Traumatic rib fractures are common injuries following blunt chest trauma, often requiring chest tube insertion to manage complications such as pneumothorax or haemothorax. However, chest tube placement can lead to intercostal nerve injury, resulting in intercostal neuralgia-a debilitating condition characterized by chronic, neuropathic pain along the intercostal nerves. Despite its clinical significance, the incidence, risk factors, and long-term outcomes of intercostal neuralgia in this patient population remain poorly understood.

Chronic pain following thoracic trauma, including intercostal neuralgia, has been shown to significantly impair quality of life and functional outcomes, leading to prolonged disability and increased healthcare utilization. Current literature highlights the need for better understanding and management of this condition, particularly in patients undergoing invasive procedures such as chest tube insertion. This study aims to prospectively evaluate the development of intercostal neuralgia in patients with chest tube insertion following traumatic rib fractures.

Intercostal neuralgia is defined as pain along the intercostal nerve distribution with neuropathic features. Chronic intercostal neuralgia is defined as having intercostal neuralgia symptoms for >3 months.

Intercostal neuralgia pain will be specifically differentiated from persistent rib fracture pain through the presence of neuropathic pain at the level of the chest tube/pigtail that is reproducible with brushing/light touch to the chest tube scar site.

The following data will be collected:

Baseline:

• Demographic information (age, sex, ethnicity, comorbidities).
• Pain assessment using numerical rating scale at rest and with deep inspiration
• Pre-existing chronic pain conditions (e.g., fibromyalgia, chronic regional pain syndrome) and history of prior thoracic surgery or chest tube insertion.
• Injury characteristics (mechanism of injury including presence of foreign bodies and additional penetrating injuries, number and location of rib fractures, associated injuries including vertebral body fractures, sternal fracture, transverse process fracture).
• Neurologic assessment (Glasgow Coma Scale [GCS] on presentation and at time of recruitment)
• Brain imaging findings on presentation (if applicable)
• Chest tube / pigtail details (size, insertion site, duration of placement).
• Spirometry testing including forced vital capacity (FVC) and forced expiratory volume (FEV1) at time of enrolment of study

Additional information to be collected following hospital stay:

• Analgesic use including dose of opioids, use of regional anesthesia techniques, and adjunct analgesic medications while in hospital
• Length of hospital stay
• Presence and duration of mechanical ventilation
• Number of surgeries

Follow ups: 1 (± 3 days) and 3 months (± 1 week) via telephone

• Pain assessment using the numerical rating scale at rest and with deep inspiration
• Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) for neuropathic pain
• EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L) for health related quality of life
• Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance 6a for sleep
• Medication use (analgesics, neuropathic pain medications)
• Neurologic assessment at discharge (GCS, diagnosis of traumatic brain injury)
• Brain imaging findings on presentation (if applicable)

Patients who are found to have intercostal neuralgia at 3 month follow up assessment can be referred to the pain clinic and choose to be sent for formal ultrasound to identify and characterize findings to indicate the presence of neuroma (a non-cancerous tumor or growth of nerve tissue), degree of scarring, or any other pain generating causes, if agreed. Participants' preferences regarding the disclosure of neuroma, including their right to know or not to know, will be respected (as described in the consent form).

Inclusion Criteria:

• Adults (≥18 years) with traumatic rib fractures requiring chest tube insertion
• Chest tube or pigtail insertion performed during their initial hospitalization for trauma

Exclusion Criteria:

• Patients with spinal cord injury
• Inability to complete follow-up assessments (e.g., language barriers, lack of telephone access)

Exclusion Criteria:

• Patients with traumatic brain injury
• Patients with spinal cord injury
• Inability to complete follow-up assessments (e.g., language barriers, lack of telephone access)

Patients with acute traumatic rib fractures requiring chest tube insertion for management.