Puzzling Periscapular Pain - Page #4
 

Working Diagnosis:
Nondisplaced fracture of left 3rd rib immediately behind the left transverse process

Treatment:
Upper extremity and contact activity was restricted until she was pain free. The patient was given Motrin and Robxin for pain control and had several trigger point injections in the trapezius and rhomboid area for associated muscular spasm. A bone stimulator was applied to encourage healing of the partial union.

Outcome:
The patient is now completely pain free and has progressed back to full activities in the weight room without modifications. However, she has no plans to return to rugby.

Author's Comments:
We were unable to find a case study or case series of this particular type of fracture to guide our treatment plan. This case was discussed at our bimonthly departmental case presentation series. Consideration was given to using calcitonin for pain control, but there is no evidence for calcitonin use in a partial union fracture. In addition, we considered a diagnostic and therapeutic injection between the rib and transverse process to confirm that the area of the fracture was the main pain generator.

Editor's Comments:
This is an unusual case as it involves fracture of the third rib and delayed healing in an otherwise healthy athlete. It is thought that the prevalence of rib fracture is underestimated as many rib fractures are missed on radiographs and this is likely a contributing factor to the lack of evidence based treatment algorythms (1). Although third rib fractures are not described in the literature a case review of trumatic first rib fractures performed by Marcussen show an overall return to contact sport at the 12 week mark with some athletes returning sooner with conservative rest and protection (2).

References:
1. Gauger, E; et al. Outcomes after operative management of symptomatic rib nonunion J Ortho Trauma 2015; 29(6):283-289
2. Marcussen, B; et al. A case series and literature review: Isolated traumatic first rib fractures in athletes. Clin J Sports Med 2018; 0:1-10

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