Case of the Month #35: Analgesia for Rib Fractures by Dr Mariam Latif

Mr M, a 57y old gentleman, presented to the Emergency Department (ED) following a fall earlier that day. It was raining and he slipped down the concrete stairs leading from his flat, landing on his right-hand side. He remained conscious the entire time. He has a medical history of hypertension and diabetes but is otherwise fit, active and independent. His medications include Ramipril and Metformin and he has no known drug allergies.

His main complaint was tenderness over the right side of his chest extending posteriorly to his back, made worse on movement. He was given IV morphine in the ED, followed by oral paracetamol, which provided some relief. 

A subsequent trauma series, including CXR and CT chest/abdomen/pelvis confirmed a small volume right haemo-pneumothorax, which was not amenable to drainage, with posterior lung contusions. There were fractures of the 4th-8th ribs on the right hand side, with right-sided thoracic wall subcutaneous emphysema. There was no flail segment. There was a non-displaced fracture of the right transverse process on the T6 vertebra. All else was clear. 

He remained stable and was admitted to the acute surgical ward for conservative management of his injuries. The next morning, you are called to see him as part of the acute pain team, as he couldn’t lie flat or sleep overnight and despite being prescribed regular paracetamol and ibuprofen on the drug chart, he continues to be in significant pain.

• What specific questions would you like to ask as part of your pain history?

• How can you describe the pattern of rib fractures? 

• Do you know of any scoring systems that consider clinical and anatomical information regarding rib fractures to help stratify risk and guide management?

• How would you optimise his pain management?