Working Diagnosis:
Right First Non-displaced Rib Fracture.

Treatment:
Due to the physical exam displaying point tenderness over the right first rib and a mechanism of injury consistent with causing a fracture, the patient was treated for an acute right non-displaced first rib fracture. He was instructed to avoid non-steroidal anti-inflammatory medications since these medications can potentially delay bone healing. He was started on calcium and vitamin D3 supplementation twice a day to help promote bone healing. The patient was held out of contact sports and instructed to rest to allow the fracture to heal.

Outcome:
The patient was held out of contact sports for an additional 3 weeks to allow the fracture to heal. The patient was re-evaluated at 6 weeks and 5 days from date of injury. At that appointment, he no longer had any tenderness to palpation and had full active/passive range of motion with minimal pain. Repeat X-rays revealed the fracture to be clinically stable with callus formation and periosteal reaction. He was cleared to return to sport.

Author's Comments:
Since the fracture was of the first rib, it was critical to ensure that the fracture remained in proper alignment and appropriate callus formation and periosteal reaction was seen before return to play was initiated since this bone is adjacent to many vital structures.

Editor's Comments:
Fractures of the first rib are unique with their anatomy. The anterior scalene inserts on the scalene tubercle adjacent to the subclavian artery which is an area of anatomical weakness that can be a common etiology of a first rib fracture (4). Sudden contracture of these neck muscles can result in enough pulling force to produce this fracture and is seen in sports such as a football player having a hard collision which produces a violent head movement (3,5). These fractures commonly heal with conservative management after 4-6 weeks. Due to the location, some complications may arise and it is important for these patients to have follow-up. Excessive callus formation can lead to a brachial plexus palsy which may require surgical management. In the setting of this type of nerve injury, partial or complete resection of the rib is considered. Other complications could include Horner syndrome or thoracic outlet syndrome.

References:
1. Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, Kormas P. Isolated first rib fracture in athletes. Br J Sports Med. 2004;38(3):e5.

2. Eighmy JB, Hatcher RA. Fracture Management for Primary Care. Elsevier, 2017.

3. Weis JL. Nontraumatic First Rib Fractures Secondary to Opposing Muscle Contractions: A Case Series. JBJS Journal of Orthopaedics for Physician Assistants. 2019:e0009.

4. Albers JE, Rath RK, Glaser RS, Poddar PK. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg. 1982;33(6):614-618.

5. Sheng DL, Burnham K, Boutin RD, Ray JW. Ultrasound Identifies First Rib Stress Fractures: A Case Series in Division I Athletes. J Athl Train. 2022;10.4085/1062-6050-0375.21.

Return To The Case Studies List.