Original Article
Spontaneous rib fractures Ozgur Katrancioglu1, Yucel Akkas2, Sulhattin Arslan3 and Ekber Sahin1
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 701–703 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315586485 aan.sagepub.com
Abstract Background: Other than trauma, rib fracture can occur spontaneously due to a severe cough or sneeze. In this study, patients with spontaneous rib fractures were analyzed according to age, sex, underlying pathology, treatment, and complications. Methods: Twelve patients who presented between February 2009 and February 2011 with spontaneous rib fracture were reviewed retrospectively. The patients’ data were evaluated according to anamnesis, physical examination, and chest radiographs. Results: The ages of the patients ranged from 34 to 77 years (mean 55.91 12.20 years), and 7 (58.4%) were male. All patients had severe cough and chest pain. The fractures were most frequently between 4th and 9th ribs; multiple rib fractures were detected in 5 (41.7%) patients. Eight (66.7%) patients had chronic obstructive pulmonary disease, 2 (16.7%) had bronchial asthma, and 2 (16.7%) had osteoporosis. Bone densitometry revealed a high risk of bone fracture in all patients. Patients with chronic obstructive pulmonary disease or bronchial asthma had been treated with high-dose steroids for over a year. Conclusions: Spontaneous rib fracture due to severe cough may occur in patients with osteoporosis, chronic obstructive pulmonary disease, or bronchial asthma, receiving long-term steroid therapy. If these patients have severe chest pain, chest radiography should be performed to check for bone lesions.
Keywords Asthma, Chest pain, Cough, Osteoporosis, Pulmonary disease, chronic obstructive, Rib fractures
Introduction Rib fractures are classified as traumatic and nontraumatic. The most common cause of rib fracture is thoracic trauma; 35% to 40% of thoracic injuries cause rib fractures.1 Rib fractures may also arise spontaneously due to a severe cough or sneeze. Reports of spontaneous rib fracture are generally not comprehensive series but case reports. The aim of our study was to evaluate patients with spontaneous rib fracture according to age, sex, underlying pathology, treatment, and complications.
Patients and methods The study was approved by the ethics committee for clinical research at the Cumhuriyet University Faculty of Medicine (date/number: 31.05.2011/159). The data of 12 patients with rib fractures and no previous history of trauma, who consulted our hospital between
February 2009 and February 2011, were reviewed retrospectively. Seven (58.4%) patients were male and 5 (41.6%) were female. Their ages ranged from 34 to 77 years (mean 55.91 12.20 years). All patients complained of severe cough and chest pain. The patients were evaluated according to anamnesis, physical examinations, and chest radiographs. During physical examination by palpation, increased sensitivity was present in the costal fracture areas. 1 Department of Thoracic Surgery, Cumhuriyet University School of Medicine, Sivas, Turkey 2 Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey 3 Department of Chest Diseases, Cumhuriyet University School of Medicine, Sivas, Turkey
Corresponding author: Yucel Akkas, MD, Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
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Asian Cardiovascular & Thoracic Annals 23(6)
Posteroanterior chest radiographs of the patients were obtained, and costal fractures, pneumothorax, hemothorax, and atelectasis were evaluated. We used only chest radiography to diagnose rib fractures. Patients with costal fractures were hospitalized. All patients with fractures were asked whether they took steroids for the treatment of diseases such as chronic obstructive pulmonary disease (COPD) or asthma, or had a history of osteoporosis. A specialist consultation was requested when confirmation of COPD or asthma was needed. The patients were treated with intercostal nerve blockade, intravenous or intramuscular analgesics, expectorants, deep tracheal aspiration, and oxygen therapy. Bone mineral densities were measured in all patients, and those with T-scores below 2.5 were considered to be osteoporotic (at increased risk of bone fracture). A physiotherapy and rehabilitation consultation was requested for patients with a diagnosis of osteoporosis. All patients were evaluated by physical examination and chest radiography throughout their hospital stay. There were no findings that suggested malignancy in the patients’ histories, physical examinations, routine blood tests, or chest radiographs, therefore, we did not search for malignant tumors, myeloma, or lymphomas involving the systemic bone system. Patients who showed improvement and had no complications such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, or lung hernia, according to their chest radiographs, were discharged. Study data were evaluated with Statistical Package for the Social Sciences version 14.0 software (SPSS, Inc., Chicago, IL, USA), and frequency ranges were examined. Data are given as mean standard deviation.
Results The fractures were mostly in the 4th to 9th ribs. Multiple rib fractures were present in 5 (41.7%) patients. No differences were observed in patients with one rib fracture and those with multiple rib fractures, according to etiology such as COPD, asthma, or osteoporosis, but patients with multiple rib fractures suffered more chest pain than these with a single rib fracture. The mean duration of hospitalization was 4.00 1.47 days (range 3–7 days). Eight (66.7%) patients had COPD, 2 (16.7%) had bronchial asthma, and 2 (16.7%) had a history of osteoporosis. Eight of the patients with COPD or bronchial asthma had used high-dose inhalation therapies and frequent courses of systemic steroids during periods of acute attack. Bone mineral density measurements showed a high risk of bone fractures with T-scores below 2.5 in all patients. There were no complications resulting from the rib
fractures, such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, or lung hernia.
Discussion While the most frequent cause of rib fracture is trauma, fractures are also caused by an increase in intrathoracic pressure due to coughing or lifting heavy loads. Nontraumatic spontaneous rib fracture may be seen following a severe cough in patients with osteoporosis or those receiving high-dose steroid therapy. Coughing is a defense mechanism of the lower respiratory tract. Inspiratory and expiratory muscles are contracted in the coughing mechanism, and various complications may arise due to the great alterations in intrapleural pressure.2–4 Coughing sends an opposite-directed force into the ribs, which is sometimes more than they can tolerate. Thus stress fractures may develop in a weak region of the bone.2,5 Repetitive trauma such as paroxysmal coughing causes fractures, especially in the weakest rib (the 3rd rib).5 In a national study, fractures caused by coughing were reported in the 7th or 8th rib in 2 cases, whereas the first rib was reported to be the most common location of rib fractures in international studies.2,3,5–8 In our study, severe coughing and a subsequent history of severe chest pain were present in all patients. Multiple rib fractures were present in 5 (41.7%) patients, whereas one fracture was present in 7 (58.3%). The fractures were mostly between the 4th and 9th ribs. Transdiaphragmatic lung herniation towards the outer part of the chest wall following spontaneous rib fracture caused by severe coughing has been reported in the literature.9,10 However, no lung herniation was observed among our patients. Radiological diagnosis of coughing-induced spontaneous fracture is possible by plain chest radiography.2 Thin-section helical computed tomography, focused particularly on the most painful area, can also diagnose this kind of fracture.11 Vrbanic and colleagues12 reported that focal osteolytic lesions of the costae are the first sign of osteoporosis, and diagnosis may be performed by plain radiography and bone densitometry.13 The diagnoses of our patients were obtained by chest radiography and bone mineral densitometry. Spontaneous rib fractures have been reported familially and are sometimes due to the over-expression of certain genes that include information on bones.14,15 The morphogenetic proteins of bone are expressed in the skeletal tissue, stored in the bone and cartilage, and play a role in the development and strength of bony masses in the affected region, particularly in adults. Some authors have reported that over-expression of the BMP3 gene may cause spontaneous rib fractures.15 Mohammed and colleagues14 reported the case
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
Katrancioglu et al.
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of a woman with spontaneous rib fracture due to familial hypocalciuric hypercalcemia. No genetic disease was present in the anamneses of our patients. Systemic steroids (especially oral steroids) are prescribed by physicians to treat inflammatory diseases such as obstructive respiratory tract disease or rheumatoid arthritis, and the risk of bone fracture increases in patients treated with oral steroids.16–19 De Vries and colleagues16 investigated the risk of bone fracture in patients using intermittent high-dose oral steroids, and found a minimal osteoporotic fracture risk increase in patients using a daily dose >15 mg and a cumulative exposure 15 mg and a cumulative exposure >1 mg. Similarly, our patients were long-term high-dose inhaled steroid users due to COPD or bronchial asthma. In addition, long-term inhalants and high-dose oral systemic steroids were used on a few occasions by COPD and asthma patients during attack periods. Pharmacological treatment and close clinical observation are applied in the treatment of spontaneous rib fractures. If complications are observed, such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, lung hernia, tube thoracostomy and surgical intervention may be indicated.2–4 These complications were not observed in our patients, so pharmacological treatment and close clinical observation were the first choices of therapy in our patients. We concluded that spontaneous rib fracture may occur due to severe coughing in patients with COPD or asthma who are using long-term inhaled steroids and receiving systemic steroids during their acute attack periods, and in patients with osteoporosis. Rib fracture does not necessarily develop due to a history of trauma, thus patients with chest pain should be evaluated for fractures by radiography. Presented at the Turkish National Thoracic Surgery VI. Annual Congress, Antalya, Turkey, April 28–May 1, 2011, and the European Respiratory Society Annual Congress, Vienna, Austria, September 1–5, 2012.
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Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors. 17.
Conflict of interest statement None declared.
18.
References 1. Soysal O¨. Ku¨nt toraks travmaları. In: Yu¨ksel M, Kalaycı G (eds) Go¨g˘u¨s Cerrahisi. Istanbul: Bilmedya Grup, 2001, pp. 447–464. 2. Kılıc¸ Dalokay, Fındıkog˘lu A, Hatipog˘lu A. Spontaneous rib fracture caused by coughing: report of two cases. Turkiye Klinikleri J Med Sci 2007;27:468–70.
19.
Available at: http://www.turkiyeklinikleri.com/article/enspontaneous-rib-fracture-caused-by-coughing-report-oftwo-cases-47694.html. Accessed April 19, 2015. George L, Rehman SU and Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000; 117: 1200–1201. Ross RT and Burnett CM. Atraumatic lung hernia. Ann Thorac Surg 1999; 67: 1496–1497. Leung HY and Stirling AJ. Stress fracture of the first rib without associated injuries. Injury 1991; 22: 483–484. Mikawa Y and Kobori M. Stress fracture of the first rib in a weightlifter. Arch Orthop Trauma Surg 1991; 110: 121–122. Sternfeld M, Hay E and Eliraz A. Postnasal drip causing multiple cough fractures. Ann Emerg Med 1992; 21: 587. Derbes VJ and Haran T. Rib fractures from muscular effort with particular reference to cough. Surgery 1954; 35: 294–321. Henriques AC, Malena CR, Freitas AC, Waisberg J and Pires AC. Transdiaphragmatic intercostal hernia after spontaneous rib fractures secondary to coughing fit. Rev Col Bras Cir 2010; 37: 78–80. Schnu¨riger B and Lerf B. Unstable thorax after a coughing fit in a 70-year-old adipose patient. Chirurg 2006; 77: 459–462. De Maeseneer M, De Mey J, Debaere C, Meysman M and Osteaux M. Rib fractures induced by coughing: an unusual cause of acute chest pain. Am J Emerg Med 2000; 18: 194–197. Vrbanic TS, Novak S, Sestan B, Tudor A and Gulan G. A case of pathological rib fractures: focal osteolysis or osteoporosis? West Indian Med J 2008; 57: 178–181. Suga K, Nishigauchi K, Fujita T, et al. Bone scintigraphy in two cases with cough related stress fractures of rib. Kaku Igaku 1992; 29: 495–499. Mohammed R, Bray MB, Koch CA and Uwaifo GI. Spontaneous rib fractures in a black woman with familial hypocalciuric hypercalcemia. Med Sci Monit 2008; 14: CS102–CS106. Gamer LW, Cox K, Carlo JM and Rosen V. Overexpression of BMP3 in the Developing Skeleton Alters Endochondral Bone Formation Resulting in Spontaneous Rib Fractures. Dev Dyn 2009; 238: 2374–2381. De Vries F, Bracke M, Leufkens HG, Lammers JW, Cooper C and Van Staa TP. Fracture risk with intermittent high-dose oral glucocorticoid therapy. Arthritis Rheum 2007; 56: 208–214. Kanis JA, Johansson H, Oden A, et al. A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 2004; 19: 893–899. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B and Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res 2000; 15: 993–1000. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B and Cooper C. Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. Rheumatology (Oxford) 2000; 39: 1383–1389.
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
Spontaneous rib fractures Ozgur Katrancioglu1, Yucel Akkas2, Sulhattin Arslan3 and Ekber Sahin1
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 701–703 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315586485 aan.sagepub.com
Abstract Background: Other than trauma, rib fracture can occur spontaneously due to a severe cough or sneeze. In this study, patients with spontaneous rib fractures were analyzed according to age, sex, underlying pathology, treatment, and complications. Methods: Twelve patients who presented between February 2009 and February 2011 with spontaneous rib fracture were reviewed retrospectively. The patients’ data were evaluated according to anamnesis, physical examination, and chest radiographs. Results: The ages of the patients ranged from 34 to 77 years (mean 55.91 12.20 years), and 7 (58.4%) were male. All patients had severe cough and chest pain. The fractures were most frequently between 4th and 9th ribs; multiple rib fractures were detected in 5 (41.7%) patients. Eight (66.7%) patients had chronic obstructive pulmonary disease, 2 (16.7%) had bronchial asthma, and 2 (16.7%) had osteoporosis. Bone densitometry revealed a high risk of bone fracture in all patients. Patients with chronic obstructive pulmonary disease or bronchial asthma had been treated with high-dose steroids for over a year. Conclusions: Spontaneous rib fracture due to severe cough may occur in patients with osteoporosis, chronic obstructive pulmonary disease, or bronchial asthma, receiving long-term steroid therapy. If these patients have severe chest pain, chest radiography should be performed to check for bone lesions.
Keywords Asthma, Chest pain, Cough, Osteoporosis, Pulmonary disease, chronic obstructive, Rib fractures
Introduction Rib fractures are classified as traumatic and nontraumatic. The most common cause of rib fracture is thoracic trauma; 35% to 40% of thoracic injuries cause rib fractures.1 Rib fractures may also arise spontaneously due to a severe cough or sneeze. Reports of spontaneous rib fracture are generally not comprehensive series but case reports. The aim of our study was to evaluate patients with spontaneous rib fracture according to age, sex, underlying pathology, treatment, and complications.
Patients and methods The study was approved by the ethics committee for clinical research at the Cumhuriyet University Faculty of Medicine (date/number: 31.05.2011/159). The data of 12 patients with rib fractures and no previous history of trauma, who consulted our hospital between
February 2009 and February 2011, were reviewed retrospectively. Seven (58.4%) patients were male and 5 (41.6%) were female. Their ages ranged from 34 to 77 years (mean 55.91 12.20 years). All patients complained of severe cough and chest pain. The patients were evaluated according to anamnesis, physical examinations, and chest radiographs. During physical examination by palpation, increased sensitivity was present in the costal fracture areas. 1 Department of Thoracic Surgery, Cumhuriyet University School of Medicine, Sivas, Turkey 2 Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey 3 Department of Chest Diseases, Cumhuriyet University School of Medicine, Sivas, Turkey
Corresponding author: Yucel Akkas, MD, Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
702
Asian Cardiovascular & Thoracic Annals 23(6)
Posteroanterior chest radiographs of the patients were obtained, and costal fractures, pneumothorax, hemothorax, and atelectasis were evaluated. We used only chest radiography to diagnose rib fractures. Patients with costal fractures were hospitalized. All patients with fractures were asked whether they took steroids for the treatment of diseases such as chronic obstructive pulmonary disease (COPD) or asthma, or had a history of osteoporosis. A specialist consultation was requested when confirmation of COPD or asthma was needed. The patients were treated with intercostal nerve blockade, intravenous or intramuscular analgesics, expectorants, deep tracheal aspiration, and oxygen therapy. Bone mineral densities were measured in all patients, and those with T-scores below 2.5 were considered to be osteoporotic (at increased risk of bone fracture). A physiotherapy and rehabilitation consultation was requested for patients with a diagnosis of osteoporosis. All patients were evaluated by physical examination and chest radiography throughout their hospital stay. There were no findings that suggested malignancy in the patients’ histories, physical examinations, routine blood tests, or chest radiographs, therefore, we did not search for malignant tumors, myeloma, or lymphomas involving the systemic bone system. Patients who showed improvement and had no complications such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, or lung hernia, according to their chest radiographs, were discharged. Study data were evaluated with Statistical Package for the Social Sciences version 14.0 software (SPSS, Inc., Chicago, IL, USA), and frequency ranges were examined. Data are given as mean standard deviation.
Results The fractures were mostly in the 4th to 9th ribs. Multiple rib fractures were present in 5 (41.7%) patients. No differences were observed in patients with one rib fracture and those with multiple rib fractures, according to etiology such as COPD, asthma, or osteoporosis, but patients with multiple rib fractures suffered more chest pain than these with a single rib fracture. The mean duration of hospitalization was 4.00 1.47 days (range 3–7 days). Eight (66.7%) patients had COPD, 2 (16.7%) had bronchial asthma, and 2 (16.7%) had a history of osteoporosis. Eight of the patients with COPD or bronchial asthma had used high-dose inhalation therapies and frequent courses of systemic steroids during periods of acute attack. Bone mineral density measurements showed a high risk of bone fractures with T-scores below 2.5 in all patients. There were no complications resulting from the rib
fractures, such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, or lung hernia.
Discussion While the most frequent cause of rib fracture is trauma, fractures are also caused by an increase in intrathoracic pressure due to coughing or lifting heavy loads. Nontraumatic spontaneous rib fracture may be seen following a severe cough in patients with osteoporosis or those receiving high-dose steroid therapy. Coughing is a defense mechanism of the lower respiratory tract. Inspiratory and expiratory muscles are contracted in the coughing mechanism, and various complications may arise due to the great alterations in intrapleural pressure.2–4 Coughing sends an opposite-directed force into the ribs, which is sometimes more than they can tolerate. Thus stress fractures may develop in a weak region of the bone.2,5 Repetitive trauma such as paroxysmal coughing causes fractures, especially in the weakest rib (the 3rd rib).5 In a national study, fractures caused by coughing were reported in the 7th or 8th rib in 2 cases, whereas the first rib was reported to be the most common location of rib fractures in international studies.2,3,5–8 In our study, severe coughing and a subsequent history of severe chest pain were present in all patients. Multiple rib fractures were present in 5 (41.7%) patients, whereas one fracture was present in 7 (58.3%). The fractures were mostly between the 4th and 9th ribs. Transdiaphragmatic lung herniation towards the outer part of the chest wall following spontaneous rib fracture caused by severe coughing has been reported in the literature.9,10 However, no lung herniation was observed among our patients. Radiological diagnosis of coughing-induced spontaneous fracture is possible by plain chest radiography.2 Thin-section helical computed tomography, focused particularly on the most painful area, can also diagnose this kind of fracture.11 Vrbanic and colleagues12 reported that focal osteolytic lesions of the costae are the first sign of osteoporosis, and diagnosis may be performed by plain radiography and bone densitometry.13 The diagnoses of our patients were obtained by chest radiography and bone mineral densitometry. Spontaneous rib fractures have been reported familially and are sometimes due to the over-expression of certain genes that include information on bones.14,15 The morphogenetic proteins of bone are expressed in the skeletal tissue, stored in the bone and cartilage, and play a role in the development and strength of bony masses in the affected region, particularly in adults. Some authors have reported that over-expression of the BMP3 gene may cause spontaneous rib fractures.15 Mohammed and colleagues14 reported the case
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
Katrancioglu et al.
703
of a woman with spontaneous rib fracture due to familial hypocalciuric hypercalcemia. No genetic disease was present in the anamneses of our patients. Systemic steroids (especially oral steroids) are prescribed by physicians to treat inflammatory diseases such as obstructive respiratory tract disease or rheumatoid arthritis, and the risk of bone fracture increases in patients treated with oral steroids.16–19 De Vries and colleagues16 investigated the risk of bone fracture in patients using intermittent high-dose oral steroids, and found a minimal osteoporotic fracture risk increase in patients using a daily dose >15 mg and a cumulative exposure 15 mg and a cumulative exposure >1 mg. Similarly, our patients were long-term high-dose inhaled steroid users due to COPD or bronchial asthma. In addition, long-term inhalants and high-dose oral systemic steroids were used on a few occasions by COPD and asthma patients during attack periods. Pharmacological treatment and close clinical observation are applied in the treatment of spontaneous rib fractures. If complications are observed, such as pneumothorax, pleural effusion, subcutaneous emphysema, hemothorax, hematoma, diaphragmatic rupture, lung hernia, tube thoracostomy and surgical intervention may be indicated.2–4 These complications were not observed in our patients, so pharmacological treatment and close clinical observation were the first choices of therapy in our patients. We concluded that spontaneous rib fracture may occur due to severe coughing in patients with COPD or asthma who are using long-term inhaled steroids and receiving systemic steroids during their acute attack periods, and in patients with osteoporosis. Rib fracture does not necessarily develop due to a history of trauma, thus patients with chest pain should be evaluated for fractures by radiography. Presented at the Turkish National Thoracic Surgery VI. Annual Congress, Antalya, Turkey, April 28–May 1, 2011, and the European Respiratory Society Annual Congress, Vienna, Austria, September 1–5, 2012.
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Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors. 17.
Conflict of interest statement None declared.
18.
References 1. Soysal O¨. Ku¨nt toraks travmaları. In: Yu¨ksel M, Kalaycı G (eds) Go¨g˘u¨s Cerrahisi. Istanbul: Bilmedya Grup, 2001, pp. 447–464. 2. Kılıc¸ Dalokay, Fındıkog˘lu A, Hatipog˘lu A. Spontaneous rib fracture caused by coughing: report of two cases. Turkiye Klinikleri J Med Sci 2007;27:468–70.
19.
Available at: http://www.turkiyeklinikleri.com/article/enspontaneous-rib-fracture-caused-by-coughing-report-oftwo-cases-47694.html. Accessed April 19, 2015. George L, Rehman SU and Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000; 117: 1200–1201. Ross RT and Burnett CM. Atraumatic lung hernia. Ann Thorac Surg 1999; 67: 1496–1497. Leung HY and Stirling AJ. Stress fracture of the first rib without associated injuries. Injury 1991; 22: 483–484. Mikawa Y and Kobori M. Stress fracture of the first rib in a weightlifter. Arch Orthop Trauma Surg 1991; 110: 121–122. Sternfeld M, Hay E and Eliraz A. Postnasal drip causing multiple cough fractures. Ann Emerg Med 1992; 21: 587. Derbes VJ and Haran T. Rib fractures from muscular effort with particular reference to cough. Surgery 1954; 35: 294–321. Henriques AC, Malena CR, Freitas AC, Waisberg J and Pires AC. Transdiaphragmatic intercostal hernia after spontaneous rib fractures secondary to coughing fit. Rev Col Bras Cir 2010; 37: 78–80. Schnu¨riger B and Lerf B. Unstable thorax after a coughing fit in a 70-year-old adipose patient. Chirurg 2006; 77: 459–462. De Maeseneer M, De Mey J, Debaere C, Meysman M and Osteaux M. Rib fractures induced by coughing: an unusual cause of acute chest pain. Am J Emerg Med 2000; 18: 194–197. Vrbanic TS, Novak S, Sestan B, Tudor A and Gulan G. A case of pathological rib fractures: focal osteolysis or osteoporosis? West Indian Med J 2008; 57: 178–181. Suga K, Nishigauchi K, Fujita T, et al. Bone scintigraphy in two cases with cough related stress fractures of rib. Kaku Igaku 1992; 29: 495–499. Mohammed R, Bray MB, Koch CA and Uwaifo GI. Spontaneous rib fractures in a black woman with familial hypocalciuric hypercalcemia. Med Sci Monit 2008; 14: CS102–CS106. Gamer LW, Cox K, Carlo JM and Rosen V. Overexpression of BMP3 in the Developing Skeleton Alters Endochondral Bone Formation Resulting in Spontaneous Rib Fractures. Dev Dyn 2009; 238: 2374–2381. De Vries F, Bracke M, Leufkens HG, Lammers JW, Cooper C and Van Staa TP. Fracture risk with intermittent high-dose oral glucocorticoid therapy. Arthritis Rheum 2007; 56: 208–214. Kanis JA, Johansson H, Oden A, et al. A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 2004; 19: 893–899. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B and Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res 2000; 15: 993–1000. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B and Cooper C. Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. Rheumatology (Oxford) 2000; 39: 1383–1389.
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on June 5, 2016
