Working Diagnosis:
Brachial plexus injury coinciding with closed fracture of the 1st rib

Treatment:
The patient was held from sports for approximately 8 weeks and was also referred to physical therapy during that time with a focus on rotator cuff, triceps and bicep strengthening as well as neuromuscular reactivation.

Outcome:
The patient followed up in clinic 2-, 6-, and 8-weeks post-injury with progressive improvement of his symptoms. Repeat X-rays were obtained at 6 weeks and at 8 weeks post injury which showed healing of the fracture. The patient attended a total of 6 sessions of physical therapy during an 8-week period, and was graduated with instructions for home exercises, once he had regained his strength and had full ROM and was able to throw again. Patient was able to return to his sports after that.

Author's Comments:
Isolated first rib fractures are rare, with only a few cases published in literature1. The most common mechanism of fracture of the first rib is direct trauma, but it has also been noticed with sudden contraction of the scalenius anterior muscle. Fractures of the 1st rib have been associated with sports involving excessive overhead activity. The 1st rib is in very close proximity to the long thoracic nerve. Long thoracic nerve neuropathy from palpation of the 1st rib has also been reported in the past2.
To our knowledge this is the first published case of a 1st rib fracture associated with the sport of Spikeball. Therefore, it is important to keep a 1st rib fracture in the differential for the athletes who perform a sport with overhead activity and present in clinic with a broad shoulder pain complaint. In addition, the presence of a brachial plexus palsy added to the complexity of the decision-making in regards to the length of therapy and return to activity.

Editor's Comments:
Non-traumatic first rib fractures are uncommonly encountered in young athletes. Typically, direct trauma injures the first rib, which is a small, flat rib and arises from the T1 vertebrae. The mechanism of injury for non-traumatic fractures is thought to be due to forceful contractions of opposing muscle forces on developing bone (3). The case illustrates the importance of rib fractures as a cause of shoulder pain and illustrates the complications (weakness) in the atraumatic throwing athlete.

References:
1. Vikramaditya, Pritty P. Two cases of isolated first rib fracture. Emergency Medicine Journal 2001;18:498-499.

2. Gregory P. Ernst & Dana Shippey (1999) Long Thoracic Neuropathy Resulting From First Rib Palpation, Journal of Manual & Manipulative Therapy, 7:2, 92-96, DOI: 10.1179/106698199790811771
Acknowledgements

3. Weis, Jamie L. "Nontraumatic First Rib Fractures Secondary to Opposing Muscle Contractions: A Case Series." JBJS Journal of Orthopaedics for Physician Assistants 7.3 (2019): e0009.

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