The Journal of Emergency Medicine, Vol. 43, No. 2, pp. e119–e121, 2012Copyright � 2012 Published by Elsevier Inc.

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doi:10.1016/j.jemermed.2011.06.144

RECEIVED: 29 JaACCEPTED: 4 Jun

ClinicalCommunications: Pediatrics

JUVENILE FIRST RIB FRACTURE CAUSED BY MORNING STRETCHING

Seung-Joon Lee, MD, PHD, Kilsoo Yie, MD, and Sung Bin Chon, MD

Emergency Medicine and Respiratory Center of Kangwon National University Hospital and School of Medicine, Kangwon National University,Chuncheon, South Korea

Reprint Address:Kilsoo Yie, MD, Respiratory Center & Department of Thoracic and Cardiovascular Surgery of KangwonNational University andNational Hospital, Hyoja3dong 17-1, Chuncheon 200-947, South Korea

, Abstract—Background: First rib fractures are very rare,being primarily associatedwith external blunt trauma.Relatedconditions, such as sudden contraction of the neck muscle,stress fractures, and fatigue fractures, have been reported spo-radically. These fractures aremostly related to repetitive or ex-plosive physical training. However, anatomical relationshipsand related injury mechanisms may cause first rib fractureswithout repetitive sports activity. Objective: To present a caseof juvenile first rib fracture caused bymorning stretchingwith-out sports activity. Case Report:We present a rare case reportof juvenile atraumatic first rib fracture. Conclusion: Physi-cians should be aware that evenmorning stretchingwith yawn-ing can cause a first rib fracture in children. Awareness isimportant for early recognition, and proper management iscritical for a pain-free return to normal life. An understandingof the mechanism of atraumatic first rib fracture isimportant. � 2012 Published by Elsevier Inc.

, Keywords—first rib fracture; atraumatic; stressfracture; mechanism; juvenile rib fracture

INTRODUCTION

First rib fractures are very rare, being primarily associ-ated with external blunt trauma. Related conditions,such as sudden contraction of the neck muscles, stressfractures, and fatigue fractures, have been sporadicallyreported. These fractures are mostly related to repetitiveor explosive physical training. However, certain anatom-ical relationships and related injury mechanisms maycause first rib fractures without repetitive sports activity.

nuary 2011; FINAL SUBMISSION RECEIVED: 29 Mae 2011

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CASE REPORT

A 13-year-old boy presented to our Emergency Depart-ment (ED) with a sudden sharp, stabbing pain in theleft shoulder and neck immediately after stretching witha yawn in the morning. His mother said that he wokeup with his right arm flexed pointing upward and hisleft arm outstretched pointing downward. He yawnedand turned his head to the right side, and suddenly hearda click in his neck. He had no history of genetic disease,recent trauma, or sports activity. He denied any childabuse and seemed to be well nourished. On physicalexamination, he had neither muscle atrophy of theshoulder girdle nor asymmetry of the scapular region.Although both shoulders exhibited full range of motion,scapula retraction produced a nagging pain in the leftshoulder and medial scapular area. There was minimalsupraclavicular tenderness. The pain was relieved some-what by resting. The patient felt occasional numbness inhis left upper limb when it was stretched. The numbnesswas absent in the normal position. Laboratory findings,including complete blood cell count, electrolytes, hepato-biliary test, renal function test, urine analysis, C-reactiveprotein, and erythrocyte sedimentation rate, were unre-markable. However, a radiograph of the left ribs revealeda first rib fracture (Figure 1). Because there was no signif-icant neurological or musculoskeletal complication, thepatient was treated conservatively and underwent routinefollow-up. A nonsteroidal anti-inflammatory drug wasprescribed for 3 days and effectively alleviated the pain.

rch 2011;

Figure 1. Simple chest radiograph showing first rib fracture(arrow).

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He was advised to avoid any physical activity, includingparticipating in physical education classes at school.A nerve conduction study was performed the next dayin the Neurology outpatient department; it did not revealany abnormal electrophysiological finding. Two monthslater, the fracture site had healed with callus formation,and the numbness associated with limb stretching hadcompletely disappeared.

DISCUSSION

Atraumatic isolated first rib fracture in juveniles isuncommon. It can be caused by sudden muscular pulls,fatigue, or stress fractures, or heavy mechanical loadingon the first rib. The diagnosis is made by obtaining a care-ful history, finding focal tenderness (although it wasnot severe in this case) on physical examination, andperforming plain radiography. Identifying concomitantneurovascular injury and controlling the pain and compli-cations is not complex in most cases. However, the mech-anism of injury should be determined in each case. Somepossible mechanisms of juvenile atraumatic first rib frac-ture follow. Matsumoto et al. suggest that simultaneouseccentric muscle contraction of the scalenus anterior, sca-lenus medius, and serratus anterior can cause the first ribto fracture (1). Anatomically, the scalenus muscles andthe serratus muscle insert on the superior and inferior sur-faces of the first rib, respectively. Contraction of the sca-lenus anterior pulls the lateral portion of the first ribproximally and posterolaterally, whereas contraction ofthe scalenus medius pulls the medial portion of the firstrib proximally and medially. On the other hand, the serra-tus anterior pulls the first rib posterolaterally and inferi-orly. Simultaneous contraction of these muscles canexert a shearing force at the groove of the subclavian ar-tery, which is the thinnest portion of the first rib. This sit-uation may not be associated with repetitive use of theupper extremity; it can be seen with ‘‘heading’’ actions,especially in laterally bending heading of a soccer player,

with coughing, and with nervous tics in children (1–3).Although there is no published report identical to ourcase, we believe that the cause of first rib fracture inour patient was by this mechanism.

It has been theorized that chronic repetitive muscleaction at a younger age also can be a cause of stress frac-tures of the first rib (4). Vigorous sports activity and respi-ratory distress require maximum increase in the capacityof the thoracic cavity with forced inspiration using acces-sory breathing muscles such as the serratus and scalenus.Children carrying heavy schoolbags using only one strapare at higher risk for this situation (5). In adults, on theother hand, pseudoarthrosis formation of the costoma-nubrial joint of the first rib results in limitation of ‘‘buckethandle’’ motion during respiration, and this is assumed tobe associated with reduced ‘‘buffer power’’ during mus-cular impacts, and predisposes to stress fracture (6).Finally, child abuse must be considered, especially inyoung individuals presenting with first rib fractures.The possible mechanisms involved in child abuse couldbe direct impact force, compressive force, shaking, oracute axial load (slamming), the latter two of which causeindirect fractures.

For an accurate diagnosis, considering the possibilityof first rib fracture along with thorough history-takingand physical examination are most important in childrenwho have a complaint of pain in the shoulder or neck. Itusually can be visualized on anteroposterior chest orshoulder radiographs, mainly in the region of the groovefor the subclavian artery. Controversies exist regardingthe need for additional imaging in this type of injury.Although it may not be necessary for the diagnosis, com-puted tomography scan is useful to delineate the anatomyof the fracture, to rule out pathologic lesions, and to con-firm healing at follow-up. Bone scans can assist in deter-mining the acuity of the fracture (7).

Generally, symptomatic treatment with activity modi-fication for 4–6 weeks and pain control should suffice, butany hidden neurovascular injury should be identified. Thetiming of the patient’s return to physical activitiesdepends on symptoms. Late complications that requiresurgical decompression such as brachial plexus palsy,thoracic outlet syndrome, and Horner syndrome, arerare but possible due to extensive callus formation (4,5).

CONCLUSION

Physicians should be aware that even morning stretchingwith yawning can cause a first rib fracture in youngerpatients. Awareness is important for early recognition,and proper management is critical for a pain-free returnto normal life. An understanding of the mechanism,associated findings, and prognosis of atraumatic first ribfracture is important.

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REFERENCES

1. Matsumoto T, Fujita K, Fujioka H, et al. Stress fracture of the first ribin a soccer player: a rare etiology of shoulder pain. J Shoulder ElbowSurg 2003;12:197–9.

2. Prasad S, Baur LA. Fracture of the first rib as a consequence ofpertussis infection. J Paediatr Child Health 2001;37:91–3.

3. Moon BS, Price CT, Campbell JB. Upper extremity and rib stressfractures in a child. Skeletal Radiol 1998;27:403–5.

4. Young EJ, Curtis RJ. First rib fractures related to hitting in twobaseball teammates. Clin J Sport Med 2008;18:300–1.

5. Papadimitriou NG, Christophoridis G, Papadimitriou A,Beslikas TA. Acute torticollis after isolated stress fracture of the firstrib in a child. A case report. J Bone Joint Surg Am 2005;87:2537–40.

6. O’Neal M, Ganey TM, Ogden JA. First rib stress fracture and pseu-darthrosis in the adolescent athlete: the role of costosternal anatomy.Clin J Sport Med 2009;19:65–7.

7. Coris EE, Higgings HW. First rib stress fractures in throwing athletes.Am J Sports Med 2005;33:1400–4.