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

Rib fractures will vary in extent and pattern and therefore, it is useful to be able to objectively capture this information for each patient. The fracture information, within a clinical patient context can give us a better idea of the risk of complications and help guide management. Rib fractures are commonly described by¹:

• Number of ribs broken
• Unilateral or bilateral injuries
• Position on the rib (anterior, lateral or posterior)
• Displaced or un-displaced
• The presence or absence of a flail segment (clinical or radiological evidence) 

Clinically, a flail chest can be seen as paradoxical chest wall movement in a patient who is breathing spontaneously, whilst radiologically, is the presence of three or more consecutive rib fractures in two or more locations. Mr M did not have evidence of a flail segment; if he had, this would be associated with increased morbidity and a mortality risk of up to 16 %².
 

Risk stratification tools:

There is currently no nationally standardised risk assessment score exclusively for rib fractures. Many trusts across the UK use a system that incorporates the above-mentioned fracture pattern, including the nature of fracture, the presence of associated injuries, age and overall health, specifically chronic lung disease and use of anti-coagulants; the presence of which instantly puts patients at higher probability of serious complications following chest wall trauma.  This can then be turned into, most commonly, a rib fracture score (RFS), RibScore, or chest trauma score (CTS) to help triage patients into a category that can help guide management.
The RFS score has a score of 3-6 = minor, 7-10 = moderate, 11-15 = severe and 16 or higher = critical. Mr M scored 4 on presentation to ED, placing him in the minor category, so in the first instance, regular simple analgesia, including a weak opioid, is recommended with PRN opioid such as Oramorph. Following further imaging and examination, he was escalated to the 'severe' category due to the presence of pulmonary contusions. Furthermore, his history of poor sleep and compromised chest wall movement, limiting him to shallow breathing and weak cough leads you to explore other options.

• What else can you offer Mr M for his pain?