Rib Fractures / Blunt Chest Wall Trauma

The fracture is not the problem; the breathing is. Pain splints the chest, the patient stops taking deep breaths, secretions are not cleared, and a pneumonia arrives on day 3 — after the decision that caused it was made on day 0. In the over-65s…

STUMBL score — analgesia is the treatment

The pathway

1 · Look for what else the energy did

First rib, second rib or scapular fracture = high-energy transfer — look for more
Lower ribs (9–12): liver, spleen, kidney underneath
Flail segment — 3+ consecutive ribs fractured in 2+ places, paradoxical movement
Surgical emphysema, tracheal deviation, absent breath sounds — decompress before imaging
Sternal fracture: 12-lead ECG and troponin for cardiac contusion

2 · Score the risk — STUMBL

Age, number of rib fractures, anticoagulant, chronic lung disease, oxygen saturation
11 or more: admit — high risk of pulmonary complications
26 or more: discuss with critical care
Under 11 may go home with a plan, not just a prescription

3 · Analgesia is the treatment, not the comfort

Regular, not as-required — paracetamol plus an NSAID if renal function and bleeding risk allow
Add a strong opioid, titrated, and prescribe an antiemetic and a laxative with it
The target is a deep breath and a cough, not a pain score
Reassess within an hour. Analgesia that has not worked is an escalation, not a rewrite

4 · Escalate to a block early

If pain still prevents deep breathing, ask for regional analgesia — do not keep adding opioid
Serratus anterior and erector spinae plane blocks are the usual options; some units use paravertebral or epidural
Ask anaesthetics or the acute pain team by name and early — the block exists to prevent the pneumonia, so it is worth less on day 3

5 · Prevent the pneumonia deliberately

Physiotherapy from day one, not when the sats fall
Incentive spirometry, sitting upright, and encouragement to cough with the chest supported
Watch for it on day 2–4: rising temperature, new oxygen requirement, falling volumes
Avoid strapping or binding the chest — it reduces expansion and causes the thing you are trying to prevent

6 · Who needs an operation

Flail chest, or failure to wean from ventilation
Severe pain not controlled despite a block
Significantly displaced fractures with chest wall deformity
Refer to the local chest wall injury or thoracic service — fixation is time-sensitive and is generally better within 72 hours

7 · Before they go home

Regular analgesia for at least a week, with a plan to step down rather than stop
Safety-net explicitly: fever, worsening breathlessness or new confusion means come back
Tell them the pain typically peaks at day 2–3 and takes 6 weeks or more to settle, so it feeling worse tomorrow is not a failure

Drugs

Drug	Dose	Route	Notes
Paracetamol	1g QDS	PO/IV	Regular, as the base of everything else. Reduce if under 50kg.
Ibuprofen or naproxen	As per BNF	PO	Only if renal function, bleeding risk and cardiac history allow — and with gastric protection. Genuinely useful for chest wall pain.
Oxycodone or morphine	Titrated	PO/SC	Prescribe an antiemetic and a laxative alongside. Titrate to the ability to cough, and reassess within the hour.
Regional block	Anaesthetic-led	Regional	Serratus anterior or erector spinae plane. This is an escalation to be requested early, not a drug to prescribe.

When to escalate

Flail segment, or paradoxical chest wall movement,Pain preventing deep breathing despite regular opioid — ask for a block now,New oxygen requirement or falling saturations at any point,STUMBL 26 or more — discuss with critical care,First rib, scapular or sternal fracture — high energy, look for the rest

Reference: Battle et al, Emerg Med J 2014 (STUMBL) / NICE NG39 Major trauma

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