Stress fracture of the first rib in a weightlifter

Rib Stress Fractures and a Novel Muscle-Sparing Rib Fixation Plating in an Elite Tennis Player: A Systematic Review of the Literature and Case Report

A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.

Ultrasound Identifies First Rib Stress Fractures: A Case Series in National Collegiate Athletic Association Division I Athletes

Isolated first rib stress fractures in athletes are thought to be rare. In this case series, 3 National Collegiate Athletic Association Division I athletes developed isolated first rib stress fractures over the span of 1 year, indicating that these injuries may occur more often than previously understood. These fractures can be easily missed because of the low incidence, lack of clinical suspicion, and vague presentation. Further, radiographs can fail to reveal such fractures. To our knowledge, this is the largest case series of athletes with first rib stress fractures presenting with vague rhomboid interscapular pain. We also demonstrated that ultrasound successfully visualized these injuries; in the hands of an ultrasonographer or clinical provider trained in musculoskeletal ultrasound, this technique offers an advantageous point-of-care screening imaging modality.

Classification of stress fractures of the first rib in adolescent athletes

Stress fractures of the first rib occur infrequently in adolescent athletes; therefore, there have been few case reports. Initial radiographs do not always lead to the diagnosis of first rib stress fractures. This study proposed a classification system and a possible mechanism for stress fractures of the first rib using three-dimensional computed tomography (3D-CT). The data of 10 stress fractures of the first rib in adolescent athletes obtained using 3D-CT between 2007 and 2018 were reviewed. Fractures of the first rib were classified according to the location and type of the fracture line. Stress fractures of the first rib were classified into three types: type 1, center-transverse fracture; type 2, center to posterior-oblique fracture; and type 3, posterior-transverse fracture. There were three type 1 fractures, five type 2 fractures, and two type 3 fractures. The fracture lines of types 1 and 2 were on the deep groove of the subclavian artery between the anterior and middle scalene muscle attachments, which is the thinnest and weakest portion of the first rib. However, the fracture line of type 3 was across the posterior part of the first rib and located slightly away from the deep groove of the subclavian artery. A 3D-CT classification of stress fractures of the first rib in adolescent athletes was proposed. Our results suggested that there are three types of the fracture and different mechanisms that cause this type of injury. This classification system helped to implement adequate conservative therapeutic plans based on the proposed mechanism.

First-rib stress fracture in two adolescent swimmers: a case report

First-rib stress fractures have been described in adolescent athletes in various sports, with only one prior case report of first-rib stress fractures in an adolescent female swimmer. There is a need for research on the cause, management, and prevention of these injuries as they lead to significant morbidity and critical time away from sport for these aspiring athletes. We aimed to describe first-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent swimmers and to discuss the different presentations, unique risk factors, treatment, and potential injury prevention strategies of such fractures. We discussed two such cases which were successfully treated with activity modification with restriction of all overhead activity, gradually progressive physical therapy and a return to swimming protocol. First-rib stress fractures can vary in presentation and should be in the differential diagnosis in adolescent swimmers with chronic shoulder pain. These injuries can be successfully managed with rest from overhead activities and physical therapy. Gradual return to competitive swimming can be achieved even with non-union of a first-rib stress fracture. Emphasis on balanced strength training in different muscle groups and proper swimming technique is essential to prevent these injuries.

Spontaneous rib fractures

BACKGROUND

Other than trauma, rib fracture can occur spontaneously due to a severe cough or sneeze. In this study, patients with spontaneous rib fractures were analyzed according to age, sex, underlying pathology, treatment, and complications.

METHODS

Twelve patients who presented between February 2009 and February 2011 with spontaneous rib fracture were reviewed retrospectively. The patients' data were evaluated according to anamnesis, physical examination, and chest radiographs.

RESULTS

The ages of the patients ranged from 34 to 77 years (mean 55.91 ± 12.20 years), and 7 (58.4%) were male. All patients had severe cough and chest pain. The fractures were most frequently between 4th and 9th ribs; multiple rib fractures were detected in 5 (41.7%) patients. Eight (66.7%) patients had chronic obstructive pulmonary disease, 2 (16.7%) had bronchial asthma, and 2 (16.7%) had osteoporosis. Bone densitometry revealed a high risk of bone fracture in all patients. Patients with chronic obstructive pulmonary disease or bronchial asthma had been treated with high-dose steroids for over a year.

CONCLUSIONS

Spontaneous rib fracture due to severe cough may occur in patients with osteoporosis, chronic obstructive pulmonary disease, or bronchial asthma, receiving long-term steroid therapy. If these patients have severe chest pain, chest radiography should be performed to check for bone lesions.

First-rib stress fracture in a high-school lacrosse player: a case report and short clinical review

A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days' duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.

First rib fractures in abused infants: a report of three cases

The authors describe 4 first rib fractures in 3 infants, highlighting the difficulty in detecting first rib fractures on skeletal survey. All 4 fractures were the result of physical abuse. A literature search does not find a case of first rib fracture in a healthy infant that is not the result of child abuse. The diagnosis of first rib fracture in an infant should prompt a thorough medical and social evaluation for child abuse.

Stress fracture of the first rib in a weightlifter

A 20-year-old woman elite weightlifter presented with acute onset debilitating right shoulder pain while attempting the "clean and jerk." There was no previous relevant history, including no prior fracture in the region. Examination confirmed vague tenderness in the right supraclavicular fossa with no discernible neurologic or vascular deficit within the right arm. X-ray was normal. The patient had a bone scan, including SPECT, suggesting a fracture of the right first rib, subsequently confirmed on CT examination.

Upper Extremity Stress Fractures

Although less common than lower-extremity stress fractures, upper-extremity stress fractures are becoming recognized much more frequently. A majority of these fractures are caused by overuse and fatigue of the surrounding musculature and, as a result, may be prevented by appropriate training and conditioning. Diagnosis is made by history and physical examination with the aid of plain radiographs, bone scans, and MRI. Most of these fractures heal with a period of relative rest followed by a structured rehabilitation program. A small percentage of these fractures, however, may require surgical fixation. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.

Rib stress fractures

The ribs are an uncommon site of stress fracture. Typical locations are the first rib anterolaterally, the fourth through ninth ribs laterally and posterolaterally, and the posteromedial upper ribs. Muscular forces are predominantly responsible for these fractures. This article reviews the mechanisms of injury in various activities and illustrates the scintigraphic appearance of rib stress fractures.

Fracture of the first rib as a consequence of pertussis infection

We report the first described case of a first rib fracture secondary to pertussis infection. An 11-year-old boy presented with sudden onset of severe right-sided pleuritic chest pain on a background of a 6 week history of a coughing illness and considerable weight loss. Pertussis was clinically suspected and proven on serology. A cause for the severe pain was initially difficult to confirm, causing some concern regarding possible underlying pathology, but was later demonstrated to be due to a first rib fracture. The anatomy of the first rib, and the biomechanical forces placed upon it that are exacerbated during a coughing illness are described.

An unusual cause of stress fracture of the first rib

An unusual case of stress fracture of the first rib that occurred in a young male as a result of the constant loading due to carrying a heavy schoolbag is reported. This case demonstrates the difficulty in diagnosis and highlights the need for awareness of this condition, thus avoiding invasive investigation.

Stress fractures of the ribs in golfers

During a collaborative review at three institutions, we documented 19 cases of stress fractures of the ribs in golfers. There were 13 men and 6 women with an average age of 39 years (range, 29 to 51). The 4th to 6th ribs were the most commonly injured. All fractures occurred along the posterolateral aspect of the ribs, and nine patients had fractures in more than one rib. Sixteen golfers sustained injury on the leading arm side of the trunk. Eighteen golfers were beginners, and the one experienced golfer had dramatically increased his practice time on the driving range before injury. Plain radiographs were usually diagnostic. However, bone scintigraphy was necessary to reach a diagnosis in three cases. A delay in diagnosis of 6 to 8 months occurred in two cases that were originally misdiagnosed as back strains. Stress fractures of the ribs in golfers may be more common than previously realized and may be incorrectly diagnosed as recalcitrant back strains. Based on the findings of other studies, we think fatigue of the serratus anterior is the mechanism of injury. We recommend strengthening the serratus anterior as rehabilitation after this injury and in a general conditioning program for golfers.