First-rib stress fracture in a high-school lacrosse player: a case report and short clinical review

Stress fracture of the first rib in a hockey goalie

First rib stress fractures are uncommon in athletes and diagnosis requires a high degree of clinical suspicion. Diagnostic delay may increase risk of poor healing and long-term complications. Case reports and series describe these injuries primarily in overhead athletes; proposed contributing factors include anatomic susceptibility to stress and repetitive opposing muscular forces. We describe an ice hockey goalie with acute-on-chronic thoracic back pain who was found to have a first rib stress fracture, which to our knowledge is the first reported in this sport. We hypothesize that biomechanical stress from new stick positioning contributed to the injury. Our patient recovered symptomatically with conservative treatment; however, imaging suggested nonunion of the fracture site and possible pseudoarthrosis.

Rib Stress Fractures and a Novel Muscle-Sparing Rib Fixation Plating in an Elite Tennis Player: A Systematic Review of the Literature and Case Report

A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.

Stress Fractures of the First Rib Related to Soft Tennis, Associated with the Tennis Ground Stroke

Stress fractures of the first rib are uncommon and thought to be associated with overhead-throwing athletes. Soft tennis is similar to regular tennis but uses a much softer rubber ball. In the current report, a 14-year-old girl suffered from shoulder girdle pain, especially at the end of her tennis ground stroke. Plain radiographs showed overgrowth of bone with a fracture line on the first rib, and a diagnosis of stress fracture was made. She was advised to amend her stroke form to reduce force to the shoulder and was able to continue sports activity without pain 10 months after the appearance of her symptoms and before confirmation of bone healing. The current case is not associated with overhead-throwing, but possibly with repetitive exercises of her tennis ground strokes. Conservative medical follow-up with proper sport-specific professional advice allows continuation of the sport.

Ultrasound Identifies First Rib Stress Fractures: A Case Series in National Collegiate Athletic Association Division I Athletes

Isolated first rib stress fractures in athletes are thought to be rare. In this case series, 3 National Collegiate Athletic Association Division I athletes developed isolated first rib stress fractures over the span of 1 year, indicating that these injuries may occur more often than previously understood. These fractures can be easily missed because of the low incidence, lack of clinical suspicion, and vague presentation. Further, radiographs can fail to reveal such fractures. To our knowledge, this is the largest case series of athletes with first rib stress fractures presenting with vague rhomboid interscapular pain. We also demonstrated that ultrasound successfully visualized these injuries; in the hands of an ultrasonographer or clinical provider trained in musculoskeletal ultrasound, this technique offers an advantageous point-of-care screening imaging modality.

Delayed Union of Stress Fracture of the First Rib in a Yoga Instructor: A Case Report

CASE

We describe the case of a 38-year-old woman, a yoga instructor, who had pain in the right shoulder and scapular region of 4 months' duration while performing yoga. Radiography and computed tomography diagnosed delayed union of a first rib stress fracture. The delayed union of stress fracture of the first rib was successfully treated with the limiting of yoga activity and low-intensity pulsed ultrasound (LIPUS).

CONCLUSIONS

Physicians should be aware that even yoga posing can cause stress fractures of the first rib. LIPUS therapy may be effective for delayed union in addition to rest.

Athletic Injuries of the Thoracic Cage

A variety of sports require exposure to high-impact trauma or characteristic repetitive movements that predispose to injuries around the thorax. Appropriate prognostication and timely management are vital, as untreated or undertreated injuries can lead to pain, disability, loss of playing time, or early termination of sports participation. The authors review common athletic injuries of the thoracic cage, encompassing muscular, osseous, and vascular conditions, with an emphasis on mechanism, imaging features, and management. The authors also review pertinent soft-tissue and bony anatomy, along with relevant sports biomechanics. Generalized muscle trauma and more specific injuries involving the pectoralis major, latissimus dorsi, teres major, pectoralis minor, lateral abdominal wall and intercostals, serratus anterior, and rectus abdominis muscles are discussed. Osseous injuries such as stress fractures, sternoclavicular dislocation, costochondral fractures, and scapular fractures are included. Finally, thoracic conditions such as snapping scapula, thoracic outlet syndrome, and Paget-Schroetter syndrome are also described. Specific MRI protocols are highlighted to address imaging challenges such as the variable anatomic orientation of thoracic structures and artifact from breathing motion. Athletes are susceptible to a wide range of musculoskeletal thoracic trauma. An accurate imaging diagnosis of thoracic cage injury and assessment of injury severity allow development of an adequate treatment plan. This can be facilitated by an understanding of functional anatomy, sports biomechanics, and the unique injuries for which athletes are at risk. ^©RSNA, 2021.

Nontraumatic First Rib Fracture and Empyema Presenting as Shoulder Pain

Fracture of the first rib is rare because of the anatomic protection provided by surrounding structures. Osseous fatigue caused by repetitive motion and antagonistic muscular contraction is postulated to contribute to nontraumatic first rib fracture, which is most often described in adolescent athletes in sports that involve repetitive overhead motion of the arm. In this report, we describe a 49-year-old man with an occupation involving repetitive overhead motion at the shoulder who was found to have a nontraumatic first rib fracture. The condition resolved with treatment.

Arterial Thoracic Outlet Syndrome and Cerebellar Infarction Following a Stress Fracture of the First Rib and Extensive Callus Formation: A Case Report

CASE

Stress fractures of the first rib rarely have been reported in association with sports activities. We report a case of a cerebellar infarction that possibly was associated with arterial thoracic outlet syndrome (aTOS) that developed as a result of extensive callus formation in a young baseball player with a stress fracture of the first rib.

CONCLUSION

According to the literature, almost all cases of stress fracture in the first rib have a relatively good prognosis, and there are only a few reports of TOS occurring as a rare late complication. To our knowledge, there have been no prior reports of cerebellar infarction associated with aTOS following a stress fracture of the first rib.

Rib Stress Fracture in a Collegiate Softball Pitcher: A Case Report

CASE

We present the case of a twenty-one-year-old right-hand-throwing, right-hand-batting female softball pitcher who presented with a three-month history of right rib pain. A bone scan showed increased uptake in the lateral aspect of the right seventh rib, consistent with a stress fracture. The patient was managed nonoperatively and made a full recovery.

CONCLUSION

The forces created by the attachment of the serratus anterior during underhand throwing are the likely etiology of the injury in our patient. Physicians should maintain a high clinical index of suspicion for stress fracture in underhand athletes with lateral rib pain.

First-rib stress fracture in two adolescent swimmers: a case report

First-rib stress fractures have been described in adolescent athletes in various sports, with only one prior case report of first-rib stress fractures in an adolescent female swimmer. There is a need for research on the cause, management, and prevention of these injuries as they lead to significant morbidity and critical time away from sport for these aspiring athletes. We aimed to describe first-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent swimmers and to discuss the different presentations, unique risk factors, treatment, and potential injury prevention strategies of such fractures. We discussed two such cases which were successfully treated with activity modification with restriction of all overhead activity, gradually progressive physical therapy and a return to swimming protocol. First-rib stress fractures can vary in presentation and should be in the differential diagnosis in adolescent swimmers with chronic shoulder pain. These injuries can be successfully managed with rest from overhead activities and physical therapy. Gradual return to competitive swimming can be achieved even with non-union of a first-rib stress fracture. Emphasis on balanced strength training in different muscle groups and proper swimming technique is essential to prevent these injuries.

Rehabilitation following an acute traumatic first rib fracture in a collegiate football player: a case report and literature review

BACKGROUND AND PURPOSE

Isolated fractures involving the first rib are rare and often difficult to diagnose. There is a paucity of literature regarding isolated fractures and even fewer reported cases involving those due to contact. The purpose of this case report is to describe the mechanism of injury, differential diagnosis, rehabilitation, and return to sport decision making for an isolated first rib fracture secondary to acute trauma in a collegiate football player.

CASE DESCRIPTION

An 18 year-old right-hand dominant male collegiate football player was involved in a facemask-to-facemask collision during a football game while playing defensive back. His chief complaint during the sideline evaluation was left-sided neck and shoulder pain with concomitant clicking reported with active movement of his left shoulder.

OUTCOMES

A musculoskeletal ultrasound performed in the training room suggested a possible scapular spine fracture. However, a subsequent magnetic resonance image revealed an acute isolated anterolateral fracture of the first rib. The subject was treated conservatively with extensive rehabilitation and was able to return to full participation for summer training camp as well as the fall football season at the same level of play as prior to injury.

DISCUSSION

An isolated first rib fracture is extremely rare due to the unique anatomical location of the first rib posterior to the clavicle, as well as the surrounding shoulder girdle and associated layer of musculature. Identifying this injury can be challenging due to vaguely reported symptoms and the paucity of reported incidences. In the setting of an isolated injury, conservative management including structured rehabilitation can lead to successful outcomes and return to play. This is the first published rehabilitation guideline for an acute isolated first-rib fracture secondary to trauma.

LEVEL OF EVIDENCE

4 - Single case report.

Review of Lacrosse-Related Musculoskeletal Injuries in High School and Collegiate Players

Context:

Participation in lacrosse has dramatically increased since 2001. Changes in the game rules, sport equipment, and athlete characteristics have all contributed to the injury patterns in lacrosse over time.

Objective:

A summary of lacrosse-related musculoskeletal injuries.

Data Sources:

Medline, CINAHL, Scopus, and Web of Science were searched for articles relating to the epidemiology and mechanisms of lacrosse injuries in high school and collegiate lacrosse players.

Study Selection:

The search strategy used the following keywords: lacrosse, injury, musculoskeletal, high school, intercollegiate, knee, shoulder, fracture, ankle, foot, concussion, and surveillance. Studies were included if they reported injury risk, injury type, or injury mechanism in high school or collegiate lacrosse players.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data extraction:

Injury type, frequency, and mechanism as well as population were extracted.

Results:

Thirteen cohort studies and an additional 15 case series and reports were included. For all lacrosse players, ankle, knee, and hand/wrist were key sites for acute injury. Among collegiate players, preseasonal play elicits more injuries than seasonal play. Female players incur more noncontact and overuse injuries than male players. Boys have 3 to 5 times the risk for sustaining a fracture compared with girls in competition and practice. Women experienced fewer concussions but more facial fractures than men. Injuries to the foot/ankle, head, face, and wrist/hand more often required surgery in girls than in boys.

Conclusion:

Male players incur more injuries than female players. However, because of the collisional nature of play, more shoulder, arm, and upper leg injuries occur in male players. Fractures to the head and hand occur relatively more frequently in female players. Injury risk can be modified with appropriate training regimens and by respecting the game rules.

First rib fracture and Horner's syndrome due to a motor vehicle collision: a case report

A case of a first rib fracture and Horner's syndrome due to a motor vehicle collision is reported. Initial evaluation in a hospital emergency department and follow-up by a medical primary care physician failed to provide identification of the Horner's syndrome. Careful assessment and review of the patient's symptoms, signs and images revealed this uncommon and important neurologic case presentation. A brief discussion related to traumatic first rib fracture, Horner's syndrome and arterial dissections of the neck is provided.