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Clinical Practice Keywords Rib fractures/Trauma/Pain

management/Respiratory assessment
Review
Trauma This article has been
double-blind peer reviewed

In this article...
● T he injury characteristics of rib fractures and associated complications
● Why and how to carry out respiratory assessment in this group of patients
● The importance of proactive multimodal pain management

Trauma nursing 2: management

of patients with rib fractures
Key points
Authors Susana Lucena-Amaro is matron, adult critical care unit, Royal London
Rib fractures are Hospital, Barts Health NHS Trust, and honorary lecturer in major trauma, City,
common and can University of London; Parjam Zolfaghari is consultant in intensive care medicine and
be life threatening if anaesthesia, Royal London Hospital, Barts Health NHS Trust, and honorary senior
they are not treated lecturer, Queen Mary University of London.

Each additional rib Abstract Rib fractures are common after blunt trauma to the chest, accounting for
fracture increases 10% of hospital trauma admissions. Complications can be life threatening and can
the risk of death by result from the initial impact, as well as from persistent acute pain impairing the ability
20%, especially in to breathe effectively. Medical management remains largely conservative, and good
older people outcomes rely on expert nursing care in a multidisciplinary team. Nursing care should
focus on effective pain control to improve lung mechanics, prevent atelectasis and aid
Rib fractures are secretion clearance. Evidence shows that nursing interventions, patient monitoring
very painful, limiting and collaborative care are best delivered using standardised care processes with clear
the ability to breathe escalation pathways.
normally and cough
Citation Lucena-Amaro S, Zolfaghari P (2022) Trauma nursing 2: management of
A proactive patients with rib fractures. Nursing Times [online]; 118: 12.
approach to pain

R
management with
multimodal ib fractures are breaks in the to an inability to take deep breaths and
analgesia is key bones of the rib cage. They are cough, resulting in reduced lung volume
very common and account for and impaired gas exchange. These factors
Protocolised care 10-15% of all hospital admis- can lead to the development of pneumonia
with early escalation sions as a result of trauma globally (Peek et and a need for oxygen therapy and help with
in the case of al, 2020), and are associated with signifi- breathing. Other complications include:
respiratory distress cant pain and mortality, particularly in ● Pneumothorax (air in the pleural cavity);
and/or uncontrolled older patients. ● Haemothorax (blood in the pleural
pain is important Ribs are sturdy structures that require cavity);
considerable force to break. The most ● Atelectasis (collapsed lung);
common cause of breakage is a direct blow ● Lung contusion (bruising) (Baiu and
to the chest, often from a car accident or a Spain, 2019).
fall. When this happens, it is likely that
other, more fragile, organs in the body will Anatomy and physiology
also be injured. Age, frailty and conditions, The human skeleton has 24 individual ribs,
such as osteoporosis, can make patients set as 12 pairs. They are divided into three
more prone to rib fractures through rela- main categories:
tively minor mechanisms of injury, such as a ● True ribs (ribs 1-7);
fall from standing; as such, older people are ● False ribs (ribs 8-12);
more vulnerable to rib fractures and their ● Floating ribs, which are part of the false
complications than the general population. ribs (ribs 11-12).
After a rib fracture, pain and altered They form the protective cage of
mechanics of how patients breathe can lead the thorax, where many vital organs

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Clinical Practice
Review

– including the heart and lungs – are evolve over hours and days. Contusions
Fig 1. Anatomy of the rib cage
located. Although fixed into place, ribs do can be especially bad if patients have clot-
allow for some outward movement, and ting disorders or are taking anticoagulants
this helps to stabilise the chest during for underlying conditions. Although not
inhalation and exhalation. The ribs are as immediately life threatening as the
anchored posteriorly to the 12 thoracic ver- complications already noted, lung contu-
tebrae. True ribs then attach anteriorly to sions often interfere with gas exchange
the sternum via costal cartilage (Fig 1). and lead to respiratory failure requiring
The space between each rib is called the oxygen therapy and/or mechanical ventila-
intercostal space; there are 11 intercostal tion. Effective pain control is important
spaces in the thoracic cage filled with inter- for optimising the function of the
costal muscles, arteries, veins and nerves remaining good lung by allowing deep
(Fig 2). Intercostal spaces are important Ribs Costal Sternum breathing and lung expansion.
landmarks for nurses and other health pro- Cartilage
fessionals when they are assessing lung and Breathing mechanics
heart sounds, performing needle decompres- Displaced rib fractures or flail segments
sion, and managing and placing chest drains. drain. Very occasionally, surgical interven- are likely to interfere with normal chest
tion may be required to stop the bleeding. movements or breathing mechanics, hin-
Injury characteristics dering lung expansion and eventually gas
Generally, the ribs that are most vulnerable Haemopneumothorax exchange (Fig 4).
to injury are ribs 7-10 because they are less When both air and blood collect simulta- The position and condition of the
mobile than the 11th and 12th. but any rib neously in the pleural cavity, this is called a broken ribs can also worsen underlying
can be broken. Rib fractures can be: haemopneumothorax (Fig 3). Treatment is lung bruising and lead to chronic pain due
● Simple – hairline fractures or fractures the same, but two chest tubes might be to nerve entrapment. In these cases, sur-
that are not displaced; needed: one towards the apex or top sec- gical rib fixation can be indicated to stabi-
● Complex – multiple fractures or many tion of the lung to drain the air, and one on lise the chest and promote recovery.
displaced fragments in one or more ribs. the lower section to drain the fluid.
When many adjacent ribs are broken into Medical management
multiple pieces, a segment can become Cardiac tamponade In most cases, rib fractures will heal by
free floating because it is separated from Cardiac tamponade happens when fluid, themselves and pain will settle over time.
the chest wall. This is called a ‘flail seg- such as blood from chest trauma, accumu- However, some patients, such as those with
ment’ and is a serious injury, often lates around the heart, impairing its ability multiple fractures or flail chest, will experi-
resulting in difficulty breathing and sig- to contract; it can lead to cardiac arrest if ence severe breathing problems and might
nificant lung contusion. not treated promptly. Treatment with peri- even need advanced respiratory support.
Jagged rib edges or dislodged ribs can cardiocentesis or a thoracotomy is usually Others will remain at risk of developing
pierce the lung (causing a pneumothorax) done in the emergency department or at complications that may cause impaired gas
and other organs, as well as disrupting the the bedside (Stashko and Meer, 2022). exchange and hypoventilation, particularly
intercostal vessels, causing haemothorax those with altered breathing mechanics or
and shock (Su et al, 2019). Lung contusions patients experiencing severe pain.
A lung contusion is a bruise that happens Surgical rib fixation is becoming more
Complications at the time of impact but continues to common in major trauma centres due to
Pneumothorax
A pneumothorax happens when air, either Fig 2. Intercostal spaces containing vessels and nerves
from the damaged lung or an open wound
on the chest wall, is drawn into the pleural Posterior ramus of
cavity; this air can build up in the cavity, spinal nerve Posterior intercostal
causing the lung to collapse (Fig 3). A ten- artery and vein
sion pneumothorax is a life-threatening
emergency that occurs when the accumu-
lated air displaces the mediastinal struc-
tures resulting in cardiovascular collapse Aorta Lateral branches
Intercostal nerve
(Jalota Sahota and Sayad, 2022). Diagnosis of intercostal
is made clinically or by chest X-ray, and Internal thoracic Costal groove nerve and
treatment requires the immediate inser- artery and vein vessels
tion of a chest drain.
Anterior cutaneous Collateral branches of
branch of intercostal nerve and
Haemothorax intercoastal nerve vessels
A haemothorax is similar to a pneumo-
JENNIFER N.R. SMITH

thorax but instead of air, it is blood that Anterior perforating

branches of Anterior intercoastal
collects in the pleural cavity (Fig 3). Hae- intercostal vessels artery and vein
mothorax can be diagnosed with a chest
X-ray and treated with a large-bore chest

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Clinical Practice
Review

Fig 3. Pneumothorax, haemothorax and haemopneumothorax

Normal lung Collapsed lung

Air
Air Blood

Blood

Pleural cavity

3a. Pneumothorax 3b. Haemothorax 3c. Haemopneumothorax

the development of new, less-invasive sur- patients can influence triage at the scene; circulation, disability, exposure, further
gical techniques and metal implants. How- as a result, they are usually taken to their information, goals) method, as outlined by
ever, this is only performed in a minority local hospitals rather than to a major Cathala and Moorley (2020). The key is to
of patients and, overall, treatment options trauma centre by paramedics. address problems as they are identified,
are mainly conservative. Both nursing and Assessment and care will depend on the before moving to the next letter.
medical treatments are focused on pre- patient presentation and concomitant Respiratory rate and pulse oximetry are
venting and managing the three main injuries, but it will always be focused on key parameters, not only to titrate oxygen
problems resulting from rib fractures: close monitoring of respiratory function therapy, if it is needed, but also to increase
● Hypoventilation due to pain; and effective pain control. It is also impor- monitoring and escalate concerns, as dic-
● Impaired gas exchange in a damaged tant to understand the potential for deteri- tated by early warning scoring systems.
lung underlying the fractures; oration and be able to identify and escalate Normal oxygen saturation levels are
● Impaired breathing due to altered chest red-flag symptoms, including: 94-98%; if the patient has chronic obstruc-
wall mechanics (seen in flail chest, Fig 4). ● Respiratory distress – characterised by tive pulmonary disease, the normal range
shallow or fast breathing using is 88-92% (O’Driscoll et al, 2011). It is impor-
Nursing care accessory muscles; tant to document whether the patient is
Nurses have a central role in the management ● A drop in oxygen saturation; receiving supplemental oxygen and how
of patients with rib fractures. Many patients ● Tracheal deviation; much, alongside the saturation readings.
can be safely managed on the ward with good ● Unresolved chest pain that leaves the Oxygen-flow rates should be adjusted to
nursing care. This involves effective respira- patient unable to take deep breaths; maintain target saturation levels; care
tory management, pain assessment and anal- ● Tachycardia; must be taken to avoid administering
gesia, to aid physiotherapy treatment and ● Low blood pressure (Cathala and excess oxygen. Nurses should be mindful
help prevent admissions to critical care. Moorley, 2020; Munroe and Curtis, 2011). of the factors that can lead to inaccurate
Recent studies suggest that patient outcomes oxygen saturation readings, such as bright
are improved if these interventions take place Respiratory assessment lights, false nails, nail polish or reduced
as part of protocolised care (Witt and Bulger, Nurses need to be able to carry out a com- peripheral perfusion.
2017; Sahr et al, 2013). Bundles of care for prehensive respiratory assessment as part The chest should be observed for une-
patients with rib fractures include algo- of a routine patient assessment; they should qual expansion and increased work of
rithms that feature nurses, physiotherapists follow a standardised, structured approach, breathing, which is usually manifested by
and medical staff prescribing analgesics and such as the A-G (airway, breathing, the use of accessory muscles. Pursing of
aiding mobilisation, and following standard-
ised observations that may trigger escala- Fig 4. Inspiration and expiration with a flail segment
tions of care automatically.
Most patients with significant rib frac-
tures are admitted to general wards or
trauma units at their local hospital. Those Inspiration Expiration
with more severe injuries are transferred
to major trauma centres for management
of their chest injuries and other concomi-
tant injuries.
Older patients can sustain serious inju-
ries, including rib fractures, through low- Flail segment
energy falls, and make up an increasing
number of admissions to hospitals (Kehoe
JENNIFER N.R. SMITH

et al, 2015). What may seem to be a minor

injury to a young person can have pro-
found effects on older patients. The less
severe mechanisms of injury on older

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Clinical Practice
Review

Table 1. Analgesic management algorithm used by the Royal London Hospital’s critical care team
(specific to the management of chest trauma or rib fractures)
Level of Analgesics Side-effects Nursing management
pain
Tier 1 ● Paracetamol given regularly ● NSAIDs – risk of gastric ulcer and ● Regular pain assessment
Mild ● NSAIDs given regularly bleed, kidney injury and documentation, both
● Weak opioid: codeine/tramadol (oral) if ● Opioids – drowsiness and respiratory at rest and with
kidney function is normal depression, nausea, vomiting movement
● Strong opioid: oral morphine (5-20mg) every ● Use standard scoring
2-4 hours or oxycodone 5-10mg every 4 hours system to allow for
(oral), as required for breakthrough pain comparison between
Tier 2 ● Refer to the acute pain team ● Drowsiness with higher risk of falls/less
assessors
● Regional anaesthesia
Moderate ● Paracetamol with or without NSAIDs plus: mobility
● Intravenous morphine: 1-2mg boluses ● Nausea – all meds listed should always
requires trained nursing
or PCA be prescribed with antiemetics staff to provide hourly
● PCA morphine with background infusion ● Respiratory depression and risk of
observations
● Pain relief is adequate
or fentanyl if renal impairment atelectasis through poor lung
● Gabapentin or pregabalin as adjuncts for expansion when:
● The patient can take
neuropathic pain ● Constipation
deep breaths and
Tier 3 ● Refer to the acute pain team ● Hypotension and bradycardia (related
cough
Severe ● Paracetamol with or without NSAIDs plus to thoracic epidural only) ● The patient is
regional anaesthesia with: ● Itching
comfortable mobilising
● Thoracic epidural (gold standard) ● Headache, dizziness
in bed
● Paravertebral or chest-wall nerve blocks ● Numbness
● Pain scores are >4/10
● Intrapleural block if no other option ● Systemic toxicity (very rare)
available and chest drain present
NSAID = non-steroidal anti-inflammatory drug; PCA = patient-controlled analgesia.
Source: Parjam Zolfaghari

the lips or flaring nostrils also indicate severity of pain (Galvagno et al, 2016). complications. Patients with thoracic epi-
increased work or difficulty breathing. The key objective is to achieve full pain durals need close monitoring and frequent
Palpation, by placing the hands on the control, with a safe, simple method and no observations to identify potential complica-
patient’s chest, can help nurses feel unwanted side-effects. This is challenging tions, so they must be nursed in critical care
uncleared secretions or signs of surgical in patients with severe chest injuries so, areas or specific trauma ward environments
emphysema (subcutaneous emphysema). often, a combination of methods is needed. with sufficient numbers of trained staff. Par-
Surgical emphysema feels similar to This is known as multimodal analgesia and avertebral blocks and serratus plane blocks
touching bubble wrap or as though there outlined in the World Health Organiza- are all valid alternatives, with better safety
are Rice Krispies™ under the skin, and tion’s (1996) analgesic ladder. Multimodal profiles, although none are likely to cover
occurs when air is trapped in the tissues. analgesia incorporates: the full anatomical extent of the fractures.
Possible causes include surgery or pneu- ● Simple analgesics – such as As a result of the risks and limitations
mothorax, so it is important to communi- paracetamol and non-steroidal of regional pain management methods,
cate these findings clearly to medical staff anti-inflammatory medications, systemic analgesics are often used, either
because a chest drain might be needed. including ibuprofen and diclofenac; as adjuncts to regional analgesia or as a
● Opiates – intravenous infusions or first-line treatment. Opioids are effective
Pain management enteral preparations; at controlling pain but can cause respira-
Even minor rib fractures can be very ● Local or regional analgesia – epidural tory depression, which can be counterpro-
painful because of the large number of catheters or nerve blocks. ductive when the goal is to prevent respira-
nerves surrounding the ribs. Pain control is Hospitals might use different versions tory complications.
the cornerstone of effective management of the pain ladder, depending on local pref-
of rib fractures as it enables the patient to erences and medicine supply but, in gen- Pain assessment
cough, breathe deeply and withstand phys- eral, all follow similar principles. Table 1 Effective pain management relies on accu-
iotherapy to prevent chest infections. As shows the analgesic management algo- rate and timely pain assessments to ensure
ribs move with every breath, it is impos- rithm used by the Royal London Hospital’s early escalation along the ladder. When
sible to rest the injured area, making rib critical care team. assessing pain, it is important to do so
pain difficult to manage. Patients in pain In severe chest injuries with multiple both when the patient is at rest and moving
tend to take shallow breaths, increasing the fractures, a thoracic epidural is the most (known as dynamic pain assessment) to
risk of developing atelectasis and pneu- effective way to treat pain. However, this ensure analgesia is effective enough to
monia, which have been directly correlated approach requires advanced medical and enable deep breathing and physiotherapy
with the number of rib fractures and nursing management to avoid treatment. It is also essential to use a pain

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Clinical Practice For more articles

on accidentandemergency, go to
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scoring tool to standardise the assessment Conclusion patient assessment: a step-by-step guide. Nursing
Times [online]; 116: 1, 53-55.
and ensure objectivity. Rib fractures are common in trauma. The Galvagno Jnr SM et al (2016) Pain management
Pain scales are often numerical because number of ribs fractured is directly related for blunt thoracic trauma: a joint practice
using numbers is an effective way of meas- to the risk of complications and mortality, management guideline from the Eastern
uring the response to treatment. In areas Association for the Surgery of Trauma and Trauma
particularly in older people.
Anesthesiology Society. The Journal of Trauma and
such as critical care, where patients are Nurses have an important role in the Acute Care Surgery; 81: 5, 936-951.
unconscious or unable to communicate, management of patients with rib fractures. Jalota Sahota R, Sayad E (2022) Tension
pain scales include a range of physiological Continuous respiratory and pain assess- Pneumothorax. StatPearls Publishing.
Kehoe A et al (2015) The changing face of major
and observed parameters, such as heart rate, ment identifies patients who are deterio- trauma in the UK. Emergency Medicine Journal; 32:
respiratory rate, facial tension and calmness. rating or at risk of doing so. Nursing inter- 12, 911-915.
Pain assessments should also include ventions include titration of analgesia, Munroe B, Curtis K (2011) Assessment, monitoring
and emergency nursing care in blunt chest injury: a
monitoring for unwanted effects of the anal- encouragement of frequent coughing and case study. Australasian Emergency Nursing
gesic therapies being given, particularly in deep-breathing exercises, and early mobili- Journal; 14: 4, 257-263.
older people or those who are frail. Many sation – all of which are key to achieving a O’Driscoll BR et al (2011) British Thoracic Society
emergency oxygen audits. Thorax; 66: 734-735.
non-steroidal anti-inflammatory drugs are good outcome in such patients. Peek J et al (2020) Traumatic rib fractures: a
contraindicated or must be used with cau- Prompt and effective analgesia, early marker of severe injury. A nationwide study using
tion in patients with underlying renal mobilisation, close observation and res- the National Trauma Data Bank. Trauma Surgery
impairment. These drugs can increase the piratory support are important when man- and Acute Care Open; 5: e000441.
Sahr SM et al (2013) Implementation of a rib
risk of bleeding and can be contraindicated aging patients with rib fractures and pre- fracture triage protocol in elderly trauma patients.
in trauma patients who have head injuries or venting complications. Local protocols Journal of Trauma Nursing; 20: 4, 172-175.
severe haemorrhage. Opioids are linked to can help to establish early, appropriate Stashko E, Meer JM (2022) Cardiac Tamponade.
StatPearls Publishing.
nausea, constipation and drowsiness, interventions and escalate analgesia Su Y-H et al (2019) Diagnosis and management of
leading to respiratory depression. requirements without delays. NT a trapped lung or diaphragm by fractured ribs:
Nurses need to increase the frequency analysis of patients undergoing rib fracture repair.
BMC Surgery; 19: 123.
of respiratory assessments to make sure ● The next article in this series will consider
Witt CE, Bulger EM (2017) Comprehensive
the use of opioids is not worsening any res- head injuries. approach to the management of the patient with
piratory complications in the patient. multiple rib fractures: a review and introduction of a
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