Updated: 6/1/2021

Rib Stress Fracture

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  • summary
    • A rib stress fracture in an uncommon site of stress fracture that typically occurs due to repetitive contraction of the chest wall muscles. 
    • Diagnosis can be made with radiographs but often require CT or MRI for accurate diagnosis.
    • Treatment consists of rest, analgesia and cessation of inciting activity for ~4-6 weeks.
  • Epidemiology
    • Incidence
      • uncommon site of stress fracture
    • Anatomic 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
  • Etiology
    • 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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(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?

QID: 4718
FIGURES:
1

Inspiration and expiration chest radiographs are necessary to exclude pneumothorax

1%

(60/6063)

2

Operative stabilization is indicated

0%

(29/6063)

3

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

2%

(139/6063)

4

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

86%

(5215/6063)

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%

(579/6063)

L 2 C

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