Chest trauma and fractured ribs

Causes of chest wall injuries include fractured (broken) ribs, chest wall bruising, fractured sternum (breast bone) 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 long term cough.

Each person’s experience of pain is personal and different, even with the same illness or condition. 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.

Although it is not always possible to completely get rid of your pain, you should be comfortable.

If you have problems with pain after you leave hospital, for the first 3 days you can contact your ward on the number you have been given, after 3 days please contact your General Practitioner (GP).

If your pain is well controlled you get better more quickly and may even mean that you get home sooner.

If you try to avoid coughing or taking deep breaths because of being in pain you are more likely to develop a chest infection and become even more unwell. This is why pain relief is one of the most important parts of your treatment. 

The nurses on the ward will ask you regularly if you have any pain and how bad it is. 

If you have pain at any other time, or the pain will not go away, it is important that you tell the nursing staff.

Paracetamol is a very effective pain medication when taken regularly and can reduce the amount of strong pain medication you will need. It rarely causes any side effects when taken in normal doses.

NSAIDs are very effective for mild to moderate pain. They should be taken regularly and can be given as a tablet or as a suppository into your rectum (back passage). Ibuprofen modified release (MR) is sometimes given before surgery.

Occasionally NSAIDs can be given into your vein through a drip. There are several non-steroidal anti-inflammatory drugs used in the hospital, ibuprofen (also known as Brufen or Nurofen) and diclofenac are the most commonly used. NSAIDs are given regularly with other pain medication as they reduce inflammation as well as pain. This often reduces the amount of strong pain medication needed.

A common NSAID prescribed by GPs is naproxen. You must not take naproxen with any other non-steroidal anti-inflammatory medication. Sometimes other non-steroidal anti-inflammatory drugs called COX-2 inhibitors are used, the most common being Celecoxib and Etoricoxib.

Side effects of anti-inflammatory pain medication

Most people can have NSAIDs but they can occasionally cause dizziness, sickness and indigestion. If you have had a stomach ulcer in the past, or have problems with your heart, liver or kidneys you may not be able to take NSAIDs. If this is the case we will suggest an alternative. If you develop indigestion whilst taking them please tell the nurse.

Please tell the doctors or nurses straight away if you develop any of these symptoms: 

• black poo
• blood in your vomit
• blood in your urine (wee)
•  not passing urine at all 

Lidocaine patches also help with the pain, these patches contain lidocaine which is a local anaesthetic medicine (numbing medicine). Local anaesthetics are used to temporarily block pain messages travelling along pain nerves.

The patches can be worn day or night, the nurse will apply the patch where the pain is worst. The patch in left place for 12 hours then removed and another patch is applied 12 hours later.

You may be prescribed a weak opioid pain medication in tablet form. The nurse may give you these three or four times a day.

Weak opioids are for moderate pain and when taken, reduces the amount of strong pain medication you will need.

What are the side effects of tramadol, codeine and dihydrocodeine?

Weak opioids can sometimes cause light-headedness and nausea; this can be treated by reducing the dose or with anti-sickness medication and an Acupin (very small acupuncture pin).

Acupuncture has been used for many years to treat lots of different medical problems. More recently, research has shown that using a small Acupin in the wrist is very effective in preventing and treating sickness. Read “Using acupuncture to reduce nausea and vomiting” for more information.

Codeine, dihydrocodeine and tramadol can all cause constipation but this can be treated with laxatives.

Dependence and higher tolerance can happen as a result of repeated use, so we recommend to only use them for a short amount of time. 

Morphine and oxycodone

You may be prescribed morphine or oxycodone whilst in hospital. These come in different forms, such as liquids, tablets (short and long acting) and injections.

Injections are only given to you if you are unable to eat or drink. The injection will be given subcutaneously (sub cut) through a small thin tube called a cannula which is placed in your upper thigh.

Strong opioid medication is for severe pain. If you are experiencing severe pain, tell the nurse who will then assess your pain and give you the pain medication you need.

Strong opioid medication is only recommended for short-term use as they can cause you harm if you take it for a long time.

Side effects of strong pain medications

All pain medications have side effects; opioids can cause drowsiness (feeling sleepy) and sometimes nausea (feeling sick) or vomiting (being sick).

Morphine and oxycodone both cause constipation.

Rare side effects include bad dreams or hallucinations.

Nausea and vomiting can be treated with anti-sickness medication and/or an Acupin.

If you have any of these side effects, please tell your nurse.

Will I become addicted to the pain medication?

Strong opioids, even when prescribed by a nurse or a doctor, have a serious risk of dependence and addiction, especially with long-term use. You will only be prescribed strong opioids for a short time, as long term use of strong opioids is not recommended.

If you are on strong opioids for more than 2 weeks, they should not be stopped suddenly. Strong opioids should be reduced over a period of time to avoid withdrawal problems. Withdrawal symptoms include muscle and bone pain, sleep problems, diarrhoea and vomiting (being sick).

For advice about stopping strong opioid medication, ask your GP.

If you have multiple rib fractures, you may be offered an epidural or a nerve block such as an erector spinae plane block, serratus anterior block or a paravertebral block for pain relief.

When ribs are broken the pain is caused by the nerves around the broken ribs. Epidural and local anaesthetic blocks work by blocking the pain signal travelling along these nerves.

The nerve blocks are given as an injection through your skin to the area where the nerve is, often using an ultrasound machine to identify where the nerves are.

Epidural pain relief is given to you through a small tube which the anesthetist inserts between the vertebrae (bones) of your spine. The tube is then connected to a pump which delivers a set dose of pain relief.

The benefit of an epidural or a nerve block is that they can provide excellent pain relief, reduce nausea and vomiting and improve your ability to take deep breaths, cough and move about in comfort.

If you are offered these types of pain relief the anaesthetist will discuss the benefits and risks of each option, there is also separate information available about epidurals and nerve blocks.

An alternative to an epidural or nerve block would be a PCA.

PCA is a small computerised pump containing strong pain medication, such as morphine or oxycodone and is connected to your drip. There is separate patient information if you have a PCA. 

Yes, pain medication works better if taken on a regular basis before your pain becomes severe. This may be in the first few days after trauma. The aim is to keep your pain under control, not to wait until it is very bad before treating it.

1. Breathe out completely.
2. Hold the mouth piece between your lips making a good seal around it.
3. Keep the device upright and breathe in deeply and ideally with the yellow ball held floating behind the smiling face on the plastic.
4. The physiotherapist will set a target volume with the yellow slider. You will need to ensure you breathe deeply enough for the white piston to reach this.
5. Use every hour throughout the day, taking 3 breaths in each time; leaving a short break between each breath.
6. If pain is stopping you from using it, please ask your nurse for some pain relief.
7. Continue to use the Incentive spirometer every day for 3 weeks once you get home. This will make sure your normal breathing is maintained, then throw the device away with your general household rubbish.
    

Always keep medications in their original packaging and stored/locked away in a safe place. Keep out of sight and reach of children, adolescents and pets. Only take medications that have been prescribed for you and do not share your medications with anyone else.

If you are discharged home on strong opioids please read Opioid medicines and the risk of addiction.

It is illegal to drive whilst taking prescription medication if it impairs your driving ability.

Pain medications such as morphine, oxycodone, tramadol, codeine and dihydrocodeine can all affect the ability to drive safely.

Driving safely is the responsibility of the driver. You should not drive unless you feel completely competent to do so.

Even if you do not feel impaired, you are more likely to suffer a road traffic collision if you are taking strong pain medication like morphine or oxycodone.

More information about drugs, driving and the law is available on Gov.uk.

If you are still experiencing problems with breathing, pain or ability to work 6 weeks after your injury, please contact your GP. If appropriate you may be referred to an Outpatient MSK Physiotherapist.