Working Diagnosis:
Right first rib fracture

Treatment:
Non-operative management with no specific limitation in activity and construction of a protective shield Case Photo #3 for games.

Outcome:
He followed up one day after the injury and the decision was made to construct a shield to offer additional protection during games. The shield also limited arm adduction which helped reduce pain during sport participation. One week after the injury, he was able to participate in practice and played in a game.

Author's Comments:
Isolated first rib fractures are a rare phenomenon among athletes in contact sports. They are also a rare occurrence in trauma and have historically been considered a marker of severe injury. Mechanism of injury for fracture include trauma, strong muscle contraction, and overuse. Stress fractures of the first rib, though rare, may be more common than initially thought. They tend to occur in sports with repetitive throwing, overhead activity and rowing. Potential complications include subclavian injury, pneumothorax, thoracic outlet syndrome, Horner's syndrome, nonunion, and pseudoarthrosis. There are no clear guidelines or return-to-play consensus. Athletes should be counseled on risks.

Editor's Comments:
Stress fractures of the first rib are more common than isolated traumatic fractures during sport participation. Stress fractures typically occur due to repetitive traction of muscles on the first rib during upper extremity predominant sports. Symptoms of first rib fractures are typically nonspecific and include pain throughout the shoulder girdle including medial shoulder, posterior clavicle, scapula, trapezius, posterior shoulder, and/or upper chest. Pain with range of motion, specifically in abduction and flexion of the shoulder. Associated symptoms may also include weakness, paresthesia, popping, and muscle spasm. XR often identifies first rib fractures, but may require CT or MRI for definitive diagnosis. There are no clear guidelines in treatment or return to play. However, review of the literature suggests documentation of bone healing and resolution of symptoms has occurred prior to return to sport. Although rare, first rib fractures should remain on the differential for athletes with nonspecific shoulder or scapular pain.

References:
1. Dhaniwala NS, Dhaniwala MN, Shah P, Khan KK, Jadawala V, Jadhav S. Traumatic First Rib Fracture: An Indication of Life-threatening Injuries. Journal of Orthopaedic Case Reports. 2022;12(4):54. doi:10.13107/jocr.2022.v12.i04.2764.
2. Marcussen B, Negaard M, Hosey RG, Smoot MK. A Case Series and Literature Review: Isolated Traumatic First Rib Fracture in Athletes. Clin J Sport Med. 2020;30(3):257-266. doi:10.1097/JSM.0000000000000614.
3. Sakellaridis T, Stamatelopoulos A, Andrianopoulos E, Kormas P. Isolated first ribfracture in athletes. British Journal of Sports Medicine. 2004;38(3):e5-e5.doi:10.1136/bjsm.2003.009225
4. Sheng DL, Burnham K, Boutin RD, Ray JW. Ultrasound Identifies First Rib Stress Fractures: A Case Series in National Collegiate Athletic Association Division I Athletes. J Athl Train. 2023;58(7-8):664-668. doi:10.4085/1062-6050-0375.21.
5. Wild AT, Begly JP, Garzon-Muvdi J, Desai P, McFarland EG. First-Rib Stress Fracture in a High-School Lacrosse Player: A Case Report and Short Clinical Review. Sports Health. 2011;3(6):547. doi:10.1177/1941738111416189

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