Rib Fracture Non-Union & Chronic Pain After Broken Ribs

Is this you?

Does this match what you’re dealing with?

Chronic pain after a broken rib has a recognisable pattern. Any of the following is worth a proper look:

A familiar pattern

01It is three months or more since you broke a rib and the pain has not gone

02There is a clicking, grinding or moving sensation at the site when you twist, cough, or lie on it

03You can feel a lump or a step over the old fracture

04A stabbing or burning pain follows the rib round towards the front

05You were discharged with “it will heal on its own” and no follow-up

06Your X-ray was normal, but you know something is wrong

“Pain that persists for many months changes the nervous system: the spinal cord and brain learn to amplify it, and it becomes harder to switch off even after the cause is fixed. Either answer — a fixable diagnosis, or the reassurance that the rib has healed — is better than another year of not knowing.”
Mr Marco Scarci, Consultant Thoracic Surgeon

Mechanical, nerve, or both

A sharp pain that fires when you move is usually the fracture ends shifting against each other. A burning, band-like pain that follows the rib towards the front is the nerve beneath it. Many people with chronic pain after a fracture have both a mechanical problem and a nerve problem — which is why the diagnosis has to separate them.

A lump that is growing?

A lump over an old fracture that is getting bigger, or pain that is steadily worsening rather than settling — particularly with fever, night sweats or unexplained weight loss — needs to be seen without delay.

How ribs normally heal

Six to twelve weeks, improving week on week

A fractured rib heals by forming a cuff of new bone, called callus, across the break. The process takes six to twelve weeks. Pain is worst in the first two weeks and should then improve steadily, week on week. Some residual stiffness and an ache in cold weather can persist for months and is not a cause for concern.

What is not normal is pain that plateaus, pain that gets worse again after improving, or pain at three months that is still limiting what you do. Those are the signals that something has gone wrong with the healing.

What can go wrong

Five reasons a rib keeps hurting

Non-union

The break never bridged

Sometimes the two ends of the fracture never bridge with bone. Fibrous tissue forms instead, the ends stay mobile, and every twist or cough moves them against each other. This is a non-union (also called a pseudarthrosis). It is more likely when the fracture ends were displaced or overlapping, when several ribs were broken, in the lower and more mobile ribs, and in people who smoke, have diabetes or osteoporosis, take steroids, or went back to heavy activity early because they had to.

Malunion

Malunion and excess callus

The rib may heal, but in a displaced position or with a large lump of callus. That can leave a visible or palpable deformity, pain when you lie on it, and pressure on the nerve beneath the rib.

Nerve

A trapped intercostal nerve

The nerve that runs under each rib can become caught in callus, scarred into a non-union, or pinched between fragments. The result is intercostal neuralgia: burning, electric, band-like pain, often with numb or hypersensitive skin. Many people with chronic pain after a fracture have both a mechanical problem and a nerve problem. Intercostal neuralgia →

Missed injury

An injury that was never diagnosed

X-rays cannot see cartilage. A costal cartilage fracture or costochondral separation at the front of the chest is regularly missed at the time and only comes to light when the pain refuses to settle. A blow to the lower ribs can also loosen a cartilage and cause slipping rib syndrome months later. Costal cartilage injuries → · Slipping rib syndrome →

Secondary

Guarding, stiffness and adhesions

Months of protecting one side of the chest leaves the muscles between and around the ribs weak and tight, and occasionally the lung lining scars to the chest wall. These are real, but they are usually the consequence of an unresolved problem rather than the cause, and they respond once the underlying issue is addressed.

How it is diagnosed

The history and the scan, together

The history tells much of the story: how the injury happened, how the pain behaved over time, and whether it is sharp and mechanical, burning and nerve-like, or both. Examination then looks for a precise point of tenderness, a step or lump, grinding on movement, and changes in skin sensation.

The key test: a thin-slice CT with 3D reconstruction

It shows the fracture line, whether bone has bridged it, how much the ends move and displace, and the shape of the callus. A plain X-ray is not reliable for any of this. Ultrasound adds information about cartilage and can show a segment moving in real time. Where nerve pain is suspected, a diagnostic nerve block confirms the source.

Treatment

Matched to the cause — mechanical, nerve, or both

If the fracture is still healing and steadily improving, time, targeted physiotherapy and good pain control are all that is needed, and a review at three months settles the question. For an established non-union, painful malunion or trapped nerve, the options are:

Nerve blocks

They can control nerve pain and help decide whether surgery on the nerve is worthwhile.

Confirm & treat

Non-union repair

Removing the fibrous tissue, freshening the bone ends and fixing the rib with low-profile titanium plates so that it can finally heal. Bone graft is sometimes added.

Titanium plating

Resection of a short mobile segment

Where that is simpler and gives a better result, particularly in the lower ribs.

Lower ribs

Nerve decompression or neurectomy

Freeing the nerve from callus or scar, or removing the damaged segment.

Nerve

Trimming excess callus

Where it is pressing on a nerve or catching on clothing.

Callus

These operations are done through a small incision directly over the problem, often with keyhole assistance to check the inside of the chest. Most people stay one or two nights in hospital, are back at a desk within two weeks, and back to full activity in six to eight weeks. When the pain has a clear mechanical cause, the great majority of patients get substantial or complete relief.

See a doctor promptly if…

the pain is steadily worsening rather than plateauing; a lump over the rib is growing; you have fever, night sweats or unexplained weight loss; or you are breathless or coughing up blood.

Why it is worth acting rather than waiting

Either answer is better than another year of not knowing

Pain that persists for many months changes the nervous system: the spinal cord and brain learn to amplify it, and it becomes harder to switch off even after the cause is fixed. Long-standing chest wall pain also costs sleep, fitness, mood and work. And where the injury was caused by a road traffic accident or an accident at work, an accurate diagnosis on record matters for any insurance or legal process.

A CT scan and an examination will either give you a fixable diagnosis, or the reassurance that the rib has healed and the remaining pain will respond to rehabilitation. Either answer is better than another year of not knowing.

Common questions

Rib fracture non-union — what patients ask

How common is rib fracture non-union?

Uncommon, but far more common than “never”, which is what most people are told. The risk rises with displaced or overlapping fracture ends, multiple fractures, lower rib fractures, smoking, diabetes, osteoporosis and steroid use.

My X-ray says the rib has healed. Can it still be a non-union?

Yes. Plain X-rays are poor at showing whether bone has actually bridged a rib fracture, and they cannot show movement. A thin-slice CT with 3D reconstruction is the test that answers the question.

Will plating the rib get rid of the pain?

When the pain comes from a mobile non-union, stabilising it removes the cause and most people improve substantially. When the pain is from a trapped nerve, the nerve needs to be dealt with at the same time. That is why the assessment has to separate the two before any surgery is planned.

Do the plates need to come out later?

No. They are titanium, do not set off airport security, and are designed to stay. They are removed only in the rare event of irritation or infection.

How long is recovery after non-union surgery?

Typically one or two nights in hospital, desk-based work within a couple of weeks, driving once you can brake hard without pain, and unrestricted activity at six to eight weeks.

I was injured in an accident. Does that change anything?

Not the treatment, but it does make a clear, documented diagnosis more important. Keep copies of your imaging reports and clinic letters.

Your surgeon

Mr Marco Scarci

MD(Hons) · FRCS(Eng) · FCCP · FACS · FEBTS · Consultant Thoracic Surgeon, Imperial College Healthcare NHS Trust

Non-union repair is core chest wall surgery: removing the fibrous tissue, freshening the bone ends, and fixing the rib with low-profile titanium plates so it can finally heal — and, in the same operation, freeing the intercostal nerve where it has been caught in callus or scar. Reading a thin-slice CT for movement and bridging bone, and knowing when a short resection beats a plate, is the day-to-day of a dedicated chest wall practice.

Mr Scarci holds an NHS consultant post at Hammersmith Hospital, Imperial College Healthcare NHS Trust, and runs a chest wall practice across London’s leading private hospitals. He has performed more than 5,000 procedures at consultant level since 2011 and treats rib and chest wall injuries every week, from acute trauma to the long-standing pain that other tests have failed to explain.

20+years as a consultant thoracic surgeon

5,000+procedures at consultant level

170+peer-reviewed publications

Read the full biography

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Five London clinic locations — imaging arranged on the same visit

No GP referral required. Bring your medication list and any old letters or scans — the history of how it started matters.

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