Rib injury
Simple rib injuries go home with analgesia — high-risk ones don’t.
| If you find… | …then |
|---|---|
| SpO₂ < 92%, breathless, tachypnoeic | Pneumothorax / contusion — ED |
| Age 65+ with 2 or more rib fractures, or chronic lung disease | High risk of pneumonia — ED / admission |
| On anticoagulants with significant chest trauma | Haemothorax risk — ED |
| Flail segment, surgical emphysema, reduced air entry | ED now |
| Pain with no injury / exertional, sweaty | Consider cardiac / PE |
- Mechanism (fall from standing vs high energy)
- Pain on breathing/coughing; breathlessness
- Age, smoking, COPD/asthma, anticoagulants
- Can they cough and take a deep breath?
- Obs incl. SpO₂ and RR
- Chest wall tenderness, crepitus, surgical emphysema, paradoxical movement
- Air entry, percussion
- Abdomen (lower ribs → liver/spleen)
Why analgesia matters
Pain stops deep breaths and coughing, so secretions build up and pneumonia follows, especially in older patients. Good analgesia is the treatment.
High-risk patients
Older age, multiple fractures, chronic lung disease, anticoagulants and low sats each increase complications. Scores like STUMBL help, but if you’re worried, refer.
Rib injury risk
- SpO₂ < 92% or breathless
- Age 65+ with ≥ 2 suspected fractures
- Chronic lung disease
- Anticoagulated
- Abnormal chest examination
Any present: High risk → CXR and ED / admission. None present: Low risk → analgesia and home.
| Investigation | Only if… |
|---|---|
| Chest X-ray | Breathless, low sats, abnormal chest exam, elderly/high-risk, or suspected pneumothorax |
| No X-ray | Young, well, isolated simple rib tenderness — X-rays miss many rib fractures and don’t change management |
Management & advice
- Regular analgesia so they can breathe deeply and cough
- Deep breathing exercises every hour while awake; support the chest with a pillow when coughing
- No strapping or binders
- Stop smoking; expect pain for 3–6 weeks
Refer / follow-up
- High-risk features → ED / admission
- Not improving or worsening breathlessness → urgent review
| Drug | Dose | Duration / notes |
|---|---|---|
| Paracetamol BNF ↗ | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
| Ibuprofen BNF ↗ | 400 mg three times a day with food | 3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy |
| Codeine (if NSAID unsuitable / pain uncontrolled) BNF ↗ | 30 mg up to four times a day | Short course; constipation, drowsiness; avoid in respiratory compromise |
You’ve bruised or cracked a rib. It’s painful and can take 3 to 6 weeks to settle, but it heals by itself. The most important thing is to take the painkillers regularly so you can breathe deeply and cough, which stops a chest infection. Come back or call 999 if you get more breathless, cough up blood, or feel feverish.
Come back / call 111 — or 999 if severe — if:
- Increasing breathlessness, coughing up blood, chest pain getting worse
- Fever, coughing up green/yellow sputum (chest infection)
- Feeling faint or dizzy
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
- Strapping the chest
- Sending home an elderly patient with several fractures
- Missing a pneumothorax
- Under-treating pain
Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.
✎Blank clinic note template
Rib injury — clinic note
Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.