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Surfer's rib: Isolated first rib fracture secondary to indirect trauma
CASE REPORT fractures, rib, first, indirect trauma; surfer's rib, diagnosis of
Surfer's Rib: Isolated First Rib Fracture Secondary to Indirect Trauma A case of anterolateral first rib fracture produced by indirect trauma in a surfer is presented. A 17-year-old man was seen in the emergency department with the complaint of left shoulder pain that developed while he performed a so-called lay back maneuver on a surfboard. No history of direct trauma was elicited. After physical examination revealed point tenderness high in the left axilla, radiographic evaluation of the chest showed an isolated fracture of the anterolateral aspect of the left first rib. No morbidity was associated with this fracture which, when produced by other forces, can have serious sequelae. [Bailey P: Surfer's rib: Isolated first rib fracture secondary to indirect trauma. Ann Emerg Med April 1985; 14:346-349.] INTRODUCTION First rib fracture has been described as a "harbinger of serious potential injury "1 since the association between first rib fracture and injury to the subclavian artery was reported in 1869. 2 During the past decade, it was suggested that patients with this fracture undergo arteriography.3 Studies of the usefulness of this procedure as routine when the clinical implication of an isolated first rib fracture is not clear 4 have prompted a more selective approach.3-9 The number of patients with first rib fracture reported in the literature is increasing,4, 6 and the most c o m m o n etiology is direct trauma from motor vehicle accidents.3, 6 Indirect mechanisms include shoveling, digging, plowing, and use of chest expander exercisers, and injuries from judo, volleyball, baseball, ping pong, rugby, gymnastics, tennis, chinning, 10 basketball, S falling, 6 sneezing, coughing, and heavy lifting. 7 No previous description could be found of a first rib fracture that occurred during surfing. Increasingly it is being recognized that stress-induced first rib fractures can be managed conservatively with outpatient observation. 5 As the more benign nature of stress-induced fractures is recognized, the automatic use of invasive procedures for all first rib fractures may decrease.
Patricia Bailey, MD Harbor City, California From the Department of Emergency Medicine, Kaiser Permanente Medical Care Program, Harbor City, California. Received for publication June 27, 1984. Accepted for publication October 17, 1984. Address for reprints: Patricia Bailey, MD, Department of Emergency Medicine, Kaiser Permanente Medical Care Program, 25825 South Vermont Avenue, Harbor City, California 90710.
CASE REPORT
A 17-year-old man presented with left shoulder pain that he noted while surfing that day. Specifically he felt a sharp pain while performing a lay back maneuver (Figure 1) in which he was crouched on the surfboard with his left arm extended behind him and his hand in the water. He remembered that the onset of pain coincided with a sudden pull on his extended arm by the force of the wave in which his hand was immersed. At the time he was aware of a brief period of shortness of breath. The patient was able to finish the surfing run without difficulty, but he noted pain localized to his left shoulder on all range of motion of his left arm. He denied any direct trauma. Physical examination revealed a muscular, well-developed young man in no acute distress. Vital signs were blood pressure, I10/70 m m Hg in both arms; temperature, 37 C; pulse, 68 and regular; and respirations, 18/min. The head examination was normal with full cervical range of motion. The chest was symmetrical with breath sounds equal bilaterally. The only area of chest tenderness was deep in the left axilla. No node was palpated, and the point tenderness was believed to be on palpation of the chest wall through the axillary tissue. Cardiac auscultation was normal. The left shoulder was non14:4 April 1985
Annals of Emergency Medicine
346/117
SURFER'S RIB Bailey
Fig. 1. Patient reproducing position inducing first rib fracture. In this lay back m a n e u v e r the p a t i e n t was crouched on the surfboard with the left hand dragging in the water. Fig. 2. Detail of chest film. Note anterior first rib fracture (arrow).
tender to palpation, but there was pain in the proximal upper arm along the course of the triceps on range of motion, especially with posterior extension of the arm. No tenderness was palpable along the humerus or biceps. Posteroanterior and lateral views of the chest were obtained, and a clearly visible f r a c t u r e t h r o u g h the anterolateral aspect of the left first rib was noted (Figure 2). There was a 3-ram separation of the fracture fragments, b u t no d i s p l a c e m e n t . T h e m e d i astinum did not appear widened, and no other pathology was noted on the films. An e l e c t r o c a r d i o g r a m (ECG) was normal. After telephone consultation, the patient was treated with a sling and analgesia and was discharged. Followup chest radiograph and electrocardiogram the next day were unchanged, and the patient had no complications during the ensuing weeks. One month after injury there was no discomfort w h e n t h e p a t i e n t r e p r o d u c e d the movements that provoked the injury. At that time he reported that he had resumed surfing against medical advice. There have been no delayed complications.
DISCUSSION The first rib is short, broad, flat, and thick and is in a protected position.7 It was believed for a long time that apparent fractures must be due to congenital abnormalities of the bone, and are not acquired.U Now, however, it is acknowledged that first rib fracture can occur as a result of minor trauma, 6 possibly from a strong contraction of the scalenus anterior muscle c o m b i n e d w i t h t r a c t i o n of t h e arm.5,6,n4~ Stress fracture of the first rib o c c u r s p r i m a r i l y in m u s c u l a r young men, lO,H,14,1s usually through the subclavian artery groove just posterior to the scalene tubercle, which is the weakest portion of the first ribJs When direct trauma is included, however, most first rib fractures tend to be posterior. 4, 7,16 Lazrove and colleagues 3 describe re118/347
Annals of Emergency Medicine
14:4 April 1985
Fig. 3. Musculoskeletal connections of
the first rib.
ScalenusAnt. ~t~'~i!~i~'~?~,\~,~ h~
ScalenusMeal.
Fig. 4. Skeleton reproduction of posi-
tion inducing first rib fracture.
\ f,1~\\~ .... 1stRib Serratos Anterior
s er u ,
InternalMammary:Ti!:i~: ( "P ':::::::::::....::: A r t e i r Y~ A r t e~ lra vyl a n 3
4:4 April 1985
Annals of Emergency Medicine
gions that, when injured, can result in first rib fracture-- thorax, shoulderarm, and head and neck. Each may be the source of isolated trauma or may be combined with either or both of the other regions. Lazrove postulates that the m e c h a n i s m of injury when the shoulder-arm region is involved as an isolated injury is through the connections by the costoclavicular ligament and by the upper digitation of the serratus anterior muscle from the posterior first rib and a fascial band extending between the first and second ribs (Figure 3). A view of a skeleton in approximately the same alignment as the lay back maneuver shows the bony relationships (Figure 4). Sacchetti implicates another possible mechanism of fracture, s He notes t h a t the scalenus a n t i c u s m u s c l e , which originates from multiple cervical vertebrae, inserts on the scalene tubercle on the cephalad surface of the rib. It exerts an upward pull, while the scalenus medius muscle and the first slip of the serratus anterior insert on the cephalad aspect of the posterior third of the rib, and the latter exerts a downward pull on the rib when it contracts, is T h e p r i m a r y s y m p t o m of stress fracture of the first rib is pain. The pain may be localized to the rib, or it may be described as originating in the base of the neck or radiating along the arms or the scapular region 16 or the shoulderJO The i m p o r t a n c e of diagnosis and proper treatment of first rib fracture lies in the potential severity of the resultant injury because of the proximity to major vessels, nerves, and the lung. 6 A u t h o r s w h o primarily have considered first rib fractures with direct trauma etiology have listed various criteria for invasive diagnostic procedures: presentation w i t h other rib injuries;3, 6 marked displacement of the fragments4, 7 (disagreement by Livonig); altered serial chest roentgenograms with increased pleural cap or hemothorax;3, 4 alterations in blood pressure or pulse in the affected extremity;4, z brachial plexus injury;3,4, z and subclavian groove fracture. 4 Sacchetti and colleagues who reported on 348/119
SURFER'S RIB Bailey
a case of stress fracture, state, however, that in general, if no immediate complications are present on exami n a t i o n and chest radiography shows no indication of vascular injury, angiography probably is n o t warranted and the patient can be discharged to close outpatient follow-up. There are no definite guidelines on the length of that follow-up. Hirata notes that the rib takes four to five m o n t h s to heal, lo and in that period there can be delayed complications. Thomas reported the case of a patient who suddenly became paraplegic and had proximal hypertension secondary to coarctation of the aorta n i n e days after the original injury, lz Sacchettis has f o u n d references for s u b c l a v i a n vein obstruction due to callus formation; Homer's syndrome due to cervical sympathetic chain disruption or compression by callus; delayed formation of aortic a n e u r y s m due to u n detected initial vascular injury; tracheoesophageal fistula; fibrous u n i o n with pseudoarthrosis formation; abscess formation; and, occasionally, a disturbing cosmetic deformity in the supraclavicular fossa. As a result, he advised analgesia and immobilization of the shoulder girdle and mandatory long-term follow-up to m i n i m i z e the risk of disability from delayed complications, s Periodic r e c h e c k s of t h e p a t i e n t
120/349
with serial radiographs would seem to be prudent for up to six m o n t h s following stress fracture of the first rib, with emphasis on any changes occurring in the first two weeks. The author thanks Shinichi Kishi and Russell Leong for their translation of the Hirata article, and Keith Caron for his illustration.
REFERENCES 1. Galbraith HF, Urschel Jr He, Wood RE, et al: Fracture of first rib associated with laceration of subclavian artery. J Thorac Cardiovasc Surg 1973;65:649-652. 2. Breslin FJ: Fractures of first rib unassociated with fractures of other ribs. A m J Surg 1937;38:384-389. 3. Lazrove S, Harley DP, Grinnell VS, et al: Should all patients with first rib fracture undergo arteriography? J Thorac Cardiovasc Surg 1982;83:532-537. 4. Yee ES, Thomas AN, Goodman PC: Isolated first rib fracture: Clinical significance after blunt chest trauma. Ann Thorac Surg 1981;32:278-283. 5. Sacchetti AD, Beswick DR, Morse SD: Rebound rib: Stress-induced first rib fracture. Ann Emerg Med 1983;12:177-179. 6. Albers JE, Rath RK, Glaser RS, et al: Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg 1982;33:614-618. 7. Phillips EH, Rogers WF, Gaspar MR: First rib fractures: Incidence of vascular
Annals of Emergency Medicine
injury and indications for angiography. Surgery 1981;89:42-47. 8. Rogers WF: Letter to the editor. Radiology 1983;147:598-600. 9. Livoni JP, Barcia TC: Fracture of the first and second rib: Incidence of vascular injury relative to type of fracture. Radiology 1982;145:31-33. 10. Hirata S: Fracture of the first rib: Case report of left non-traumatic chronic fracture and review of 35 cases of non-traumatic cause reported in Japan. Nippon Kyobu Shikkan Gakkai Zasshi 1982;20: 762-769. 11. Rademaker M, Redmond AD, Barber PV: Stress fracture of the first rib. Thorax 1983;38:312-313. 12. Aitken AP, Lincoln RE: Fracture of the first rib due to muscle pull. N Engl J Med 1939;220:1063-1064. 13. Weiner DS, O'Deu HW: Fractures of the first rib associated with injuries to the clavicle. ] Trauma 1969;9:412-422. 14. Jenkins SA: Spontaneous fractures of both first ribs. J Bone Joint Surg /Br] 1952;34:9-13. 15. Curran JP, Kelly DA: Stress fracture of the first rib. American Journal of Orthopedic Surgery 1966;8:16-18. 16. Dwivedi SC, Varma AN: Bilateral fracture of the first ribs. J Trauma 1983; 23:538. 17. Proceedings of the seventh annual meeting of the Samson Thoracic Surgical Society, Maui, Hawaii, June 1981.
14:4 April 1985
Surfer's Rib: Isolated First Rib Fracture Secondary to Indirect Trauma A case of anterolateral first rib fracture produced by indirect trauma in a surfer is presented. A 17-year-old man was seen in the emergency department with the complaint of left shoulder pain that developed while he performed a so-called lay back maneuver on a surfboard. No history of direct trauma was elicited. After physical examination revealed point tenderness high in the left axilla, radiographic evaluation of the chest showed an isolated fracture of the anterolateral aspect of the left first rib. No morbidity was associated with this fracture which, when produced by other forces, can have serious sequelae. [Bailey P: Surfer's rib: Isolated first rib fracture secondary to indirect trauma. Ann Emerg Med April 1985; 14:346-349.] INTRODUCTION First rib fracture has been described as a "harbinger of serious potential injury "1 since the association between first rib fracture and injury to the subclavian artery was reported in 1869. 2 During the past decade, it was suggested that patients with this fracture undergo arteriography.3 Studies of the usefulness of this procedure as routine when the clinical implication of an isolated first rib fracture is not clear 4 have prompted a more selective approach.3-9 The number of patients with first rib fracture reported in the literature is increasing,4, 6 and the most c o m m o n etiology is direct trauma from motor vehicle accidents.3, 6 Indirect mechanisms include shoveling, digging, plowing, and use of chest expander exercisers, and injuries from judo, volleyball, baseball, ping pong, rugby, gymnastics, tennis, chinning, 10 basketball, S falling, 6 sneezing, coughing, and heavy lifting. 7 No previous description could be found of a first rib fracture that occurred during surfing. Increasingly it is being recognized that stress-induced first rib fractures can be managed conservatively with outpatient observation. 5 As the more benign nature of stress-induced fractures is recognized, the automatic use of invasive procedures for all first rib fractures may decrease.
Patricia Bailey, MD Harbor City, California From the Department of Emergency Medicine, Kaiser Permanente Medical Care Program, Harbor City, California. Received for publication June 27, 1984. Accepted for publication October 17, 1984. Address for reprints: Patricia Bailey, MD, Department of Emergency Medicine, Kaiser Permanente Medical Care Program, 25825 South Vermont Avenue, Harbor City, California 90710.
CASE REPORT
A 17-year-old man presented with left shoulder pain that he noted while surfing that day. Specifically he felt a sharp pain while performing a lay back maneuver (Figure 1) in which he was crouched on the surfboard with his left arm extended behind him and his hand in the water. He remembered that the onset of pain coincided with a sudden pull on his extended arm by the force of the wave in which his hand was immersed. At the time he was aware of a brief period of shortness of breath. The patient was able to finish the surfing run without difficulty, but he noted pain localized to his left shoulder on all range of motion of his left arm. He denied any direct trauma. Physical examination revealed a muscular, well-developed young man in no acute distress. Vital signs were blood pressure, I10/70 m m Hg in both arms; temperature, 37 C; pulse, 68 and regular; and respirations, 18/min. The head examination was normal with full cervical range of motion. The chest was symmetrical with breath sounds equal bilaterally. The only area of chest tenderness was deep in the left axilla. No node was palpated, and the point tenderness was believed to be on palpation of the chest wall through the axillary tissue. Cardiac auscultation was normal. The left shoulder was non14:4 April 1985
Annals of Emergency Medicine
346/117
SURFER'S RIB Bailey
Fig. 1. Patient reproducing position inducing first rib fracture. In this lay back m a n e u v e r the p a t i e n t was crouched on the surfboard with the left hand dragging in the water. Fig. 2. Detail of chest film. Note anterior first rib fracture (arrow).
tender to palpation, but there was pain in the proximal upper arm along the course of the triceps on range of motion, especially with posterior extension of the arm. No tenderness was palpable along the humerus or biceps. Posteroanterior and lateral views of the chest were obtained, and a clearly visible f r a c t u r e t h r o u g h the anterolateral aspect of the left first rib was noted (Figure 2). There was a 3-ram separation of the fracture fragments, b u t no d i s p l a c e m e n t . T h e m e d i astinum did not appear widened, and no other pathology was noted on the films. An e l e c t r o c a r d i o g r a m (ECG) was normal. After telephone consultation, the patient was treated with a sling and analgesia and was discharged. Followup chest radiograph and electrocardiogram the next day were unchanged, and the patient had no complications during the ensuing weeks. One month after injury there was no discomfort w h e n t h e p a t i e n t r e p r o d u c e d the movements that provoked the injury. At that time he reported that he had resumed surfing against medical advice. There have been no delayed complications.
DISCUSSION The first rib is short, broad, flat, and thick and is in a protected position.7 It was believed for a long time that apparent fractures must be due to congenital abnormalities of the bone, and are not acquired.U Now, however, it is acknowledged that first rib fracture can occur as a result of minor trauma, 6 possibly from a strong contraction of the scalenus anterior muscle c o m b i n e d w i t h t r a c t i o n of t h e arm.5,6,n4~ Stress fracture of the first rib o c c u r s p r i m a r i l y in m u s c u l a r young men, lO,H,14,1s usually through the subclavian artery groove just posterior to the scalene tubercle, which is the weakest portion of the first ribJs When direct trauma is included, however, most first rib fractures tend to be posterior. 4, 7,16 Lazrove and colleagues 3 describe re118/347
Annals of Emergency Medicine
14:4 April 1985
Fig. 3. Musculoskeletal connections of
the first rib.
ScalenusAnt. ~t~'~i!~i~'~?~,\~,~ h~
ScalenusMeal.
Fig. 4. Skeleton reproduction of posi-
tion inducing first rib fracture.
\ f,1~\\~ .... 1stRib Serratos Anterior
s er u ,
InternalMammary:Ti!:i~: ( "P ':::::::::::....::: A r t e i r Y~ A r t e~ lra vyl a n 3
4:4 April 1985
Annals of Emergency Medicine
gions that, when injured, can result in first rib fracture-- thorax, shoulderarm, and head and neck. Each may be the source of isolated trauma or may be combined with either or both of the other regions. Lazrove postulates that the m e c h a n i s m of injury when the shoulder-arm region is involved as an isolated injury is through the connections by the costoclavicular ligament and by the upper digitation of the serratus anterior muscle from the posterior first rib and a fascial band extending between the first and second ribs (Figure 3). A view of a skeleton in approximately the same alignment as the lay back maneuver shows the bony relationships (Figure 4). Sacchetti implicates another possible mechanism of fracture, s He notes t h a t the scalenus a n t i c u s m u s c l e , which originates from multiple cervical vertebrae, inserts on the scalene tubercle on the cephalad surface of the rib. It exerts an upward pull, while the scalenus medius muscle and the first slip of the serratus anterior insert on the cephalad aspect of the posterior third of the rib, and the latter exerts a downward pull on the rib when it contracts, is T h e p r i m a r y s y m p t o m of stress fracture of the first rib is pain. The pain may be localized to the rib, or it may be described as originating in the base of the neck or radiating along the arms or the scapular region 16 or the shoulderJO The i m p o r t a n c e of diagnosis and proper treatment of first rib fracture lies in the potential severity of the resultant injury because of the proximity to major vessels, nerves, and the lung. 6 A u t h o r s w h o primarily have considered first rib fractures with direct trauma etiology have listed various criteria for invasive diagnostic procedures: presentation w i t h other rib injuries;3, 6 marked displacement of the fragments4, 7 (disagreement by Livonig); altered serial chest roentgenograms with increased pleural cap or hemothorax;3, 4 alterations in blood pressure or pulse in the affected extremity;4, z brachial plexus injury;3,4, z and subclavian groove fracture. 4 Sacchetti and colleagues who reported on 348/119
SURFER'S RIB Bailey
a case of stress fracture, state, however, that in general, if no immediate complications are present on exami n a t i o n and chest radiography shows no indication of vascular injury, angiography probably is n o t warranted and the patient can be discharged to close outpatient follow-up. There are no definite guidelines on the length of that follow-up. Hirata notes that the rib takes four to five m o n t h s to heal, lo and in that period there can be delayed complications. Thomas reported the case of a patient who suddenly became paraplegic and had proximal hypertension secondary to coarctation of the aorta n i n e days after the original injury, lz Sacchettis has f o u n d references for s u b c l a v i a n vein obstruction due to callus formation; Homer's syndrome due to cervical sympathetic chain disruption or compression by callus; delayed formation of aortic a n e u r y s m due to u n detected initial vascular injury; tracheoesophageal fistula; fibrous u n i o n with pseudoarthrosis formation; abscess formation; and, occasionally, a disturbing cosmetic deformity in the supraclavicular fossa. As a result, he advised analgesia and immobilization of the shoulder girdle and mandatory long-term follow-up to m i n i m i z e the risk of disability from delayed complications, s Periodic r e c h e c k s of t h e p a t i e n t
120/349
with serial radiographs would seem to be prudent for up to six m o n t h s following stress fracture of the first rib, with emphasis on any changes occurring in the first two weeks. The author thanks Shinichi Kishi and Russell Leong for their translation of the Hirata article, and Keith Caron for his illustration.
REFERENCES 1. Galbraith HF, Urschel Jr He, Wood RE, et al: Fracture of first rib associated with laceration of subclavian artery. J Thorac Cardiovasc Surg 1973;65:649-652. 2. Breslin FJ: Fractures of first rib unassociated with fractures of other ribs. A m J Surg 1937;38:384-389. 3. Lazrove S, Harley DP, Grinnell VS, et al: Should all patients with first rib fracture undergo arteriography? J Thorac Cardiovasc Surg 1982;83:532-537. 4. Yee ES, Thomas AN, Goodman PC: Isolated first rib fracture: Clinical significance after blunt chest trauma. Ann Thorac Surg 1981;32:278-283. 5. Sacchetti AD, Beswick DR, Morse SD: Rebound rib: Stress-induced first rib fracture. Ann Emerg Med 1983;12:177-179. 6. Albers JE, Rath RK, Glaser RS, et al: Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg 1982;33:614-618. 7. Phillips EH, Rogers WF, Gaspar MR: First rib fractures: Incidence of vascular
Annals of Emergency Medicine
injury and indications for angiography. Surgery 1981;89:42-47. 8. Rogers WF: Letter to the editor. Radiology 1983;147:598-600. 9. Livoni JP, Barcia TC: Fracture of the first and second rib: Incidence of vascular injury relative to type of fracture. Radiology 1982;145:31-33. 10. Hirata S: Fracture of the first rib: Case report of left non-traumatic chronic fracture and review of 35 cases of non-traumatic cause reported in Japan. Nippon Kyobu Shikkan Gakkai Zasshi 1982;20: 762-769. 11. Rademaker M, Redmond AD, Barber PV: Stress fracture of the first rib. Thorax 1983;38:312-313. 12. Aitken AP, Lincoln RE: Fracture of the first rib due to muscle pull. N Engl J Med 1939;220:1063-1064. 13. Weiner DS, O'Deu HW: Fractures of the first rib associated with injuries to the clavicle. ] Trauma 1969;9:412-422. 14. Jenkins SA: Spontaneous fractures of both first ribs. J Bone Joint Surg /Br] 1952;34:9-13. 15. Curran JP, Kelly DA: Stress fracture of the first rib. American Journal of Orthopedic Surgery 1966;8:16-18. 16. Dwivedi SC, Varma AN: Bilateral fracture of the first ribs. J Trauma 1983; 23:538. 17. Proceedings of the seventh annual meeting of the Samson Thoracic Surgical Society, Maui, Hawaii, June 1981.
14:4 April 1985