Working Diagnosis:
Nondisplaced isolated right lateral first rib fracture.

Treatment:
The patient was placed in a sling for comfort; however, rigid immobilization was not recommended in order to avoid prolonged immobility. He was held from football participation and other contact activities because of the symptomatic fracture and to allow adequate healing over the subsequent 6 weeks. <br> <br>The patient was instructed to follow up in 4 to 6 weeks for repeat imaging and clinical reevaluation.

Outcome:
Repeat imaging obtained 5 weeks after the initial radiographs, corresponding to 6 weeks after symptom onset, demonstrated interval healing with callus formation. <br> <br>At the time of reevaluation, the patient's pain had completely resolved, and he was asymptomatic. Given appropriate radiographic and clinical healing, no further follow-up was required. The patient was cleared to return to sport as tolerated with appropriate return precautions.

Author's Comments:
First rib fractures are most commonly associated with high-energy trauma and polytrauma.1 Isolated first rib fractures are uncommon and often result from either direct trauma or repetitive stress mechanisms.3 In the absence of major trauma, isolated first rib fractures may be underrecognized, potentially leading to delayed diagnosis, prolonged symptoms, delayed healing, or nonunion.2-3 <br> <br>Plain radiographs of the ribs and chest are often sufficient to establish the diagnosis.² Most athletes with isolated first rib fractures treated conservatively return to sport without long-term complications.2 <br> <br>This case supports the concept that repetitive stress and cumulative indirect forces, rather than a single major traumatic event, can result in an isolated first rib fracture. Clinicians should maintain a broad differential diagnosis when evaluating athletes with unilateral upper back, shoulder girdle, or upper thoracic pain, particularly when symptoms persist without a clearly identifiable mechanism of injury.3

Editor's Comments:
First rib fractures are uncommon injuries because of the protected anatomic location of the first rib beneath the clavicle and surrounding soft tissues. Although they are classically associated with high-energy trauma and polytrauma, they may also occur in athletes as a result of repetitive stress, muscular forces, or cumulative minor trauma.1,3 This case demonstrates that isolated first rib fractures can occur even when there is no clearly identifiable inciting event or immediate onset of symptoms. <br> <br>An important teaching point is that identification of a first rib fracture should prompt a thorough evaluation for associated injury. Owing to the proximity of the first rib to the brachial plexus, subclavian vessels, and thoracic cavity, clinicians should perform a careful neurologic, vascular, and cardiopulmonary examination and maintain a low threshold for additional imaging when the mechanism of injury, fracture pattern, or clinical presentation raises concern for complications.1 <br> <br>For sports medicine clinicians, isolated first rib fracture should remain within the differential diagnosis of unilateral upper back, shoulder girdle, or upper thoracic pain, particularly when symptoms are persistent or do not fit more common shoulder or cervical spine diagnoses. Most isolated, nondisplaced first rib fractures can be managed conservatively and allow successful return to sport following clinical and radiographic healing.2,3

References:
1. Dhaniwala NS, Dhaniwala MN, Shah P, Khan KK, Jadawala V, Jadhav S. Traumatic First Rib Fracture: An Indication of Life-threatening Injuries. J Orthop Case Rep. 2022 Apr;12(4):54-57. <br> <br>2. Eiff, M. Patrice, et al. Fracture Management for Primary Care and Emergency Medicine. Elsevier, 2020. <br> <br>3. Weis JL (2019) Non-Traumatic First Rib Fractures Secondary to Opposing Muscle Contractions: A Case Series Int J Sports Exerc Med 4:113.

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