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Rib Stress Fracture

Topic updated on 12/21/15 5:25pm
Introduction
  • Epidemiology
    • incidence
      • uncommon site of stress fracture
    • location
      • first rib
        • common site
        • occurs anterolaterally
        • activities associated with stress fx include baseball pitching, basketball, weightlifting and ballet
      • middle ribs (4-9th)
        • occurs laterally and anterolaterally
        • increased incidence in competitive rowers
      • posteromedial ribs
        • more commonly occurs in novice golfers
    • risk factors
      • amenorrhea
      • osteopenia / osteoporosis
      • extreme overuse / repetitive use
      • repetitive coughing paroxysms
  • Pathophysiology
    • pathoanatomy
      • repetitive contraction
        • stress placed on a rib during repetitive contraction of an attached muscle
        • accentuated during training because muscles strengthen more rapidly than bone
      • muscle fatigue during prolonged activity
        • places a bone at risk for fracture by lessening the ability of a muscle to absorb and dissipate opposing forces
      • anatomic sites of weakness
        • first rib stress fx
          • groove for subclavian artery is site of weakness due to superiorly directed forces from the scalene muscles and inferiorly directed forces from the serratus anterior and intercostal muscles
Presentation
  • History
    • in cases of acute injury may hear "snap" (complete fracture of fatigued bone) while performing activity (i.e., throwing, batting, lifting)
  • Symptoms
    • pain
      • insidious onset
      • worse with coughing, deep inspiration and overhead activities 
  • Physical exam
    • palpation
      • focal tenderness directly over affected rib
      • with advanced injuries, palpable callus may develop
Imaging
  • Radiographs
    • recommended views
      • AP chest
    • findings
      • x-rays are negative for fracture in as many as 60% of patients with rib fracture of any etiology
  • Bone scan
    • indications
      • when x-rays are negative and clinical suspicion remains
    • findings
      • increased activity
  • CT scan
    • indications
      • can be helpful when there is concern for pathologic fx
      • can help localize an uptake abnormality in the costotransverse region, where the anatomy is complex
    • findings
      • clear delineation of fracture pattern
  • MRI
    • indications
      • when x-rays are negative and clinical suspicion remains
      • avoids the use of radiation
      • used more commonly than bone scans in athletes
    • findings
      • marrow edema consistent with stress response; fracture line may or may not be seen
Treatment
  • Nonoperative
    • rest, analgesia, cessation of inciting activity for ~4-6 weeks, correction of training errors or faulty mechanics
      • indications
        • majority of rib stress fx
      • outcomes
        • majority heal uneventfully
Complications
  • Non-union

 

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Qbank (1 Questions)

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(OBQ13.83) A 23-year-old male Olympic rower presents with left sided chest pain exacerbated by cough. Bone scan results are shown in Figure A. Pain started 6 weeks after switching to a new oar with a bigger blade and a change in training regimen to include long-endurance rows at low stroke rates. Which of the following is correct? Topic Review Topic
FIGURES: A          

1. Inspiration and expiration chest radiographs are necessary to exclude pneumothorax
2. Operative stabilization is indicated
3. The bone scan appearance of this lesion differs when caused by chronic cough rather than rowing
4. Treatment typically includes rest, analgesia, and slow return to rowing
5. A modified rowing pattern involving more scapula protraction at the beginning of the stroke, and more retraction at the end of the stroke is recommended to prevent further lesions

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