Broken or bruised ribs

What are rib injuries?

Rib injuries include bruising a rib or the muscles surrounding or between the ribs. They also include rib fractures- a break in one or more of the rib bones.

Children and babies are less likely to break ribs because their bones are more elastic. So, if a young child or baby has a rib fracture, it is very important to know what caused the injury. If there is no clear cause, the possibility of child abuse should be considered.

How long do rib injuries take to heal?

Broken (fractured) or bruised ribs often heal in about six weeks. However, the recovery time may be longer, especially for displaced fractures (when the broken ends of the rib no longer line up with one another). It is unusual to have pain persisting beyond 3 months and medical advice should be sought in this case.

What do bruised or broken ribs feel like?

Ribs that are broken (fractured ribs) are usually:

• Painful, particularly with movement, deep breaths, or coughing.

• Tender when pressed.

How are broken or bruised ribs diagnosed?

Usually, a broken or bruised rib diagnosis is made from the details given to a doctor (history) plus an examination. The chest wall will usually be inspected for swelling, redness or bruising, examined for tenderness and the chest listened to with a stethoscope The diagnosis usually based on this. A chest X-ray is not required unless there are suspected complications (detailed below).

If a broken rib is suspected, the main purpose of a chest X-ray is to look for complications rather than to diagnose the fracture itself. X-rays are not used unless necessary because of the radiation involved and because the treatment is the same for both broken and bruised ribs. This especially applies to women who are, or who may be, pregnant.

How to treat broken or bruised ribs

The most important treatment is to have good pain relief

Good pain relief for broken or bruised ribs is important as it helps to enable normal breathing and coughing. Simply putting up with the pain is not a good idea, as it can lead to taking shallow breaths which increases the risk of developing chest infections. (See the 'Complications' section below) . Painkillers help to prevent these problems.

Effective and safe pain relief is especially important for people who are more prone to chest infections. This includes, for example, smokers and people with persistent (chronic) chest conditions such as chronic obstructive pulmonary disease (COPD) or heart failure.

What pain relief should I use?

Three types of painkillers can be used:

• Paracetamol.

• Non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen, diclofenac, ibuprofen or aspirin.

• Strong painkillers containing codeine or dihydrocodeine.

How should I take the painkillers?

For painful rib injuries, it is best to take painkillers regularly without waiting until the pain becomes severe. As the ribs heal, the dose of the painkillers should be reduced. General advice is:

• For mild-to-moderate pain, take paracetamol.

• For moderate-to-severe pain, take paracetamol OR codeine OR paracetamol plus an anti-inflammatory painkiller. You can take paracetamol and codeine together, but studies suggest the resulting pain relief is not much better than taking one or other alone.

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?

Paracetamol is not likely to cause side-effects. Codeine and dihydrocodeine may cause drowsiness or constipation.

For constipation, standard laxatives (bought over the counter) can be used such as:

• Senna tablets.

• Lactulose.

• Fibrogel.

Diet and lifestyle changes, alongside any medication, can help. These include:

• Increasing fruit intake.

• Increasing fibre.

• Increasing the amount of water drunk.

• Increasing the amount of exercise - even just walking.

It is important to treat constipation promptly because straining worsens rib pain. Codeine can be continued, together with enough laxative to relieve the constipation. Codeine can cause drowsiness in some people - driving should be avoided if affected and the dose reduced.

Anti-inflammatory painkillers (such as naproxen or ibuprofen) can cause stomach ulcers or stomach inflammation (gastritis). 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 painkillers if also taking anti-clotting medicines such as warfarin, heparin or similar medication.

Before taking anti-inflammatory painkillers, take advice from a pharmacist or other healthcare professional if:

• You are aged over 60 years.

• You have a history of stomach ulcer or stomach bleeding.

• You have a history of heart disease, stroke or peripheral artery disease.

• 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.

A different painkiller may be suggested or a medicine to protect the stomach (for example, omeprazole). Stomach inflammation or ulcers can cause pain in the upper part of the tummy (abdomen). If this occurs then anti-inflammatory tablets should be stopped and medical advice sought.

Black tarry stools, blood in vomit or vomit that looks like coffee grounds could be signs of bleeding from an ulcer. Anyone with these symptoms should attend the Emergency Department at their nearest hospital.

Are there any other treatments?

For severe pain, another option is a nerve block with local anaesthetic near to the injury. This is rarely necessary and is not usually available.

Surgery may be offered if there are multiple rib fractures following major trauma. This may be required if the damage to the chest wall is so severe that the muscles are unable to support the movements of the lungs. It is not usually offered in other circumstances and current evidence suggests that it does not help speed the healing process.

Note:

It is important NOT to wrap a bandage tightly round the chest to support it. Although this may help the pain, it stops the lungs from expanding fully and can lead to pneumonia. It is important that the ribs and muscles are allowed to move normally which is why pain relief is necessary.

What are the complications of broken or bruised ribs?

Most rib injuries heal well with no ongoing problems. Complications can occur if internal organs are damaged by the sharp end of a broken rib.

Pneumothorax

Pneumothorax 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 be suspected from listening to the chest with a stethoscope and can show on a chest X-ray. It may need treatment under local anaesthetic to remove the trapped air.

A pneumothorax is usually noticed soon after the injury. However, it can occasionally occur later, even several days afterwards. It is important to be alert for symptoms such as shortness of breath, increasing chest pain, or pain that is not near the break (fracture) and urgent medical advice should be sought for 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.

Note: anyone who has chest pain associated with difficulty breathing or who feels more breathless than usual needs immediate medical help - call for an emergency ambulance immediately- 999 in the UK - or attend the local Emergency Department.

Surgical emphysema

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.

Tummy (abdominal) injuries

The lower part of the rib cage is near the liver, spleen and kidneys. Rib fractures can cause internal damage to these organs. Symptoms are tummy or back pain (rarely, pain may travel to the shoulder). If there is internal bleeding, this can cause faintness or a feeling of being very unwell. Urgent surgery may be needed.

Chest infections

Rib fractures or bruising often make it difficult to breathe deeply or cough properly due to pain. This can make it difficult to clear mucus in the chest, leading to chest infections. Good pain relief helps to prevent chest infections. (See 'How to treat a rib injury', above.)

Even with good painkillers, some people may develop a chest infection. Medical advice should be sought for symptoms such as cough, high temperature (fever), chest pain, shortness of breath or increasing phlegm (sputum) following a rib injury.

Complications are more likely if the injury involved a large force and if the injured person is frail or has other medical problems. If a complication is suspected, medical advice should be sought.

Frequently asked questions

There are some common questions about broken and bruised ribs people may ask from a GP or search online.

How long should I be off work with a broken rib?

Most people will not need any significant amount of time off work following a simple rib injury. Depending on the nature of the work, some people may need some time off, particularly if the work involves lifting or moving around a lot. If there are multiple rib fractures from a severe injury such as a car accident or fall from a height, then this may require a significant amount of time off work.

Why does the pain from a broken rib get worse after the first week?

Sometimes it can feel that pain gets worse before it gets better. The initial pain is often due to the injury itself whereas, as the injured area starts to heal, it becomes inflamed as part of the healing process. This can feel more painful than the injury itself did.

Pain can also feel worse because people are trying to get back to normal activities too soon or because they have reduced their painkillers too soon and need to restart them.

Can you break a rib from coughing?

Rib injuries can occasionally be caused by coughing or straining. This is more likely if there is weakness of the ribs such as occurs with 'thinning of the bones' (osteoporosis) or other disease in the bone.