Working Diagnosis:
Non-displaced fracture of the left first rib.

Treatment:
The patient was managed conservatively with acetaminophen and tramadol. He was held out of weight lifting and football for an initial four weeks until pain improved.

Outcome:
Radiographs of left shoulder were initially interpreted as normal. The patient was managed conservatively with oral analgesics, and held out of football and weight lifting for four weeks. After four weeks, the patient continued to experience pain. An MRI and repeat radiographs of the left shoulder were subsequently ordered. A first rib fracture was diagnosed at this time. An orthopedic consult advised continuation of non-operative management. The patient was able to return to football within four months of initial presentation. He currently has no pain.

Author's Comments:
First rib fractures are the rarest of all rib fractures due to the first rib's protected anatomic position posterior to the clavicle, as well as surrounding shoulder girdle and musculature. Incidence is estimated at 0.001-0.005%. Isolated first rib fractures are typically associated with four mechanisms of injury: direct trauma (e.g a kick directly to rib), indirect trauma (e.g. falling on outstretched hand), pre-existing stress fracture, and violent musculature contracture (e.g. sudden scalene muscle contracture due to heavy lifting or baseball pitching).

Clinical features typically include a history of dull, aching pain localized to posterior shoulder, scapula, or ipsilateral lower cervical pain, and pain with shoulder range of motion, especially abduction over 90 degrees. Due to the close anatomic proximity of the first rib to the subclavian vein and artery, brachial plexus, apex of lung, aortic arch, esophagus, and trachea, there is increased potential for associated injury to these areas. However, risk of additional injury with an isolated non-displaced first rib fracture is low. Consequently, aggressive diagnostic procedures such as angiography are rarely indicated for isolated, non-displaced first rib fractures.

Take home points include the following:
Athletes complaining of neck and/or shoulder pain should be evaluated for first rib fracture if no other etiology can be determined.
This type of fracture should be followed up carefully given that nonunion or second impact displacement of an unrecognized, nondisplaced first rib fracture can lead to severe complications, including vascular and/or neurogenic thoracic outlet syndrome, rupture of apex of lung, pneumothorax, emphysema, aortic arch aneurysm, Horner’s syndrome, and ruptured subclavian artery.

References:
Sclafani MP, Amin Nirav, Delehanty E, et al. Rehabilitation following an acute traumatic first rib fracture in a collegiate football player: A case report and literature review. Int J Sports Phys Ther 2014; 9(7): 1021-1029.

Lee SJ, Chu SJ, Tsai SH. Isolated bilateral first-rib fractures. J of Emer Med 2010; 39 (2): 204-205.

Sakellaridis T, Stamatelopoulos A, et al. Isolated first rib fractures in atheletes. J Sports Med 2004; 38: e5.

Terabayashi N, Ohno T, Nichimoto Y, et al. Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: A case report. J Shoulder Elbow Surg 2010; 19: e20-23.

Colosimo AJ, Byrne E, Heidt Jr RS, et al. Acute traumatic first-rib fracture in the contract athlete: A case report. Am J Sports Med 2004; 32(5): 1310-1312.

Sinha S, Mummidi SK, et al. Isolated fracture of the first rib without associated injuries: A case report. Emerg Med J 2001; 18:315.

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