The American Journal of Surgery (2013) 205, 511-516

North Pacific Surgical Association

Prolonged pain and disability are common after rib

fractures
Loic Fabricant, M.D., Bruce Ham, M.D., Richard Mullins, M.D., John Mayberry, M.D.*

Division of Trauma, Critical Care, & Acute Care Surgery, Department of Surgery, Oregon Health & Science University,
L611, 3181 SW Sam Jackson Park Road, Portland, OR 97239

KEYWORDS: Abstract
Rib fracture; BACKGROUND: The contribution of rib fractures to prolonged pain and disability may be underap-
Thoracic trauma; preciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures
Chronic pain; resolves in 6 to 8 weeks.
Disability METHODS: This study was a prospective observation of 203 patients with rib fractures at a level
1 trauma center. Chest wall pain was evaluated by the McGill Pain Questionnaire (MPQ) pain rating
index (PRI) and present pain intensity (PPI). Prolonged pain was defined as a PRI of 8 or more at 2
months after injury. Prolonged disability was defined as a decrease in 1 or more levels of work or func-
tional status at 2 months after injury. Predictors of prolonged pain and disability were determined by
multivariate analysis.
RESULTS: One hundred forty-five male patients and 58 female patients with a mean injury severity
score (ISS) of 20 (range, 1 to 59) had a mean of 5.4 rib fractures (range, 1 to 29). Forty-four (22%)
patients had bilateral fractures, 15 (7%) had flail chest, and 92 (45%) had associated injury. One hun-
dred eighty-seven patients were followed 2 months or more. One hundred ten (59%) patients had pro-
longed chest wall pain and 142 (76%) had prolonged disability. Among 111 patients with isolated rib
fractures, 67 (64%) had prolonged chest wall pain and 69 (66%) had prolonged disability. MPQ PPI
was predictive of prolonged pain (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4 to 2.5),
and prolonged disability (OR, 2.2; 95% CI, 1.5 to 3.4). The presence of significant associated injuries
was predictive of prolonged disability (OR, 5.9; 95% CI, 1.4 to 29).
CONCLUSIONS: Prolonged chest wall pain is common, and the contribution of rib fractures to dis-
ability is greater than traditionally expected. Further investigation into more effective therapies that pre-
vent prolonged pain and disability after rib fractures is needed.
Ó 2013 Elsevier Inc. All rights reserved.

Rib fractures are responsible for a substantial portion of

Supported by a grant from the Medical Research Foundation of Ore-
gon.
John C. Mayberry, M.D. has disclosed consultant fees and honoraria of
less than $10,000 over the past 5 years from Acute Innovations, LLC.
Presented at the 99th Annual Meeting of the North Pacific Surgical
Association, November 9–10, 2012, Spokane, WA.
* Corresponding author. Tel.: 11-503-494-5300; fax: 11-503-494-
6519.
E-mail address: mayberrj@ohsu.edu
Manuscript received November 7, 2012; revised manuscript December
26, 2012
injury-related morbidity in the United States.1,2 Patients
sustain rib fractures in circumstances that range from
ground- level falls to motor vehicle crashes to industrial
or work-related incidents, and they experience a spectrum
of outcomes, from a temporary need for pain medication
to prolonged and significant disability.3–7 As the number
of fractured ribs increases, a patient’s risk for undesired
outcomes is increased not only because of other serious in-
juries but also because of the respiratory complications that

0002-9610/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2012.12.007
512
are a direct consequence of the pain and impaired capacity
to ventilate.1,8,9 Patients with multiple rib fractures or a flail
chest may require mechanical ventilation and are at risk for
death.
Current inpatient therapy for rib fractures consists of
nonoperative measures that control pain and enable the
patient to ventilate. Multiple prospective clinical trials have
reported the benefits of aggressive in-hospital pain control
and respiratory therapy.10,11 Outpatients are counseled to
keep their pain under control, to cough and breathe deeply
to prevent the development of pneumonia, and to expect
their rib fractures to heal and become relatively pain free
in 6 to 8weeks. However, few prospective studies have val-
idated this oft-quoted expectation. With this prospective ob-
servational trial of patients with rib fractures we sought to
establish evidence-based pain and disability expectations
and to determine acute injury characteristics that may be
associated with prolonged rib fracture pain and disability.
Methods
All injured patients evaluated in the Oregon Health &
Science University (OHSU) emergency department or inpa-
tient units from July 2005 to January 2008 were screened for
rib fractures. Patients with rib fractures confirmed by radi-
ologist interpretation of plain films or computed tomo-
graphic scan were contacted for enrollment within 14 days
of injury. Exclusion criteria included patients 15 years or
younger, non–English-speaking patients, patients deter-
mined by the investigators as being unlikely to be able to
report pain levels or complete the survey instruments at
60 days (eg, patients with severe head injury, dementia, or
delirium), and patients not expected to survive 60 days after
injury. Patients or their legally authorized representatives
provided informed consent for participation. The Oregon
Health & Science University Institutional Review Board
approved and monitored the conduct of this study.
At study entry, the age, sex, race or ethnicity, preinjury
work status (employed, unemployed, retired), preinjury
functional status (physical labor, nonphysical labor, dis-
abled), and preinjury level of activity (vigorous, moderately
active, ambulatory, sedentary, or requires care) were deter-
mined. Pre-existing comorbidities were recorded and the
Charlson comorbidity index was calculated.12 Associated
injuries and their corresponding organ injury scale (OIS)
were recorded and the injury severity score (ISS) was cal-
culated. The number of rib fractures, bilaterality of rib frac-
tures, the chest wall region where the majority of the rib
fractures were located (anterior, lateral, posterior), the pres-
ence of flail chest, the need for mechanical ventilation, and
the use of epidural pain control and lidocaine patches were
also recorded. The McGill Pain Questionnaire (MPQ) was
administered to patients who were able to communicate
within 7 to 14 days after injury. The MPQ is a validated in-
strument designed to provide quantitative measurements of
subjective pain that can be treated statistically. Twenty
The American Journal of Surgery, Vol 205, No 5, May 2013
questions of pain descriptors are asked of the patient
from which the pain rating index (PRI) is calculated.13
Values ranging from 0 to 50 are possible. The present
pain intensity (PPI) is based on a scale of 0 to 5 and is cal-
culated from a single question of 6 pain descriptors. The
types of analgesics received by the patient in the 24 hours
before administration of the MPQ were recorded.
At 2 months (65 days), participants were seen in person
or contacted by phone to complete another MPQ. The types
of analgesics used in the preceding 24 hours were again
recorded. Patients were asked whether they had returned to
employment. Level of activity after injury and functional
status were also determined.
Prolonged chest wall pain was defined as an MPQ PRI
of 8 or greater at 2 months after injury. In our pilot study,
rib fracture pain diminished from approximately 6 of 10 on
day 1 to 2.5 of 10 at 60 days (42% drop).6 Mean acute frac-
ture pain determined by the MPQ PRI was approximately
20 of 50.14 A corresponding decrease of 40% would bring
the expected PRI to 8. Prolonged disability was defined as a
decrease in 1 or more levels of work or functional status at
2 months.
The patient demographic, injury, and pain characteristics
listed earlier were evaluated with univariate analysis (chi-
square or t test) to determine associations with prolonged
chest wall pain or disability. Variables with a P value of
.2 or less were selected for inclusion in a multivariate anal-
ysis to determine independent associations with prolonged
pain or disability. Among variables with significant covari-
ance, only 1 variable was chosen to include in the model.
Odds ratio (OR) and 95% confidence interval (CI) were cal-
culated and a P value less than .05 was chosen to indicate
statistical significance. Subset analysis for patients with iso-
lated rib fractures (no associated injuries with an OIS R3)
was repeated as described earlier.
Results
One hundred forty-five male patients and 58 female
patients with a mean ISS of 20 (range, 1 to 59) had a mean
of 5.4 rib fractures (range, 1 to 29). Forty-four (22%)
patients had bilateral fractures, 15 (7%) had flail chest, and
92 (45%) had 1 or more associated injuries with an OIS of 2
or more. The region of the chest wall with the most rib
fractures was posterior in 50%, lateral in 26%, and anterior
in 24% of patients.
Race and ethnicity included white non-Hispanic (191
patients [94%]), Native American (7 patients [3%]), His-
panic (3 patients [1%]), and black non-Hispanic (1 patient
[,1%]). One hundred fifty-two participants (75%) were
employed, 27 (13%) were unemployed, and 23 (11%) were
retired at the time of injury. One hundred four (51%)
reported a vigorous activity level, 66 (33%) a moderate
activity level, 24 (12%) an ambulatory activity level, and 8
(4%) a sedentary or ‘‘requires care’’ activity level. Func-
tional status reported included physical labor (122 patients
L. Fabricant et al. Prolonged pain and disability after rib fractures
[60%]), nonphysical labor (67 patients [33%]), and disabled
(13 patients [6%]). The Charlson comorbidity index was 0
in 79%, 1 in 8%, 2 in 7%, 3 in 3%, and 4 or more in 2% of
patients (range, 0 to 7).
One hundred ninety-three (95%) patients were admitted
as inpatients and stayed for more than 24 hours. Mean
length of stay was 8.3 days (range, 0 to 56). Mean length of
stay in the intensive care unit was 3.8 days (range, 0 to 33).
Fifty (25%) patients required mechanical ventilation. Ep-
idural analgesia was used in 18 (9%) patients. Lidocaine
patches were used in 29 (14%) patients. Chest wall MPQ
PPI and MPQ PRI on enrollment (9 6 2 days after injury)
were a median of 3 (range, 0 to 5) and a mean of 28 6 16
(range, 0 to 70), respectively. Table 1 lists the types of an-
algesics received by the patient in the 24 hours before en-
rollment. Twenty-two percent of patients received 2 or
more specific opioids (morphine, hydromorphone, hydroco-
done, or fentanyl) or received opioids by different routes of
administration simultaneously (intravenous, oral, or patch),
or both. No patient received paravertebral or intercostal
nerve blocks and none had surgical rib fracture fixation.
Eighty-six percent of patients were discharged home and
14% were discharged to a skilled nursing facility or other
acute care facility. There were 5 deaths, all occurring after
discharge. Four patients died of complications relating to
their injuries and comorbidities, and 1 patient died from in-
juries suffered in a subsequent motor vehicle crash.
One hundred eighty-seven (92%) patients were followed
for 2 months. Chest wall MPQ PPI and MPQ PRI at 2
months were a median of 1 (range, 0 to 5) and a mean of
10.6 6 10.9 (range, 0 to 44), respectively. Table 1 lists the
types of analgesics taken by the patient in the 24 hours be-
fore the 2-month MPQ. Nineteen percent of patients took 2
or more specific opioids orally and 5% of patients were us-
ing a fentanyl patch. One hundred ten patients (59%) had
prolonged chest wall pain and 142 (76%) had prolonged
disability. In univariate analysis, the following acute patient
characteristics were associated with prolonged chest wall
pain: enrollment MPQ PPI and MPQ PRI, preinjury func-
tional status, ISS, number of rib fractures, bilateral rib frac-
tures, and associated injuries. The following characteristics
Table 1 Percent use of various medications at enrollment and 60 days after injury for all patients and for those with isolated rib
fractures (no significant associated injuries)
All patients (%)
Medication Enrollment* 60 d
Opioids 89 66
Acetaminophen 55 33
NSAID 25 26
Lidocaine patch 19 14
Gabapentin/pregabalin 4 5
Benzodiazepine 4 3
Antidepressant 4 4
NSAID 5 Nonsteroidal anti-inflammatory drug.
*7–14 days after injury.
513
were associated with prolonged disability: enrollment MPQ
PPI, ISS, number of rib fractures, bilateral rib fractures, and
associated injuries. In multivariate analysis, enrollment
MPQ PPI was independently predictive of prolonged pain
(OR, 1.8; 95% CI, 1.4 to 2.5) and prolonged disability
(OR, 2.2; 95% CI, 1.5 to 3.4), and the presence of associ-
ated injuries was independently predictive of prolonged dis-
ability (OR, 5.9; 95% CI, 1.4 to 29).
Among 111 patients with isolated rib fractures, chest
wall MPQ PPI and MPQ PRI at enrollment were a median
of 3 (range, 0 to 5) and a mean of 31 6 14 (range 0 to 70),
respectively. One hundred four (94%) patients were fol-
lowed 2 months or longer. Chest wall MPQ PPI and MPQ
PRI at 2 months were a median of 1 (range, 0 to 5) and a
mean of 11.3 6 10.9 (range, 0 to 42), respectively. Sixty-
seven (64%) patients had prolonged chest wall pain and 69
(66%) had prolonged disability. In multivariate analysis,
enrollment MPQ PPI was independently predictive of
prolonged chest wall pain (OR, 1.6; 95% CI, 1.1 to 2.3)
and enrollment MPQ PPI (OR, 3.2; 95% CI, 1.8 to 6.5) and
ISS were independently predictive of prolonged disability
(OR, 1.2; 95% CI, 1.1 to 1.4).
Comments
Although rib fractures are notoriously painful, the
natural history of rib fracture pain and disability has not
been well studied.6 The expectations that most rib fracture
pain resolves by 8 weeks and that rib fractures contribute
little to long-term disability have never been subjected to
prospective scrutiny. These unvalidated expectations have
been an obstacle to the development of treatments that
might be expected to improve the outcome of patients
with rib fractures. With this prospective observation of a
large number of patients with rib fractures presenting to
the emergency department and inpatient wards of our hos-
pital, we report that significant chest wall pain and overall
disability at or beyond 8 weeks after injury is common.
This is true for patients with and those without significant
associated injuries, indicating that rib fractures themselves
Patients with isolated rib fracture (%)
Enrollment* 60 d
68 31
46 68
35 5
2 3
9 4
4 3
6 1
514
contribute substantially to prolonged pain and disability.
The fact that the most predictive indicator of both pro-
longed pain and disability is the pain intensity within the
first several days after injury is intriguing. These results
mirror the findings of Katz et al15 who found that the sever-
ity of acute pain after thoracotomy predicted long-term
pain after thoracotomy. Surprisingly, none of the traditional
acute injury characteristics, including the number and bilat-
erality of rib fractures, were independently predictive of
prolonged pain or disability.
These results raise some interesting questions. First, are
we doing enough to control pain in the acute phase and if
not how could we do better? Acute pain from injury is a
challenging problem, but fortunately there are several
analgesic modalities available and much progress has
recently been made in identifying more optimal manage-
ment.10 Traditional injury pain control is heavily reliant on
opioid analgesics. Opioids have been extensively studied,
and their benefits and detriments are well described.16 Opi-
oids primarily act centrally and at the spinal cord level to
mute the neurotransmitter response to ascending pain sig-
nals. Common adverse effects of opioids include dysphoria,
pruritus, nausea, constipation, delirium, immune suppres-
sion, and respiratory depression. Also, in an unknown per-
centage of patients, opioids cause hyperalgesia, a
phenomenon in which acute pain intensity increases with
opioid use. Additionally, opioid dependence has become
an alarming public health problem in the United States.
Many researchers and clinicians have thus described dissat-
isfaction with the emphasis on opioids and recommend that
opioids be used only in conjunction with other analgesic
modalities.10
Other medications and modalities available in the clinical
evaluation phase for acute injury pain control include acet-
aminophen, nonsteroidal anti-inflammatory drugs, the anti-
convulsants gabapentin and pregabalin, cannabinoids, topical
lidocaine patch, acupuncture, transcutaneous nerve stimula-
tion, and dietary soy.17–19 Gabapentin, which most likely
works through calcium channel blockade, has an opioid-
sparing effect in acute postoperative pain management.20
The 5% lidocaine patch (Lidoderm, Endo Pharmaceuticals,
Chadds Ford, PA) is associated with a reduction in pain scores
in patients with rib fractures within 24 hours of placement
and, interestingly, a sustained reduction in pain that outlasts
the duration of therapy.19 A randomized trial of the lidocaine
patch failed to show a benefit, but this study was underpow-
ered and the investigators did not use enough patches per pa-
tient.21 Each of these nonopioid medications has a modest
analgesic effect on rib fracture pain individually, but their
more benign safety profile should encourage clinicians to
use them adjunctively to reduce opioid use.
Regional pain control such as epidural catheter analgesia
has shown benefit in several prospective trials but is
frequently not an option for patients with multiple in-
juries.11,22 Contraindications to epidural catheter placement
include thoracic vertebral body or spinal cord injury, coag-
ulopathy, significant brain injury, and the presence of
The American Journal of Surgery, Vol 205, No 5, May 2013
infection; there are numerous relative contraindications as
well. Even in centers with an emphasis on epidural pain
control, a minority of patients with severe rib fractures re-
ceive epidural catheters.11,22 A recent meta-analysis raises
doubts regarding the clinical effectiveness of epidural
pain control for rib fractures in general practice.23
Interest in local anesthetic pain control with the ‘‘caine’’
family of amides and esters has recently resurged. Truitt
et al24 have extensively evaluated continuous intercostal
nerve blockade with local anesthetic instilled through a cath-
eter placed at the bedside in the extrathoracic paraspinous re-
gion directly over the ribs posteriorly. Compared with
historical controls, this modality significantly improved pul-
monary function and pain control and shortened hospital
length of stay. Eighty percent of patients were discharged
home with the catheters in place and returned to the clinic
for removal. No other pain medications were used in 92%
of patients. ‘‘Caine’’ analgesics work through blockade of
the voltage-gated sodium channels within the neuronal cell
membrane.25 By binding to receptors on damaged nerves,
these drugs attenuate abnormal ectopic discharges, and the
transmission of the pain signal is interrupted. Furthermore,
sprouting of abnormal nerve fibers can occur in damaged
nerves, leading to hyperirritability. Lidocaine has been
shown to decrease nerve sprouting in injured nerves.26 It
can thus be theorized that an early emphasis on local anes-
thetic analgesia in the acute phase of injury may stabilize
damaged neurons, encourage neuronal healing, and diminish
neuropathic pain.
Second, if rib fracture pain were better controlled in the
acute phase would patients experience less prolonged pain
and disability? In response to tissue or nerve injury, neurons
in the dorsal horn of the spinal cord and in the brain
become sensitized.27 Sensitized neurons demonstrate de-
creased activation thresholds, increased receptive field
size, and increased spontaneous activity. Inhibitory inter-
neurons that normally regulate the spinal cord response to
excitatory input may also be damaged. These changes are
demonstrated both peripherally and centrally and may per-
sist in the long term, contributing to chronic pain. Modali-
ties such as local anesthetics that block the noxious signals
at their origin may thus diminish sensitization and the risk
of long-term pain.
Third, do differences in pain tolerance account for the
development of prolonged pain? Evidence for individual
predispositions to chronic pain is accumulating.28 The dif-
fuse noxious inhibitory control test administered preopera-
tively to patients undergoing elective thoracotomy was
predictive of chronic post-thoracotomy pain and has been
touted as a diagnostic approach that may allow individually
tailored pain management.29
Fourth, does surgical intervention have a role in acute rib
fracture pain management? Certainly there is evidence that
rib fracture fixation is beneficial in selected patients with
flail chest.30 It is likewise possible that select patients with
multiple displaced rib fractures that would not anatomically
qualify for the diagnosis of flail chest would benefit from
L. Fabricant et al. Prolonged pain and disability after rib fractures
surgical intervention and have less prolonged pain and dis-
ability.31–33 This is a fertile area for study.
Limitations of this study include the inherent heteroge-
neity of this injured populationdincluding patients with
pre-existing disabilities and the elderlydthe confounding
role of associated injuries, and the possibility of potentially
debilitating injuries with an OIS of 2 or less in the isolated
fracture cohort. In addition, we did not screen patients for
pre-existing pain syndromes or narcotic use.
In summary, prolonged rib fracture pain and disability is
common after rib fractures, and the intensity of acute pain
in the several days after injury independently predicts both.
More effective measures for controlling acute pain from rib
fractures are sorely needed. We postulate that an emphasis
on nonopioid medications such as anti-inflammatory
agents, nerve stabilization agents such as gabapentin, and
local anesthetic continuous nerve block may improve acute
pain control and lead to less prolonged morbidity. The role
of surgical intervention in selected patients with more
severe rib fractures to improve pain and disability outcomes
is unknown.
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Discussion
Paul Lin, M.D. (Spokane, WA).
Dr Fabricant and his colleagues did a very elaborate
study evaluating the long-term pain and disability of more
than 200 patients with rib fractures. The 2 subsets of
patients, those with associated trauma and those with
isolated rib fractures, had self-reported disability rates of
76% and 64%, respectively. It would be interesting to know
how this broke down in your different demographics:
preinjury work status, preinjury functional status, and
preinjury activity level. You state that you asked about
return to work status, but this was not reported in your
results. I also find it interesting that despite a very high rate
of self-reported disability, the median present pain intensity
(PPI) at 2 months was only 1, which means half the patients
had mild or no pain and the majority of the remaining half
had only ‘‘discomforting pain’’ as defined by the McGill
Pain Questionnaire (MPQ). I understand that you used a
516
pain rating index (PRI) greater than 8 to define prolonged
pain. I do not have a very good idea of what a PRI of 8
means. A PPI of 1 on a scale of 0 to 5 is easier for me to
comprehend.
There seem to be 2 conflicting statements in your
manuscript that you could perhaps clarify for me. You
state that the number of rib fractures and bilaterality were
associated with prolonged disability, but then you go on
to say that the number and bilaterality of rib fractures
were not independent predictors of prolonged pain and
disability.
The American Journal of Surgery, Vol 205, No 5, May 2013
Your finding that the best predictor of both prolonged
pain and disability is the pain intensity within the first
several days after injury is indeed intriguing as you state.
Does this mean patients who perceive a lot of pain at time
of injury will perceive a lot of pain at 2 months, or do you
imply that if we do a better job of managing the acute pain,
we can reduce the incidence of chronic pain? If the latter is
true, we certainly need to do a better job of pain control
early on, not just for the pulmonary complications we
usually worry about but also to reduce long-term pain and
disability.