathe and cough comfortably while the
injury heals. After a rib injury, if you feel unwell or more breathless
than usual, get medical advice urgently.
This leaflet is for non-severe rib injuries where patients do not
require hospital admission. It does not cover severe or multiple
injuries where in-patient treatment is needed. Injuries with more than
three broken ribs may be the severe type.
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.
References
-
Doty C; Emedicine: Fracture, rib. Updated February 2008.
-
Nadalo, LA; Emedicine: Rib, fractures. Updated January 2008.
Comprehensive patient resources are available at www.patient.co.uk
© EMIS and PiP 2008 Updated: 20 Mar 2008
