Updated: 10/6/2016

Rib Stress Fracture

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Topic
Review Topic
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Questions
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Evidence
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https://upload.orthobullets.com/topic/12108/images/rsf.jpg
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https://upload.orthobullets.com/topic/12108/images/bsrsf.jpg
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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Questions (1)

(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? Review Topic | Tested Concept

QID: 4718
FIGURES:
1

Inspiration and expiration chest radiographs are necessary to exclude pneumothorax

1%

(49/5547)

2

Operative stabilization is indicated

0%

(25/5547)

3

The bone scan appearance of this lesion differs when caused by chronic cough rather than rowing

2%

(123/5547)

4

Treatment typically includes rest, analgesia, and slow return to rowing

86%

(4777/5547)

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

10%

(536/5547)

L 2 C

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