(Kiosk 2) Spare Ribs Anyone? Unusual Presentation of 1st Rib Fracture

Case Diagnosis: Non-Traumatic First Rib Fracture

Case Description or Program Description: A 26-year-old female with a history of chronic upper back pain/tightness onset 2 years prior to the office visit. The patient reported right-sided neck and shoulder pain rated a 6/10 on the Visual Analogue Scale (VAS) for the last month with numbness and tingling down the right arm exacerbated by overhead motion and reaching for objects. She reported a recent right cervical medial branch block (MBB) with an interventional pain physician with no relief.

Setting: Outpatient Clinic

Assessment/Results: The patient was referred after an unsuccessful MBB. Physical examination revealed tenderness in the right rhomboid and lower trapezius region and limited active range of motion of the cervical spine in rotation. Special tests, Spurling and cervical facet loading, were negative. Follow-up X-ray imaging of the cervical spine revealed a subacute right lateral first rib fracture. The patient started physical therapy, with significant improvement in pain rated at 1/10 on the VAS.

Discussion (relevance): Fractures of the first rib are infrequent and typically caused by severe direct trauma. This case emphasizes the possibility that low-velocity injuries can also lead to first rib fractures, and may be associated with strong muscle contractures of the anterior scalene or the serratus anterior. Diagnosis is intricate given the close association of many major anatomical structures, necessitating physical examination of all major structures associated, as well as ordering imaging. Diagnosis is usually made with chest radiography and CT scan. Treatment for low-velocity first rib fractures is mainly conservative, including analgesia and physical therapy to emphasize proper mechanics and eliminate movement patterns to avoid recurrence.

Conclusions: Fractures of the first rib are rare and typically cause by severe direct trauma, however, they can also result from low-velocity injuries associated with muscle contractions. Diagnosis is typically made with imaging studies and treatment is mainly conservative, with physical therapy being the initial choice.