Chest trauma and fractured ribs

Chest wall injuries are injuries to the chest wall (the bones, skin, fat and muscles protecting your lungs, including your ribs and sternum) or any of the organs inside the chest.

Causes of chest wall injury include broken (fractured) ribs, chest wall bruising, fractured sternum and muscular sprains. These injuries are often caused by a fall or road traffic collision, but can also occur during contact sports or from having a bad cough.

Pain is the most common symptom of a chest wall injury and will be worse when you take a deep breath or try to cough as breathing involves moving your chest wall.

Often chest injuries are treated conservatively, without invasive care such as surgery. Whilst the body repairs itself, pain is normal to experience. Each person’s experience of pain is different, even with the same illness or condition. Although it is not always possible to completely get rid of your pain, you should be comfortable.

Taking pain relief will help you recover and may mean that you leave hospital earlier. If pain makes you avoid coughing or taking deep breaths, you are more likely to develop a chest infection and become even more unwell, therefore pain relief is the most important part of your treatment.

The nurses on the ward will ask you regularly about any pain you have and how bad it is. If you have pain at any other time, or the pain won’t go away, it is important that you tell the nursing staff.

The treatment you receive will suit your needs. The treatment of your pain will be based on a combination of pain medication. Treating pain this way reduces the amount of strong pain medication you need and helps to reduce the risk of side effects. For most chest wall injuries regular strong pain medication will be enough, but for patients with multiple fractured ribs Epidural pain relief is often required.

Paracetamol

Paracetamol when taken regularly and in normal doses is a useful pain medication and rarely causes any side effects.

Anti-inflammatory pain medication

These can be very effective for mild to moderate pain, and should be taken regularly with or after food. You may be given these in addition to other pain medication. There are several types of anti-inflammatory pain tablets used in the hospital such as ibuprofen (also known as Brufen or Nurofen) and diclofenac.

The benefits of anti-inflammatory pain medication are that they reduce inflammation as well as pain and also reduce the amount of strong pain medication you will need. If you have stomach or kidney problems, or heart failure you may not be able to take anti-inflammatory drugs.

All anti-inflammatory pain medication can cause indigestion. If you develop indigestion whilst taking them please inform your nurse/doctor.

A common anti-inflammatory used by GPs is naproxen, you must not take naproxen with ibuprofen or diclofenac.

Lidocaine 5% patches

Lidocaine patches are a safe and effective method of pain relief for fractured ribs. The patch contains lidocaine 5%, which is a local anaesthetic and is applied directly to the skin over the affected area. The patch should be worn for 12 hours then removed; a new patch can be applied 12 hours later.

You may be discharged with a 5 day supply of lidocaine patches, please be aware your GP will not issue any more of these.

Morphine and oxycodone

You may be prescribed morphine or oxycodone slow-release tablets and/or liquid.

Strong pain medication is given for moderate or severe pain, and is taken for short periods only. If you are experiencing moderate or severe pain tell the nurse who is looking after you.

Morphine and oxycodone can cause slight drowsiness, which is normal. They can also cause constipation if this occurs please inform the nurses as constipation can be treated. Very rare side effects include bad dreams or hallucinations. If these occur, please tell your nurse. Some patients do feel nauseous (feeling sick) which can be treated if this happens.

On the rare occasion you are discharged with a supply of morphine or oxycodone it will be for 5-7 days only, your GP will not issue any more.

Epidural

If you have more than one rib fracture then you may be offered an epidural as a method of pain relief. Epidural pain relief is given to you through a small tube which the anaesthetist inserts between the vertebrae (bones) of your spine. The tube is then connected to a pump which delivers a dose of pain relief. The benefit of an epidural is that it can provide excellent pain relief, reduce nausea and vomiting and improve your ability to move about in comfort.

There is a separate information leaflet explaining in more detail about epidurals.

PCA (Patient Controlled Analgesia)

If you are unable to have an epidural and can’t take oral pain relief you may be given Patient Controlled Analgesia (PCA). Having a PCA means you will be able to give the pain relief to yourself as it will be connected to your drip. The benefit of a PCA is that you are in control and don’t have to wait for the nurses to give you pain medication. There is a separate information leaflet which gives more detail about PCA.

Tramadol, codeine and dihydrocodeine

You may be prescribed tramadol, codeine and dihydrocodeine in tablet form. These pain medications are for moderate pain and can cause slight nausea (feeling sick) but this can normally be treated. They can also cause constipation, if this occurs please inform the nurses as constipation can be treated.

All of these pain medication can occasionally cause light-headedness. Your medical team may reduce the dose or change you to another method of pain relief if this happens.

Yes, pain medication works better if taken regularly, before your pain becomes severe. The aim is to keep your pain under control, not to wait until it is severe before treating it.

It is rare to become addicted when you are taking pain medication to treat pain for a short period of time. If you are on morphine or oxycodone for more than two weeks it must not be stopped suddenly, but reduced slowly by your GP.

It is important to keep mobile and breathe normally; breathing exercises will help to reduce any potential breathing problems.

You will be given a device called an incentive spirometer by one of the chest physiotherapists. This will exercise your lungs and reduce the risk of developing a chest infection or pneumonia.

1. Breathe out completely.
2. Hold mouthpiece between lips making a good seal.
3. Keep the device upright and breathe in deeply and ideally with the yellow ball held floating behind the happy face.
4. The white piston should reach target volume set with the yellow slider by the physiotherapist.
5. Use hourly through the day, 3 breaths in each time.
6. If pain prevents you from using it then ask your nurse for some pain relief.
7. Continue to use for a few days once you get home to make sure you keep breathing normally, and then throw the device away with your general household rubbish.

Keep mobile; you should aim to alternate periods of rest with gentle activity such as walking and making yourself a drink or something to eat.

• don’t stay in bed all day
• do not try to lift anything heavy
• avoid contact sports for at least 4 weeks
• avoid smoking as the risk of getting a chest infection is higher in those who smoke

You will be sent home with a supply of pain medication and for most people, once this supply has finished, then paracetamol will be sufficient.

If you do experience pain despite taking regular paracetamol, and this interferes with your normal activities, then please contact your GP practice.

If 6 weeks after your chest injury, you are still experiencing problems with breathing, pain or the ability to work as before; please contact your GP practice.