Working Diagnosis:
Right posterior first rib fracture

Treatment:
We initially recommended the patient continue physical therapy to maintain strength, range of motion, and flexibility and to help with pain. He was restricted from sport for a total of 2 months. The patient was followed regularly until there was evidence of healing. After 2 months of restriction he was cleared to participate in batting practice, but not full practice or a game.

Outcome:
The patient ultimately re-injured the fractured rib almost immediately upon return to batting practice. This was diagnosed on shoulder x-rays taken at an outside facility. Case Photo #6 Given the recurrence of his injury, he was referred to pediatric surgery. At the time of his consultation 2 weeks later, the patient reported good pain control and had a reassuring physical exam. Additional conservative management was encouraged.

Author's Comments:
Right posterior first rib fractures are exceedingly rare outside the context of significant traumatic injury. There have been cases described in the literature of athletes and military men and women who have suffered this fracture outside the context of direct trauma. This seems to be related to a violent pull of the anterior scalene muscle on a thin and vulnerable aspect of the first rib between the subclavian artery and vein grooves. We suspect this to be the case in our patient. The violent pull was likely from overexertion during batting practice. Diagnosis can be difficulty given the deep location of the rib, with pain commonly referring to the shoulder and neck. Additionally, the healing process can take several months. Repeat imaging may continue to show a fracture in some stage of healing despite symptomatic improvement.

Editor's Comments:
Non traumatic fracture of the first rib in athletes is an uncommon diagnosis, but should be considered in the differential for athletes presenting with acute or persistent posterior shoulder pain. X-ray may be sufficient for diagnosis, but CT or MRI may be necessary when the diagnosis is uncertain. There are no clear return-to-play protocols for these injuries, but the literature suggests that conservative management and return to play when asymptomatic may be appropriate.

References:
Jenkins SA. Spontaneous fractures of both first ribs. The Journal of Bone and Joint Surgery. British Volume 1952; 34:9-13.

Moore RS. Fracture of the first rib: an uncommon throwing injury. Injury 1991; 22:149-50.

Sakellaridis T, et al. Isolated first rib fracture in athletes. British Journal of Sports Medicine 2004; 38: e5.

Vikramaditya PP. Two cases of isolated first rib fracture. Emergency Medicine Journal 2001; 18:498-9.

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