INJURY CLINIC
Sports Medicine 12 (I): 66-69, 1991 0112-1642/91/0007-0066/$02.00/0 © Adis International Limited. All rights reserved. SP0129
Rib Fractures in Athletes John W. Miles and Gene R. Barrett Department Sports Medicine, Sharp Rees-Steely Medical Group, San Diego, California, and Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
Contents 66 66 67 67 67
68 69
Summary
Summary 1. Mechanisms of Injury 2. Diagnosis 3. Treatment 4. Associated Injuries 5. Athletic Rib Fractures 6. Conclusion
Rib fractures are the most common serious injury of the chest. They occur most commonly in the middle and lower ribs with blunt trauma, and also with direct force to a small area of the chest wall and violent muscle contractions. Diagnosis is generally not difficult. The athlete should have a chest x-ray to confirm the diagnosis. Differential diagnosis includes severe rib contusion, costochondral separations, muscle strains and pneumothorax. Ifno internal problems exist, treatment consists of ice, NSAIDs, analgesics and a rib belt or tape. Healing should be well on its way before a return to sports. Fractures of the first 4 ribs or the last 2 ribs, multiple fractures and flail segments are less benign than other fractures, and may result in injury to surrounding structures. First rib and floating rib fractures are uniquely athletic fractures; they are avulsion fractures caused by a sudden vigorous contraction in different directions of pull.
Rib fractures are the most common serious injury of the chest. The incidence of rib fractures increases as the elasticity and flexibility of the thorax decreases with advancing age. Thus, rib fractures are uncommon in children (Kirsch & Sloan 1977).
1. Mechanisms of Injury Fractures occur most commonly in the middle and lower ribs with blunt trauma. There are several mechanisms of injury. Most common is an ap-
plication of force in the anteroposterior plane. As the radius of the ribs decreases, tension increases along the lateral aspect of the rib. These fractures are usually located at the posterior angles of the fifth to the ninth ribs (Rutherford 1979). Another mechanism of rib fracture is a direct force applied over a small area of the chest wall, with fractures occurring immediately beneath the point of impact. An uncommon mechanism is violent muscle contractions.
67
Rib Fractures
2. Diagnosis The diagnosis of rib fractures is generally not difficult. The athlete will give a history of a traumatic event with resultant localised pain. There is pain with inspiration or coughing resulting in shallow, rapid breathing. It is sometimes possible to feel crepitus over a fractured rib. Localised tenderness over the fractures will be noted. Occasionally, subcutaneous emphysema will be noted. The athlete should have a chest x-ray to establish the diagnosis and exclude any complication. Rib fractures will be identified on a posteroanterior chest film in about 90% of cases (Kirsch & Sloan 1977). Anterior and lateral fractures are frequently missed but may be detected by oblique views and use of the Bucky Technique. The differential diagnosis includes: a severe rib contusion, costochondral separations, muscle strains of the lower thoracic musculature and pneumothorax. A severe contusion to the ribs is often difficult to distinguish from a fracture. Because of bruising of the intercostal muscles, there may be both pain on inspiration and localised tenderness (Roy & Irvin 1983). A chest film will rule out rib fractures or pneumothorax. Treatment involves ice, a nonsteroidal, possibly a rib belt and adequate padding if involved in contact sports. Costochondral separations frequently occur in sports such as wrestling and football. The patient gives a history of feeling a pop. On examination localised swelling, tenderness and possibly displacement suggest the diagnosis. Treatment utilises ice, NSAIDs, taping and judicious use of corticosteroid injection. Strains of the thoracoabdominal muscles are commonly associated with tennis and other racquet sports as well as soccer. Forceful contraction of the thoracic muscles during a tennis serve is often the precipitating event. The treatment involves a programme of rest, ice, NSAIDs and rehabilitation. The reader is referred to an excellent article dealing with the rehabilitation (Lehman 1988). A spontaneous pneumothorax can develop in a previously healthy athlete after blunt trauma. There will be shortness of breath, chest pain, shallow,
rapid, respiration and possibly cyanosis. Hyperresonance to percussion and decreased breath sounds over the affected lung will be noted. The diagnosis is confirmed on a chest radiograph. A minimal pneumothorax may not require any specific form of treatment.
3. Treatment The treatment of solitary rib fractures per se is easy, in that they have no effect on lung mechanics and even overlapping fragments heal satisfactorily (Borrie 1980). The problem is with the possible underlying pulmonary injuries. If no internal problems exist, then the management initially consists of pain relief using ice, NSAIDs, analgesics and a rib belt or tape on the involved side of the chest wall. This is all that will be required in the vast majority of patients. Occasionally, a useful adjunct is an intercostal nerve block with bupivacaine which may be repeated several times. The technique is described in several reviews (Borrie 1980; Kirsch & Sloan 1977; Steichen 1985). Continuous epidural fentanyl analgesia has been used with success in hospitalised trauma patients with severe injuries including multiple rib fractures or a flail chest (MacKersie et al. 1987). Healing should be well on its way before the athlete is allowed to return to sports participation, mainly because of the danger of a pneumothorax caused by a fractured rib penetrating the pleura. This is usually around 3 weeks for contact sports. The athlete should then wear protective padding over the fracture if participating in contact sports and commercial vests are available (Cain et al. 1981; Roy & Irvin 1983).
4. Associated Injuries The vast majority of rib fractures behave in a benign fashion; however, some locations are associated with more serious injuries. These are fractures of the first 4 ribs, the last 2 ribs, multiple rib fractures and flail segments. Fractures of the upper 4 ribs are uncommon because of their protected position beneath the shoulder girdle. They are usually the result of high speed
Sports Medicine 12 (l) 1991
68
vehicular trauma, not athletics. When first rib fractures are associated with multiple rib fractures, there is a significant chance of associated major intrathoracic injury including: subclavian artery injury, aortic injury, significant pulmonary contusion, pneumothorax, haemothorax, bronchial rupture (Albers et al. 1982). Isolated first rib fractures have a low incidence of vascular injury. In a series of trauma patients, arteriography was felt to be indicated only if one of the following was present: (a) diminished upper extremity pulses; (b) evidence of brachial plexus injury; or (c) displaced first rib fractures, particularly posterior displacement (Phillips et al. 1981). Multiple rib fractures indicate more trauma. As the number of rib fractures increases, so does the chance of internal injury. Bassett et al. (1968) showed that the incidence of intrathoracic injuries rises with each rib fractured. Fracture of the lower 2 ribs is associated with increased trauma and the direct force required to fracture these ribs may damage the underlying kidneys or spleen (Rutherford 1979). Flail chest is defined as fracture of 3 or more ribs in 2 locations, creating a free-floating segment of the chest wall. It is a major injury with a high association of internal injury. This is usually the result of vehicular trauma not sports. Management may include epidural analgesia, mechanical ventilation, operative stabilisation of the chest wall or possibly only supportive therapy (Glinz 1986). The problems with rib fractures are not with the fractures themselves but the result of injury to the surrounding structures. These problems include pneumothorax, haemothorax, cardiac contusion and cardiac tamponade.
5. Athletic Rib Fractures There are 2 unique types of athletic rib fractures: first rib fractures and floating rib fractures of the lower 3 ribs. Floating rib fractures involve the lower 3 'floating' ribs. These fractures are avulsion fractures of the attachments of the external oblique muscle. There are multiple muscle attachments in this region. A sudden vigorous contrac-
tion with different directions of pull is thought to be the aetiology. These fractures have been reported in baseball pitchers and batters by Tullos et al. (1972). The condition can be differentiated from the more common strain of the external oblique muscle by radiographs. The fracture sites can be injected with a local anaesthetic and steroid preparation for pain relief. First rib fractures have been reported in tennis, baseball, surfing, windsurfing, football, 'jive dancing', rowers and basketball players (Bailey 1985; Brooke 1959; Gurtler et al. 1985; Lankenner & Micheli 1985; Pereira 1985; Sacchetti et al. 1983). Fractures of the first rib have been reported to occur as a result of direct external trauma, indirect trauma (falling on an outstretched arm, hyperabduction of the arm) and fatigue or stress fractures (Albers et al. 1982; Bailey 1985; Blichert-Toft 1968; Breslin 1937; Lorentzen & Movin 1976). Many first rib fractures are located in an area of anatomic weakness, a shallow groove where the subclavian artery crosses the rib (Barrett et al. 1988; Blichert-Toft 1968). The rib is rigidly attached posteriorly and anteriorly. There are multiple muscle attachments immobilising or providing caudal pull. The scalenus anterior attaches to the scalene tubercle between the subclavian artery and vein and provides cephalad pull. It has been suggested that sudden powerful contractions of the scalene muscles may fracture the rib at its thinnest segment, where the subclavian artery crosses it (Barrett et al. 1988; Blichert-Toft 1968; Breslin 1937; Brooke 1959; Griffin & Minnis 1957; Gurtler et al. 1985; Jenkins 1952; Powell 1950; Tullos et al. 1972). This may occur when the head is thrown backwards or sideways. Heavy lifting with sudden contraction of the scalenus anterior may also lead to fracture (Breslin 1937; Jenkins 1952). Muscular pull may be the aetiology in cases of acute fractures in tennis playing and baseball pitching (Gurtler et al. 1985; Lankenner & Micheli 1985; Tullos et al. 1972). These patients often describe feeling a snap in the shoulder and an acute onset of pain. Some authors have noted a distinction between a single acute event in normal bone and those due to repetitive stresses which result in mechanical
Rib Fractures
failure of bone (Blichert-Toft 1968; Hartley 1945). Repeated insults such as baseball pitching can lead to stress or fatigue fractures (Blichert-Toft 1968; Gurtler et a1. 1985; Tullos et a1. 1972). Stress fractures of the first rib are nondisplaced (Aitken & Lincoln 1939; Alderson 1947; BlichertToft 1968; Breslin 1937; Curran & Kelley 1966; Freiberger & Mayer 1964; Jenkins 1952; Lorentzen & Movin 1976; Powell 1950). They are more easily noted on a chest radiograph than on an AP shoulder radiograph (Barrett et a1. 1988). Occasionally a bone scan has been used (Gurtler et a1. 1985). No acute neurovascular complications have been reported. Very few late complications, such as Horner's syndrome have been recorded (Blichert-Toft 1968; Breslin 1937; Fordham 1977; Lorentzen & Movin 1976; Yee et a1. 1981). There is a tendency toward slow healing and pseudoarthrosis or non unions have been described (Aspin 1950; Blichert-Toft 1968; Fordham 1977; Lorentzen & Movin 1976; Yee et al. 1981). However, nonunions are described as nonpainful.
6. Conclusion Rib fractures in athletes are a diverse group of injuries which are generally easily identified. Treatment of rib fractures is not difficult; however, attention to the underlying structures is critical.
References Aitken AP, Lincoln RE. Fracture of the first rib due to muscle pull. New England Journal of Medicine 110: 1063-1064, 1939 Albers JE, Rath RK, et al. Severity of intrathoracic injuries associated with first rib fractures. Annals of Thoracic Surgery 33: 614-618, 1982 Alderson BR. Further observations on fracture of the first rib. British Journal of Radiology 20: 345-359, 1947 Aspin J. Anomalous ossification of ribs as a cause of pseudoarthrosis. British Journal of Radiology 23: 15-17, 1950 Bailey P. Surfer's rib: isolated first rib fracture secondary to indirect trauam. Annals of Emergency Medicine 141: 346-349, 1985 Barrett GR, Shelton WR, Miles JW. First rib fractures in football players. 16: 674-676, 1988 Bassett JS, Gibson RD, et al. Blunt injuries to the chest. Journal of Trauma 8: 418-429, 1968
69
Blichert-Toft M. Fatigue fractures of the first rib. Acta Chirurgica Scandinavica 135: 675-678, 1968 Borrie J. Management of thoracic emergencies, 3rd ed., Appleton Century-Crofts, Englewood Oiffs, NJ, 1980 Breslin FJ. Fractures of the first rib unassociated with fractures of other ribs. American Journal of Surgery 35: 384-389, 1937 Brooke R. Jive fracture of the first rib. Journal of Bone and Joint Surgery 41B: 370-371, 1959 Cain TE, et al. Use of the air inflated jacket in football. American Journal of Sports Medicine 9: 240-243, 1981 Curran JP, Kelley DA. Stress fracture of the first rib. American Journal of Orthopedics 8: 16-18, 1966 Fordham SO. The significance of first fib fractures. Medical Times 105: 118-119, 1977 Freiberger RH, Mayer V. Ununited bilateral fatigue fractures of the first ribs. a case report and review of the literature. Journal of Bone and Joint Surgery 46A, 615-618, 1964 Glinz W. Problems caused by the unstable thoracic wall and by cardiac injury due to blunt injury. Injury 17: 322-326, 1986 Griffin EH, Minnis JF. Traumatic fracture displacement of the first rib. New York Journal of Medicine 57: 2407-2408, 1957 Gurtler R, Pavlov H, Torg JS. Stress fracture of the ipsilateral first rib in a pitcher. American Journal of Sports Medicine 13: 277-279, 1985 Hartley JB. Stress fractures of the first rib. Lancet I: 446-447, 1945 Jenkins SA. Spontaneous fractures of both first ribs. Journal of Bone and Joint Surgery 34B: 9-13, 1952 Kirsch MM, Sloan H. Injuries to the chest wall. In Blunt chest trauma, Little, Brown and Co, Boston, 1977 Lankenner PA, Micheli U. Stress fracture of the first rib: a case report. Journal of Bone and Joint Surgery 67A: 159-160, 1985 Lehman RC. Thoracoabdominal musculoskeletal injuries in racquet sports. Oinics in Sports Medicine 7: 267-276, 1988 Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthopaedica Scandinavica 47: 632-634, 1976 Mackersie RC, et al. Continuous epidural fentanyl analgesia: ventilatory function improvement with routine use in treatment of blunt chest injury. Journal of Trauma 27: 1207-1212, 1987 Pereira J. Stress fracture of a rib. British Journal of Sports Medicine 19: 26, 1985 Phillips EG, Rogers WF, Gaspar MR. First rib fractures; incidence of vascular injury and indications for angiography. Surgery 89: 4247, 1981 Powell Fl. Fracture of the first rib; its occurrence and clinical diagnosis. British Medical Journal I: 282-285, 1950 Roy S, Irvin R. Chest, abdominal and genital injuries. In Sports medicine, Prentice-Hall, Inc, Englewood Cliffs NJ, 1983 Rutherford RB. Thoracic injuries. In The management of trauma, 3rd ed., WB Saunders Co, 1979 Sacchetti AD, Beswick DR, Morse SO. Rebound rib: stress-induced first rib fractures. Annals of Emergency Medicine 12: 177-179,1983 Steichen FM. Intercostal nerve block for rib fractures. Surgical Rounds 78-79, 1985 Tullos HW, Erwin WO, Woods GW, et al. Unusual lesions of the pitching arm. Clinical Orthopedics 88: 169-182, 1972 Yee ES, Thomas AN, Goodman PC. Isolated first rib fracture: clinical significance after blunt chest trauma. Annals of Thoracic Surgery 32: 278-282, 1981 Correspondence and reprints: Dr Gene R. Barrett, Mississippi Sports Medicine and Orthopedic Center, 1325 Fortification Sum, Jackson, MS 39202, USA.
Sports Medicine 12 (I): 66-69, 1991 0112-1642/91/0007-0066/$02.00/0 © Adis International Limited. All rights reserved. SP0129
Rib Fractures in Athletes John W. Miles and Gene R. Barrett Department Sports Medicine, Sharp Rees-Steely Medical Group, San Diego, California, and Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, USA
Contents 66 66 67 67 67
68 69
Summary
Summary 1. Mechanisms of Injury 2. Diagnosis 3. Treatment 4. Associated Injuries 5. Athletic Rib Fractures 6. Conclusion
Rib fractures are the most common serious injury of the chest. They occur most commonly in the middle and lower ribs with blunt trauma, and also with direct force to a small area of the chest wall and violent muscle contractions. Diagnosis is generally not difficult. The athlete should have a chest x-ray to confirm the diagnosis. Differential diagnosis includes severe rib contusion, costochondral separations, muscle strains and pneumothorax. Ifno internal problems exist, treatment consists of ice, NSAIDs, analgesics and a rib belt or tape. Healing should be well on its way before a return to sports. Fractures of the first 4 ribs or the last 2 ribs, multiple fractures and flail segments are less benign than other fractures, and may result in injury to surrounding structures. First rib and floating rib fractures are uniquely athletic fractures; they are avulsion fractures caused by a sudden vigorous contraction in different directions of pull.
Rib fractures are the most common serious injury of the chest. The incidence of rib fractures increases as the elasticity and flexibility of the thorax decreases with advancing age. Thus, rib fractures are uncommon in children (Kirsch & Sloan 1977).
1. Mechanisms of Injury Fractures occur most commonly in the middle and lower ribs with blunt trauma. There are several mechanisms of injury. Most common is an ap-
plication of force in the anteroposterior plane. As the radius of the ribs decreases, tension increases along the lateral aspect of the rib. These fractures are usually located at the posterior angles of the fifth to the ninth ribs (Rutherford 1979). Another mechanism of rib fracture is a direct force applied over a small area of the chest wall, with fractures occurring immediately beneath the point of impact. An uncommon mechanism is violent muscle contractions.
67
Rib Fractures
2. Diagnosis The diagnosis of rib fractures is generally not difficult. The athlete will give a history of a traumatic event with resultant localised pain. There is pain with inspiration or coughing resulting in shallow, rapid breathing. It is sometimes possible to feel crepitus over a fractured rib. Localised tenderness over the fractures will be noted. Occasionally, subcutaneous emphysema will be noted. The athlete should have a chest x-ray to establish the diagnosis and exclude any complication. Rib fractures will be identified on a posteroanterior chest film in about 90% of cases (Kirsch & Sloan 1977). Anterior and lateral fractures are frequently missed but may be detected by oblique views and use of the Bucky Technique. The differential diagnosis includes: a severe rib contusion, costochondral separations, muscle strains of the lower thoracic musculature and pneumothorax. A severe contusion to the ribs is often difficult to distinguish from a fracture. Because of bruising of the intercostal muscles, there may be both pain on inspiration and localised tenderness (Roy & Irvin 1983). A chest film will rule out rib fractures or pneumothorax. Treatment involves ice, a nonsteroidal, possibly a rib belt and adequate padding if involved in contact sports. Costochondral separations frequently occur in sports such as wrestling and football. The patient gives a history of feeling a pop. On examination localised swelling, tenderness and possibly displacement suggest the diagnosis. Treatment utilises ice, NSAIDs, taping and judicious use of corticosteroid injection. Strains of the thoracoabdominal muscles are commonly associated with tennis and other racquet sports as well as soccer. Forceful contraction of the thoracic muscles during a tennis serve is often the precipitating event. The treatment involves a programme of rest, ice, NSAIDs and rehabilitation. The reader is referred to an excellent article dealing with the rehabilitation (Lehman 1988). A spontaneous pneumothorax can develop in a previously healthy athlete after blunt trauma. There will be shortness of breath, chest pain, shallow,
rapid, respiration and possibly cyanosis. Hyperresonance to percussion and decreased breath sounds over the affected lung will be noted. The diagnosis is confirmed on a chest radiograph. A minimal pneumothorax may not require any specific form of treatment.
3. Treatment The treatment of solitary rib fractures per se is easy, in that they have no effect on lung mechanics and even overlapping fragments heal satisfactorily (Borrie 1980). The problem is with the possible underlying pulmonary injuries. If no internal problems exist, then the management initially consists of pain relief using ice, NSAIDs, analgesics and a rib belt or tape on the involved side of the chest wall. This is all that will be required in the vast majority of patients. Occasionally, a useful adjunct is an intercostal nerve block with bupivacaine which may be repeated several times. The technique is described in several reviews (Borrie 1980; Kirsch & Sloan 1977; Steichen 1985). Continuous epidural fentanyl analgesia has been used with success in hospitalised trauma patients with severe injuries including multiple rib fractures or a flail chest (MacKersie et al. 1987). Healing should be well on its way before the athlete is allowed to return to sports participation, mainly because of the danger of a pneumothorax caused by a fractured rib penetrating the pleura. This is usually around 3 weeks for contact sports. The athlete should then wear protective padding over the fracture if participating in contact sports and commercial vests are available (Cain et al. 1981; Roy & Irvin 1983).
4. Associated Injuries The vast majority of rib fractures behave in a benign fashion; however, some locations are associated with more serious injuries. These are fractures of the first 4 ribs, the last 2 ribs, multiple rib fractures and flail segments. Fractures of the upper 4 ribs are uncommon because of their protected position beneath the shoulder girdle. They are usually the result of high speed
Sports Medicine 12 (l) 1991
68
vehicular trauma, not athletics. When first rib fractures are associated with multiple rib fractures, there is a significant chance of associated major intrathoracic injury including: subclavian artery injury, aortic injury, significant pulmonary contusion, pneumothorax, haemothorax, bronchial rupture (Albers et al. 1982). Isolated first rib fractures have a low incidence of vascular injury. In a series of trauma patients, arteriography was felt to be indicated only if one of the following was present: (a) diminished upper extremity pulses; (b) evidence of brachial plexus injury; or (c) displaced first rib fractures, particularly posterior displacement (Phillips et al. 1981). Multiple rib fractures indicate more trauma. As the number of rib fractures increases, so does the chance of internal injury. Bassett et al. (1968) showed that the incidence of intrathoracic injuries rises with each rib fractured. Fracture of the lower 2 ribs is associated with increased trauma and the direct force required to fracture these ribs may damage the underlying kidneys or spleen (Rutherford 1979). Flail chest is defined as fracture of 3 or more ribs in 2 locations, creating a free-floating segment of the chest wall. It is a major injury with a high association of internal injury. This is usually the result of vehicular trauma not sports. Management may include epidural analgesia, mechanical ventilation, operative stabilisation of the chest wall or possibly only supportive therapy (Glinz 1986). The problems with rib fractures are not with the fractures themselves but the result of injury to the surrounding structures. These problems include pneumothorax, haemothorax, cardiac contusion and cardiac tamponade.
5. Athletic Rib Fractures There are 2 unique types of athletic rib fractures: first rib fractures and floating rib fractures of the lower 3 ribs. Floating rib fractures involve the lower 3 'floating' ribs. These fractures are avulsion fractures of the attachments of the external oblique muscle. There are multiple muscle attachments in this region. A sudden vigorous contrac-
tion with different directions of pull is thought to be the aetiology. These fractures have been reported in baseball pitchers and batters by Tullos et al. (1972). The condition can be differentiated from the more common strain of the external oblique muscle by radiographs. The fracture sites can be injected with a local anaesthetic and steroid preparation for pain relief. First rib fractures have been reported in tennis, baseball, surfing, windsurfing, football, 'jive dancing', rowers and basketball players (Bailey 1985; Brooke 1959; Gurtler et al. 1985; Lankenner & Micheli 1985; Pereira 1985; Sacchetti et al. 1983). Fractures of the first rib have been reported to occur as a result of direct external trauma, indirect trauma (falling on an outstretched arm, hyperabduction of the arm) and fatigue or stress fractures (Albers et al. 1982; Bailey 1985; Blichert-Toft 1968; Breslin 1937; Lorentzen & Movin 1976). Many first rib fractures are located in an area of anatomic weakness, a shallow groove where the subclavian artery crosses the rib (Barrett et al. 1988; Blichert-Toft 1968). The rib is rigidly attached posteriorly and anteriorly. There are multiple muscle attachments immobilising or providing caudal pull. The scalenus anterior attaches to the scalene tubercle between the subclavian artery and vein and provides cephalad pull. It has been suggested that sudden powerful contractions of the scalene muscles may fracture the rib at its thinnest segment, where the subclavian artery crosses it (Barrett et al. 1988; Blichert-Toft 1968; Breslin 1937; Brooke 1959; Griffin & Minnis 1957; Gurtler et al. 1985; Jenkins 1952; Powell 1950; Tullos et al. 1972). This may occur when the head is thrown backwards or sideways. Heavy lifting with sudden contraction of the scalenus anterior may also lead to fracture (Breslin 1937; Jenkins 1952). Muscular pull may be the aetiology in cases of acute fractures in tennis playing and baseball pitching (Gurtler et al. 1985; Lankenner & Micheli 1985; Tullos et al. 1972). These patients often describe feeling a snap in the shoulder and an acute onset of pain. Some authors have noted a distinction between a single acute event in normal bone and those due to repetitive stresses which result in mechanical
Rib Fractures
failure of bone (Blichert-Toft 1968; Hartley 1945). Repeated insults such as baseball pitching can lead to stress or fatigue fractures (Blichert-Toft 1968; Gurtler et a1. 1985; Tullos et a1. 1972). Stress fractures of the first rib are nondisplaced (Aitken & Lincoln 1939; Alderson 1947; BlichertToft 1968; Breslin 1937; Curran & Kelley 1966; Freiberger & Mayer 1964; Jenkins 1952; Lorentzen & Movin 1976; Powell 1950). They are more easily noted on a chest radiograph than on an AP shoulder radiograph (Barrett et a1. 1988). Occasionally a bone scan has been used (Gurtler et a1. 1985). No acute neurovascular complications have been reported. Very few late complications, such as Horner's syndrome have been recorded (Blichert-Toft 1968; Breslin 1937; Fordham 1977; Lorentzen & Movin 1976; Yee et a1. 1981). There is a tendency toward slow healing and pseudoarthrosis or non unions have been described (Aspin 1950; Blichert-Toft 1968; Fordham 1977; Lorentzen & Movin 1976; Yee et al. 1981). However, nonunions are described as nonpainful.
6. Conclusion Rib fractures in athletes are a diverse group of injuries which are generally easily identified. Treatment of rib fractures is not difficult; however, attention to the underlying structures is critical.
References Aitken AP, Lincoln RE. Fracture of the first rib due to muscle pull. New England Journal of Medicine 110: 1063-1064, 1939 Albers JE, Rath RK, et al. Severity of intrathoracic injuries associated with first rib fractures. Annals of Thoracic Surgery 33: 614-618, 1982 Alderson BR. Further observations on fracture of the first rib. British Journal of Radiology 20: 345-359, 1947 Aspin J. Anomalous ossification of ribs as a cause of pseudoarthrosis. British Journal of Radiology 23: 15-17, 1950 Bailey P. Surfer's rib: isolated first rib fracture secondary to indirect trauam. Annals of Emergency Medicine 141: 346-349, 1985 Barrett GR, Shelton WR, Miles JW. First rib fractures in football players. 16: 674-676, 1988 Bassett JS, Gibson RD, et al. Blunt injuries to the chest. Journal of Trauma 8: 418-429, 1968
69
Blichert-Toft M. Fatigue fractures of the first rib. Acta Chirurgica Scandinavica 135: 675-678, 1968 Borrie J. Management of thoracic emergencies, 3rd ed., Appleton Century-Crofts, Englewood Oiffs, NJ, 1980 Breslin FJ. Fractures of the first rib unassociated with fractures of other ribs. American Journal of Surgery 35: 384-389, 1937 Brooke R. Jive fracture of the first rib. Journal of Bone and Joint Surgery 41B: 370-371, 1959 Cain TE, et al. Use of the air inflated jacket in football. American Journal of Sports Medicine 9: 240-243, 1981 Curran JP, Kelley DA. Stress fracture of the first rib. American Journal of Orthopedics 8: 16-18, 1966 Fordham SO. The significance of first fib fractures. Medical Times 105: 118-119, 1977 Freiberger RH, Mayer V. Ununited bilateral fatigue fractures of the first ribs. a case report and review of the literature. Journal of Bone and Joint Surgery 46A, 615-618, 1964 Glinz W. Problems caused by the unstable thoracic wall and by cardiac injury due to blunt injury. Injury 17: 322-326, 1986 Griffin EH, Minnis JF. Traumatic fracture displacement of the first rib. New York Journal of Medicine 57: 2407-2408, 1957 Gurtler R, Pavlov H, Torg JS. Stress fracture of the ipsilateral first rib in a pitcher. American Journal of Sports Medicine 13: 277-279, 1985 Hartley JB. Stress fractures of the first rib. Lancet I: 446-447, 1945 Jenkins SA. Spontaneous fractures of both first ribs. Journal of Bone and Joint Surgery 34B: 9-13, 1952 Kirsch MM, Sloan H. Injuries to the chest wall. In Blunt chest trauma, Little, Brown and Co, Boston, 1977 Lankenner PA, Micheli U. Stress fracture of the first rib: a case report. Journal of Bone and Joint Surgery 67A: 159-160, 1985 Lehman RC. Thoracoabdominal musculoskeletal injuries in racquet sports. Oinics in Sports Medicine 7: 267-276, 1988 Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthopaedica Scandinavica 47: 632-634, 1976 Mackersie RC, et al. Continuous epidural fentanyl analgesia: ventilatory function improvement with routine use in treatment of blunt chest injury. Journal of Trauma 27: 1207-1212, 1987 Pereira J. Stress fracture of a rib. British Journal of Sports Medicine 19: 26, 1985 Phillips EG, Rogers WF, Gaspar MR. First rib fractures; incidence of vascular injury and indications for angiography. Surgery 89: 4247, 1981 Powell Fl. Fracture of the first rib; its occurrence and clinical diagnosis. British Medical Journal I: 282-285, 1950 Roy S, Irvin R. Chest, abdominal and genital injuries. In Sports medicine, Prentice-Hall, Inc, Englewood Cliffs NJ, 1983 Rutherford RB. Thoracic injuries. In The management of trauma, 3rd ed., WB Saunders Co, 1979 Sacchetti AD, Beswick DR, Morse SO. Rebound rib: stress-induced first rib fractures. Annals of Emergency Medicine 12: 177-179,1983 Steichen FM. Intercostal nerve block for rib fractures. Surgical Rounds 78-79, 1985 Tullos HW, Erwin WO, Woods GW, et al. Unusual lesions of the pitching arm. Clinical Orthopedics 88: 169-182, 1972 Yee ES, Thomas AN, Goodman PC. Isolated first rib fracture: clinical significance after blunt chest trauma. Annals of Thoracic Surgery 32: 278-282, 1981 Correspondence and reprints: Dr Gene R. Barrett, Mississippi Sports Medicine and Orthopedic Center, 1325 Fortification Sum, Jackson, MS 39202, USA.
