Traumatic first rib fracture: is angiography necessary? A review of 730 cases

Cardiovascular Surgery, Vol. 5, No. 1, pp.48-53, 1997 0 1997 The InternationalSwiety for CardiovascularSurgery

PII: SO967-21O9(97)OOO6O-9

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Publishedby ElsevierScience Ltd. Printed in Great Britain 0967-2109/97 $17.(Y3 + 0,00

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WesternReserveCareSystem,Departmentof Surgery,500 GypsyLane,Youngstown,OH 44501 and NortheasternOhio UniversitiesCollegeof Medicine,Rootstown, OH 44272, USA SUICUS and

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traumatic first rib fracture, angiography

In an effort to standardize the indications for performing routine arch arteriography in patients with traumatic fracture of the first rib, a review of 730 literature-derived cases was performed, concentrating on thoracic anatomic relationships, mechanisms of injury, associated injuries and radiographic findings. Fracture of the first rib with associated arterial injury is rarel. It was first reported by Jones in 1869, who described a man killed by repeated blows that resulted in an injury to his first rib, subclavian artery and brachiocephalic vein2. Since then, most of these injuries have been associated with motor vehicle accidents. The first rib lies in a protected position, low in the neck, and is broad, flat and relatively thick, characteristics which help to protect it from minor injuries. Such a fracture has been interpreted as a sign of serious injury and should arouse the physician’s suspicion of major arterialinjury, regard-

less of the patient’s initial appearance. Recently, increased numbers of reports of first rib fractures have suggested that this injury may occur more frequently than previously believed4. Studies have linked subclavian artery injuries with first rib fractures in over half of such cases, with subsequent arteriograms being ordered in most instances. This trend has led to an increased interestin the appropriate assessment and optimal management of these injured patients.

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This study consists of a review of the pertinent anatomy, mechanisms of injury, patterns of associated injury and means of evaluation for potentially related trauma associated with first rib fracture. Data were collected and summarized from all available recent case reports and series.

Correspondence to: Dr J. R. Rubin

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Angiography in first rib fracture: A. Guptaet al.

A A study of the mechanisms of injury to the first rib and its associated neurovascular structures requires a detailed knowledge of the anatomy of the rim of the thoracic outlet (Figure1). The first rib is heavy, broad and flat. The superior face in the middle third is grooved by the subclavian artery SUICUS as it traverses the thoracic outlet. The rib passes anteriorly to the manubrium stemi through the first costochondral cartilage and is bound to the clavicle by the subclavian muscle and the costoclavicular ligament. The first rib originates posteriorly from the transverse process of the first thoracic vertebra and is joined to the second rib by the fascial band. The anterior scalene muscle arises from the transverseprocess of the third to sixth cervical vertebra and runs inferolaterally to insert on the scalene tubercle of the first rib between the subclavian vein and artery. The medial scalene muscle arises from the transverse processes of all the cervical vertebra, passing posteriorly to the brachial plexus and subclavian artery to insert behind the subclavian SUICUS. The serratus anterior arises from the outer surfaces of the upper eight ribs and sends its first digitation to the upper surface of the posterior third of the first rib and the costal surface of the superior angle of the scapula. In the average adult, 7.5 cm (3 inches) separate the anterior

Figure 1 Thoracicanatomy

CARDIOVASCULAR SURGERY FEBRUARY1997 VOLS NO 1

portion of the first dorsal vertebra from the sternum. These attachments fix the rib in position, primarily during inspiration. In summary, the anatomy of the first rib provides it great protection and stability; therefore, its injury serves as an important marker for the severity of trauma.

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A wide spectrum of types and magnitude of injuries causing first rib fractures has been described in majo~w of first rib fracnumerous reports1s–l1.me ‘ tures occur as a result of motor vehicle accidents; most commonly automobile, followed in incidence by motorcycle mishaps. Mechanisms usually involve a sudden forward movement of the head and neck, usually secondary to the body hitting the dashboard, steering wheel, seat belt, or front seatl. These accidents may result in severe non-penetrating blows to the sternum and anterior chest wa111G12. Household accidents accounted for 46°/0of isolated first rib fractures in the series by Albers and colleaguesll. This mechanism prevailed in the elderly patient population and was usually associated with fewer concomitant injuries than the more traumatic vehicular accidents. Mechanisms of first rib fractures fall into five categories. Alken and Lincoln were the first to describe

Angiographyin first rib fracture:A. Guptaet al.

possible mechanisms of arterial injury and first rib fractures in 188710. The first category is posteriorly directed trauma to the upper thorax or shoulder girdles>G. The first rib is less well protected by Overlying structures posteriorly and is more susceptible to the direct blow. The second mechanism is indirect due to a blow applied to the sternum and anterior chest wall transmitted through the shoulder girdle to the first rib5. The third category involves the clavicle. A blow fracturing the clavicle is transmitted by the fragments which strike and fracture the upper ribs5. Injuries to the lateral clavicle causing acromioclavicular separation may deviate the costal cartilage and the anterior first rib via the subclavian muscle, thereby fracturing it from its posterior positionlO. A fourth mechanism is a strong sudden contraction of the scalenus anticus muscle combined with traction on the arm, as might occur with a sudden movement of the head and neck. In this case, the anterior scalene and the upper slip of the serratusanterior insert on either side of the subclavian SUICUS. Sudden forceful contraction in opposite directions leads to a fracture at this weak point in the first rib1>5,@7~13. A fifth category has no identifiable cause. In this case, chest radiography incidentally elicits the finding of a first rib fracture without a history of trauma in a symptom-free patient’$7.The series by Albers et a fracaZ.l1illustratesthat minimal trauma can ture of the first rib. Although more commonly associated with violent accidents, Alderson (in ref. 4) reported 37 patients with first rib fractures in whom no history of trauma could be obtained. Alderson found 73 incidental first rib fractures while reviewing radiographs on 77607 soldiers, stating they may have been secondary to carrying heavy military equipment.

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First rib fractures have been classified in the past according to the site and type of fracture. To evaluate fully the first rib, three radiographic views must be ordered. An anteroposterior of the cervical spine, an anteroposterior of the dorsal spine, and a lateral view of the dorsal spine with the upper extremities extendedlO. These fractures are described as anterior, lateral or posterior. Fractures may be nondisplaced, minimally displaced or severely displaced, characterized as one-half the width of the rib or greaters.

D Although some authors describe the most common site of first rib fracture to be anterior (to the scalene tubercle), this is not supported by three reviews that actually document the location of fractures. The findings revealed posterior fractures in 50, 59 and

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30’XO,anterior fractures in 25, 41 and 22’7., and lateralfractures in 25, 0 and 45’7., respectively8’10’12. It may therefore be concluded that posterior fractures are more common. This may be because, anteriorly, the rib is protected by the clavicle and pectoral muscles. In Phillips’8study of seven patients with severe vascular injuries and displaced first rib fractures, five were posterior, with one each anterior and lateral. Although Livoni and Barcia14 has stated that neither the degree of displacement nor position of the fracture have any value in predicting vascular injuries, numerous other studies have disputed this finding. It is important to observe the degree of displacement in first rib fractures because of its association with vascular injuries1>2’@15. In one series of 49 fractures, 11 (22’%o) were significantly displaced (more than one-half of the width of the rib and/or 4 mm). Five were displaced posteriorly, two laterally and four anteriorly. All seven vascular injuries in this series occurred exclusively in patients with severely displaced fractures (64’%o);five were posterior, one anterior and one latera18’14. The proposed mechanism of vascular injury with caudally displaced posterior rib fractures is the result of the downward force of the blow on the posterior portion of the rib, levering the anterior part of the first rib upward against the clavicle. This causes a compression of thoracic outlet contents. The insertion of the scalenus medius is the fulcrum. In addition, the force is magnified because the distance from the neck of the rib to the scalenus medius muscle is approximately twice the distance from the medius to the subclavian artery, producing a 2 : 1 mechanical advantage. The neurovascular bundle is also caught in a scissors action between the first rib and the clavicle8. Although the proximity of the subclavian artery/ vein and the brachial plexus has led first rib fractures to be considered a marker of neurovascular injuries and severe trauma in general, a review of the literature defines a stronger association with injury to other organ systems, than with vascular injuriesl’3’4’9’11’12. Richardson’s 1975 study3 revealed a mortality rate of 360/. in patients with first rib fractures, but most of these patients died of their accompanying head injuries. Fermanis and colleaWeslG found no major vascular injuries in 15 patientswho were victims of motor vehicle accidents and had major chest injuries, including first rib fracture. Brachial plexus injuries are usually associated with first rib fractures, but are not statistically significant. The documented incidence of vascular injuries associated with first rib fractures ranges from 3~o to 45~o, with a mean of 12Y01~3>@11J12. Albers et~Z.l1 described a significantlyhigher incidence than the others reviewed in that they noted a 45’Yoincidence of vascular injury, including 34 ruptured CARDIOVASCULAR SURGERY FEBRUARY1997 VOLS NO 1

Angiographyin first rib fracture:A. Guptaet al.

aortas in 75 patients. If this series is omitted, the overall incidence falls to 7°/0consisting of 29 vascular injuries in 428 patients. Fisher and Rienhoff4, in reviewing 214 patients, stated that aortic/ brachiocephalic injury and inlet rib fractures were ‘just coincidental’. Yee and co-workersl have shown a stronger mortality/morbidity correlation of first rib fractures with maxillofacial and neurological injuries than with vascular injuries. They contend that multisystem injuries are less frequent with first rib fractures than multiple rib fractures and that vascular injuries are so rare that arteriograms should only be done when specially indicated, and not routinely. Additionally, Woodring et aZ.5 have shown that patients without upper rib fractures had a greater tendency to have great vessel injury (l4.5’%o), than those with first or second rib fractures (870). Isolated first rib fractures have a 3’XOincidence of vascular injury while first rib fractures associated with multiple rib fractures have a 24°/0 incidence. Eliminating Alber’s studyl’ would reduce the incidence to 10’XO.Ziegler et aL17have concluded that the mortality rate of multiple rib fractures is 12’70, though 90Y0of such cases have accompanying injuries, 50°/0require operative and critical care, and 33°/0 eventually require extended care facilities. Vascular injuries are usually limited to the aorta and subclavian arteries. The aorta was the most commonly injured artery,occurring in 42 of 63 injuries (660/0), followed by subclavian artery injuries which occurred in 16 (25’%0).Other arteries injured were the vertebral in three, the innominate in one, and the internal mammary in onel’334J8>11’12. Clinical signs of aortic injury such as hypertension of upper extremities, dyspnea, back pain, and decreased blood pressure in the lower extremities have been found to be insensitive and infrequent to be of any diagnostic value. Therefore, upright chest radiography is usually ordered to evaluate the aorta noninvasively2. Multiple authors have found a causal relationship of aortic rupture with first rib fractures, but Mrstier’s data18failed to show any statistical difference between aortic injury with or without rib fracturesZ&g>lA>lS. Ruptured great vessels are associated with significant mortality and morbidity. Although subclavian arterialinjury is most closely associated with first rib fractures, the incidence of vascular injuries is less than that of associated injuries to other organ sysfractemslg. As noted by Richardson et al.3, tures are a ‘hallmark of severe trauma’ and should be aggressivelyevaluated. Woodring et aL5 separated first rib fracture patients into two groups with regard to whether or not clinical signs were apparent and performed arteriogramsin all. In those patientswithout clinicalhadiographic signs of vascular injury the arteriogram did not show any vascular injuries, while those with positive signs had a 13.8Y0 incidence of CARDIOVASCUMR SURGERY FEBRUARY1997 VOLS NO 1

vascular injury. Woodring and colleagues also found a higher incidence of vascular injuries in patients without rib fractures than with fractures, and concluded that first and second rib fractures have no predictive value for underlying arterial injury5. Given the severity of injury required to fracture the first rib, concomitant injuries to other ribs and organ systems are not uncommon (Tables1 and 2). Pulmonary injuries have been reported with a range of 10–100°/01y3y4’ 8’11y12. The severity of these includes a wide spectrum from mild contusions to flail chests associated with ruptured bronchi. The combined incidence of pulmonary injuries and first rib fractures was 53°/0. The most common injury was a pulmonary contusion which was noted to occur in all 75 patients in one series of first rib fracturesll. The next most frequent organ system injured, in combination with first rib fractures, was the skeletal system. Long bone fractures, shoulder girdle injuries and pelvic fractures occurred in 30–55°/0 of patients. Additionally, there was a 66’%0incidence of other rib fractures noted when the first rib was fractured. Yeel reported orthopedic injuries in 55°/0 of patients with multiple rib fractures compared with 260/o of those with isolated first rib fracturel. Mortality and morbidity was more closely related to age than which rib was fi-actured13. Necrologic injuries were also frequent, with an overall incidence of 37°/0 (range The most common head injury was a concussion. Brachial plexus injuries were also included, this small, yet important injury occurring in 4°/0 of patients. However, in one review, three of three patients with brachial plexus injuries had vascular injuries3. Cardiac and abdominal injuries also occurred, being noted in 17’%0of those with first rib fractures. Cardiac injuries ranged most commonly from ECG changest. Shockl 1)12. Abdominal injuries followed the dictums of general surgery, being dominated by the liver and spleen. There were 23/72 splenic injuries (32Yo), and 17 liver injuries out of 72 abdominal injuries consisting of both lacerations and ruptures (23%) 1>4s,11,12. In addition to the above, first rib fractures have also been associated with esophageal, bronchial and tracheal injuries5. The mortality accompanying first rib fractures further illustrates the severity of trauma producing these injuries. As shown (Table 1), mortality rates ranged from Oto 48Y0.Usually, as the number of rib fractures increases, so does the mortality and morbidity. In contrast, Livoni14found similar incidence of thoracic arterial injury with first and second rib fractures (13.6’XO)as with those including other ribs (13.9%). In one review there was a subset of patients with 36/62 deaths in patients having multiple rib fractures combined with a first rib fracture. There were also 34 ruptured aortas in this subsetll. Only 51

Angiographyin first rib fracture: A. Guptaet al.

Table1 Fracturesand vascularinjuries Author (Year)

No. of patients

No. of first rib FXS

No. vase.inj. w/first rib Fx

Isolatedfirst First rib Fx rib Fx + mult. Fx

No. vase.inj. w/mult. Fx

Morbidity

Mortality

Wilson (1978)4 Richardson(1975)3 Yee (1981)’ Lazrove(1982)’2 Phillips (1981)8 Fisher(1966)’5 Lorentzen(1976)6 Kirshner (1983)’8 Poole(1989)2 Fermanis(1985)” Holmes(1956)2’ Livoni (1982)’4 Albers (1982)”

71 55 156 26 45 93 15 64 41 15 16 58 75

71 55 156 31 49 93 15 64 41 15 16 13 75

0

22 12 65 15 11 NIA 15 NIA NIA o 0 13 13

4 3 8 0 0 14 NIA NIA 1 0 0 6 34

51 NIA 74 NIA NIA N/A NIA NIA 4 NIA NIA NIA NIA

11 20 15 NIA 2.2% NIA NIA NIA 3 1 NIA NIA NIA

3 2 1 7 NIA o 1 0 0 0 2 0

49 43 91 11 16 NIA o NIA 41 15 0 58 62

Table2 Associatedinjuries Author (year)

Skeletal injury

Cardiac injury

Abdomen injury

Necrologic/ headinjury

Brach/ plexisinjury

Thoracic injury

Wilson (1978)4 Richardson(1975)3 Yee (1981)’ Lazrove(1982)’2 Phillips (1981)8 Fisher(1966)’5 Lorentzen(1976)6 Kirshner (1983)’8 Poole (1989)2 Fermanis(1985)’6 Holmes(1956)2’ Livoni (1982)’4 Albers (1982)”

38 41 67 13 19 NIA NIA NIA 26 5 9 NIA 20

21 8 32 3 NIA NIA N/A N/A 5 NIA o NIA 9

10

25 29 60 5 14 NIA NIA NIA 11 7 N/A NIA 25

3 5 NIA 2 3 NIA NIA N/A 4 2 3 NIA 2

52 35 72 5 6 NIA NIA NIA 4 NIA N/A NIA 75

one paper attempted to break down the causes of death. Among 11 patients, mortality etiologies were divided between neurological (three), cardiac (two), pneumonia (two), pulmonary embolus (two), ARDS (one), and vascular causes (one)’. These statistics must be considered in the context that in another review of 36 deaths there were 34 ruptured aortasl1. In summary, from the data above, it is concluded that vascular injuries cannot be predicted on the basis of a first rib fracture. Additionally, first rib fractures are usually associated with minor intrathoracic injury such as pulmonary contusions, pneumothorax and hemothoraxz. The diagnosis of a vascular injury should be based upon findings at arteriography, or on clinical signs. Nearly all patients with significant arterial injury will have clinical manifestations as stated below. Determining the need for arteriography should be based upon identifying that subgroup of patientswith the following radiographic and clinical signs: (1) Ratio of mediastinal width to chest width at the 52

18 14 3 4 NIA NIA NIA 5 2 NIA N/A 23

aortic knob on anterioposterior chest radiograph and/or alteration of serial chest radiographs. Upper-extremity pulse deficit, or acute disparity of upper-extremity pulses. Posteriorly displaced first rib fracture, subclavian groove fracture anteriorly. (4) Evidence of a brachial plexus injury and expanding hematoma. (5) Equivocal clinicalhadiographic findings. In conclusion, the successful management of first rib fractures entails treating the specific injury in the context of multiple trauma. Presented in this paper are several statisticsfrom published reviews illustrating the magnitude of trauma creating this injury. On occasion this is an isolated injury which can still be accompanied by a vascular injury. Stressingthe local physical signs of a pulse deficit or brachial plexus injury will identi& a potential vascular problem. Although arteriograms have been shown to be safe, there are some drawbacks. Some patients may not tolerate the dye, the procedure is costly, and entails CARD1OVASCULAR SURGERY FEBRUARY1997 VOL5 NO 1

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moving the patient from highly critical and monitoring areas of the hospital. In addition, it may delay appropriateoperativehherapeuticcare for the patient20. To conclude, the need for arteriography should not be based on the presence of a first rib fracture, but on the physical signs and radiologic evidence of a potential vascular injury.

A The authors thank Kevin Mellott for the medical illustration.

R 1. Yee ES, Thomas AN, Goodman PC. Isolated first rib fracture: clinical significance after blunt chest trauma. Ann ThoracSurg 1981; 32: 278-83. 2. Poole GV. Fracture of the upper ribs and injury to the great vessels.Surg GynecolObstet1989; 169: 275–82. 3. Richardson JD, McElvein RB, Trinkel JK. First rib fracture: a hallmarkof severetrauma.ArsrtSurg 1975; 181: 251L4. 4. Wilson JM, Thomas AN, Goodman PC, et al. Severe chest trauma.Arch Surg 1978; 113: 846–9. 5. Woodnng JH, Fried AM, Hatfield DR, StevensRR, Todd EP. Fracturesof first and second ribs. Predictivevalue for arterial and bronchial injury.A3R Am ~ Roentgenol1982; 138: 21 1–15. 6. Lorentzen JE, Movin M. Fracture of the first rib. Acta OrrhoP ,%and 1976; 47: 632+. 7. FrangakisEK. Fractureof the first rib. Acta OrthoPScand 1962; 38: 193-8.

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8. Phillips EH, Rogers WF, Gaspar MR. Incidence of vascular injury and indicationsfor angiography.Surgsry1981; 89: 42–7. 9. Galbraith NF, Urschel HC, Wood RE, Razzuk MA, Paulson DL. Fractureof firstrib associatedwith lacerationof subclavian anery. 3 ThoracCardiovascSurg 1973; 65: 649–52. 10. Weiner DS, Odell HW. Fracturesof the first rib associatedwith injuriesof the clavicle.3 Trauma1969; 9: 412–22. 11. AlbersJE, RathRK, GlaserRS, Poddar RK. Severityofintrathoracic injuriesassociatedwith firstrib fractures.Ann ThorazSurg 1982; 33: 614-18. 12. LazroveS, HarleyDP, GrinnellVS et al. Should all patientswith firstrib fractureundergo arreriography?~ThoracCardiovascSurg 1982; 83: 532-7. 13. Mulder DS, Greenwood FAH, Brooke CE. Post-traumaticthoracic outlet syndrome.3 Trauma1973; 13: 700–15. 14. Livoni JP, BarciaTC. Fractureof the first and second rib: incidence of vascular injury relativeto type of fracture. Radiology 1982; 145: 31-3. 15. Fisher RD, Rienhoff WF III. Subclavian artery laceration resultingfrom fracturedfirst rib. 3 Trauma1966; 6: 579–82. 16. FerrnanisGG, Deane 5A, Fitzgerald PM. The significance of first and second rib fractures.Aust NZ3 Surg 1985; 55: 383-6. 17. Ziegler DW, AgarwalNN. The morbidity and mortality of rib fractures.3 Trauma1994; 37: 975-9. 18. KirshnerR, SeltzerS, Dorsi C, DeWeeseJA. Upper rib fractures and mediastinalwidening:indicationsfor angiography.Arm Thorac Surg 1983; 35: 450–4. 19. Costa MC, Robbs JV. Nonpenetratingsubclavianarterytrauma. 3 Vatc Surg 1988; 8: 71-5. 20. Bowers VD, Walkins GM. Blunt trauma to the rhoracic outlet and angiography.Am Surg 1983; 49: 655–9. 21. Holmes TW, NettervilleRE. Complications of first rib fracture, including one case each of tracheoesophagealfistula and aortic arch aneurysm.3 ThoracSurg 1956; 32: 74.

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Paper accepted 9 Januaty1996

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