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Neurogenic Thoracic Outlet Syndrome Secondary to Non-union of Unrecognised First Rib Fracture
EJVES Extra 7, 40–42 (2004) doi: 10.1016/j.ejvsextra.2004.01.002, available online at http://www.sciencedirect.com on
SHORT REPORT
Neurogenic Thoracic Outlet Syndrome Secondary to Non-union of Unrecognised First Rib Fracture S. Subramonia* and J. D. Holdsworth Department of General Surgery, Cumberland Infirmary, Carlisle, UK Isolated fracture of the first rib resulting from indirect trauma is well recognised but may remain undiagnosed. We present a case of non-union of this fracture leading to thoracic outlet syndrome, for which surgical intervention was required. Key Words: Thoracic outlet syndrome; First rib fracture; Non-union of a fracture.
Introduction Isolated fracture of the first rib is uncommon but well recognised and for which the mechanism of injury is thought to be indirect trauma associated with sporting and other activities.1 – 4 Uneventful healing is the rule. We report a case of isolated fracture of the first rib which was undiagnosed at the time of injury and presented 2 years later with symptoms of neurogenic thoracic outlet syndrome and radiological evidence of non-union.
Case Report A 19-year-old farmer had, 2 years prior to presentation, jumped over a wall and suffered acute pain in the right shoulder that debilitated him for 4 weeks. From that time he had intermittent exacerbations of pain and discomfort in the shoulder and neck with tingling down the arm. This prevented him from driving farm vehicles and heavy lifting. On examination, there was no visible abnormality of the shoulder but supraclavicular tenderness was elicited and pulses were normal in all positions of the arm. Left lateral flexion of the head produced pain and paraesthesia radiating down the arm. Stress testing of the arm induced the symptoms *Corresponding author. Mr S. Subramonia, Registrar in Surgery, Department of Surgery, Cumberland Infirmary, Carlisle, Cumbria CA2 7JL, UK. E-mail: [email protected].
and could only be sustained for one and a half minutes. There was no evidence of sensory loss or motor weakness. Radiography (Fig. 1) of the right first rib demonstrated a radiolucent gap in the centre of the rib with abnormal callus formation consistent with a non-union of a fracture. It was considered that this finding was responsible for the symptoms. A supraclavicular exploration was performed with anterior and middle scalenectomy and removal of the central portion of the rib to include the fracture and callus. Postoperative recovery was uneventful and at six weeks followup he had recovered completely and was able to undertake those activities that were previously limited.
Discussion The first rib is situated deeply and is well protected by the muscles and bones of the shoulder girdle. Direct trauma resulting in a fracture of the first rib usually occurs in association with injuries to the surrounding bones, subclavian vessels, brachial plexus or with significant intrathoracic injuries.5,6 In contrast, isolated fractures of the first rib may follow indirect trauma and have been reported to occur with various activities such as surfing,2 gymnastics3 and weight lifting.4 This injury probably results from sudden strong contraction of the scalenus anterior muscle combined
1533–3167/030040 + 03/0 q 2004 Elsevier Ltd. Open access under CC BY-NC-ND license.
Neurogenic Thoracic Outlet Syndrome
41
Fig. 1. AP and lateral views showing non-union of a right first rib fracture.
with traction of the arm. Scalenus anterior exerts an upward pull through its attachment to the scalene tubercle of the rib and serratus anterior exerts a downward pull through its attachment to the posterior third of the rib and these opposing forces cause a fracture through the weakest part of the rib at the groove for the subclavian artery lateral to the scalene tubercule.1 Thoracic outlet syndrome comprises arterial, venous or neurological components, or any combination of these, and results from compression of the neurovascular bundle at any point between the thoracic outlet and the axilla. Neurogenic thoracic outlet syndrome, the most frequently occurring symptom complex, results in pain, paraesthesia and numbness in the distribution of the affected nerves of the brachial plexus. Late sequelae include sensory loss, motor weakness and atrophy. Most cases of neurogenic thoracic outlet syndrome follow some form of
neck trauma but non-union of a fracture of the first rib has only been reported on rare occasions.3,7,8 In our case, the rib fracture was unrecognised for 2 years prior to presentation. Thus an isolated fracture of the first rib can remain undiagnosed especially since this can follow relatively insignificant trauma. Furthermore, if non-union occurs, as in this case, there is the potential for developing thoracic outlet syndrome and this has to be considered as one of the causes of this syndrome.
References 1 Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthop Scand 1976; 47(6):632–634. 2 Bailey P. Surfer’s rib: isolated first rib fracture secondary to indirect trauma. Ann Emerg Med 1985; 14(4):346–349. 3 Proffer DS, Patton JJ, Jackson DW. Nonunion of a first rib fracture in a gymnast. Am J Sports Med 1991; 19(2):198–201. EJVES Extra, 2004
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S. Subramonia and J. D. Holdsworth
4 Mikawa Y, Kobori M. Stress fracture of the first rib in a weightlifter. Arch Orthop Trauma Surg 1991; 110(2):121–122. 5 Albers JE, Rath RK, Glaser RS, Poddar PK. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg 1982; 33(6):614–618. 6 Attia MW, Russell J. Isolated first rib fracture in a high school lacrosse player. Pediatr Emerg Care 2000; 16(1):31–32. 7 Jeung-Tak S, Byung-Guk P, Chong-II Y. Hypertrophic non-union
EJVES Extra, 2004
of the first rib causing thoracic outlet syndrome: a case report. J Korean Med Sci 2001; 16:673–676. 8 Borrelly J, Merle M, Hubert J, Grosdidier G, Wack B. Compression of the brachial plexus by a pseudarthrosis of the 1st rib. Ann Chir Main 1984; 3(3):266–268. Accepted 20 January 2004
SHORT REPORT
Neurogenic Thoracic Outlet Syndrome Secondary to Non-union of Unrecognised First Rib Fracture S. Subramonia* and J. D. Holdsworth Department of General Surgery, Cumberland Infirmary, Carlisle, UK Isolated fracture of the first rib resulting from indirect trauma is well recognised but may remain undiagnosed. We present a case of non-union of this fracture leading to thoracic outlet syndrome, for which surgical intervention was required. Key Words: Thoracic outlet syndrome; First rib fracture; Non-union of a fracture.
Introduction Isolated fracture of the first rib is uncommon but well recognised and for which the mechanism of injury is thought to be indirect trauma associated with sporting and other activities.1 – 4 Uneventful healing is the rule. We report a case of isolated fracture of the first rib which was undiagnosed at the time of injury and presented 2 years later with symptoms of neurogenic thoracic outlet syndrome and radiological evidence of non-union.
Case Report A 19-year-old farmer had, 2 years prior to presentation, jumped over a wall and suffered acute pain in the right shoulder that debilitated him for 4 weeks. From that time he had intermittent exacerbations of pain and discomfort in the shoulder and neck with tingling down the arm. This prevented him from driving farm vehicles and heavy lifting. On examination, there was no visible abnormality of the shoulder but supraclavicular tenderness was elicited and pulses were normal in all positions of the arm. Left lateral flexion of the head produced pain and paraesthesia radiating down the arm. Stress testing of the arm induced the symptoms *Corresponding author. Mr S. Subramonia, Registrar in Surgery, Department of Surgery, Cumberland Infirmary, Carlisle, Cumbria CA2 7JL, UK. E-mail: [email protected].
and could only be sustained for one and a half minutes. There was no evidence of sensory loss or motor weakness. Radiography (Fig. 1) of the right first rib demonstrated a radiolucent gap in the centre of the rib with abnormal callus formation consistent with a non-union of a fracture. It was considered that this finding was responsible for the symptoms. A supraclavicular exploration was performed with anterior and middle scalenectomy and removal of the central portion of the rib to include the fracture and callus. Postoperative recovery was uneventful and at six weeks followup he had recovered completely and was able to undertake those activities that were previously limited.
Discussion The first rib is situated deeply and is well protected by the muscles and bones of the shoulder girdle. Direct trauma resulting in a fracture of the first rib usually occurs in association with injuries to the surrounding bones, subclavian vessels, brachial plexus or with significant intrathoracic injuries.5,6 In contrast, isolated fractures of the first rib may follow indirect trauma and have been reported to occur with various activities such as surfing,2 gymnastics3 and weight lifting.4 This injury probably results from sudden strong contraction of the scalenus anterior muscle combined
1533–3167/030040 + 03/0 q 2004 Elsevier Ltd. Open access under CC BY-NC-ND license.
Neurogenic Thoracic Outlet Syndrome
41
Fig. 1. AP and lateral views showing non-union of a right first rib fracture.
with traction of the arm. Scalenus anterior exerts an upward pull through its attachment to the scalene tubercle of the rib and serratus anterior exerts a downward pull through its attachment to the posterior third of the rib and these opposing forces cause a fracture through the weakest part of the rib at the groove for the subclavian artery lateral to the scalene tubercule.1 Thoracic outlet syndrome comprises arterial, venous or neurological components, or any combination of these, and results from compression of the neurovascular bundle at any point between the thoracic outlet and the axilla. Neurogenic thoracic outlet syndrome, the most frequently occurring symptom complex, results in pain, paraesthesia and numbness in the distribution of the affected nerves of the brachial plexus. Late sequelae include sensory loss, motor weakness and atrophy. Most cases of neurogenic thoracic outlet syndrome follow some form of
neck trauma but non-union of a fracture of the first rib has only been reported on rare occasions.3,7,8 In our case, the rib fracture was unrecognised for 2 years prior to presentation. Thus an isolated fracture of the first rib can remain undiagnosed especially since this can follow relatively insignificant trauma. Furthermore, if non-union occurs, as in this case, there is the potential for developing thoracic outlet syndrome and this has to be considered as one of the causes of this syndrome.
References 1 Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthop Scand 1976; 47(6):632–634. 2 Bailey P. Surfer’s rib: isolated first rib fracture secondary to indirect trauma. Ann Emerg Med 1985; 14(4):346–349. 3 Proffer DS, Patton JJ, Jackson DW. Nonunion of a first rib fracture in a gymnast. Am J Sports Med 1991; 19(2):198–201. EJVES Extra, 2004
42
S. Subramonia and J. D. Holdsworth
4 Mikawa Y, Kobori M. Stress fracture of the first rib in a weightlifter. Arch Orthop Trauma Surg 1991; 110(2):121–122. 5 Albers JE, Rath RK, Glaser RS, Poddar PK. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg 1982; 33(6):614–618. 6 Attia MW, Russell J. Isolated first rib fracture in a high school lacrosse player. Pediatr Emerg Care 2000; 16(1):31–32. 7 Jeung-Tak S, Byung-Guk P, Chong-II Y. Hypertrophic non-union
EJVES Extra, 2004
of the first rib causing thoracic outlet syndrome: a case report. J Korean Med Sci 2001; 16:673–676. 8 Borrelly J, Merle M, Hubert J, Grosdidier G, Wack B. Compression of the brachial plexus by a pseudarthrosis of the 1st rib. Ann Chir Main 1984; 3(3):266–268. Accepted 20 January 2004