|Year : 2014 | Volume
| Issue : 5 | Page : 669-671
Bilateral first rib fractures: A case report
Dilip Amonkar, Mervyn Correia, Amey pednekar, Osborne Vaz
Department of General Surgery, Goa Medical College, Bambolim, Goa, India
|Date of Web Publication||10-Sep-2014|
Resicom Elite, Flat C- 02, Off Kadamba Depot Road, Alto-Porvorim, Bardez, Goa - 403 521
Source of Support: None, Conflict of Interest: None
From the time first rib fractures were first described in 1869, they have been a source of anxiety to attendant trauma surgeons working in the accident and emergency department of major hospitals. First rib fractures are associated with major thoracic trauma and may involve injury to subclavian vessels, brachial plexus, and mediastinal structures. But these complications are more often seen following unilateral first rib fractures. In contrast, bilateral first rib fractures may follow insignificant trauma, suggesting a different mechanism involved. Serious vascular injuries and brachial plexus injuries are rare and angiograms for evaluation of these patients aren't routinely warranted. The case that we report illustrates this very point.
Keywords: Fracture ribs, trauma, vascular injury
|How to cite this article:|
Amonkar D, Correia M, pednekar A, Vaz O. Bilateral first rib fractures: A case report. Med J DY Patil Univ 2014;7:669-71
| Introduction|| |
The fracture of the 1st rib is extremely rare and bilateral fractures are even less common. The management of the 1 st rib fractures has been a challenge to the surgeons, ever since its first description in the year 1869.  It has been noted and documented that whenever 1 st ribs are involved in traumatic fractures of the thoracic cage, there is also an associated injury of the clavicle and the scapula.  1 st rib fractures are noted in major thoracic trauma and are commonly associated with injury of brachial plexus, subclavian vessels, and mediastinal structures. The mechanism involved in the impact which leads to the 1 st rib fractures is different for unilateral and for bilateral fractures as noted from the fact that unilateral fractures are more commonly associated with fatal complications as against bilateral ones which are not.
| Case Report|| |
A 17-yr-old healthy young male was involved in a road traffic accident when he slipped on his two wheeler bike while trying to break. He gave history of receiving the impact of the bikes handle bar hub at his lower neck. There was no history of any respiratory difficulty, no history of cough. The patient was hemodynamically stable when he arrived to the emergency room with a pulse rate of 84 bpm and BP of 118/80 mmHg.
On local examination there were no abrasion or contusion marks on the chest or the neck. On palpation there was tenderness in the upper chest, more so, medially and also in the inferior aspect of the neck. However, there was no subcutaneous emphysema and no bony crepitus. There was no pulse deficit in either of the upper limb, no sensory deficit, and no muscle weakness of the either extremity. The patient could move either extremity without any increase in the pain.
Patient was sent for an X-ray chest. The X-ray chest posteroanterior (PA) view revealed fractures of bilateral 1 st ribs [Figure 1]. However, there was no evidence of fracture of any other bones in the thorax, no mediastinal widening. In our patient CT scan was not done as x-ray evidence was conclusive and the patient did not have evidence of neurovascular deficit. The patient was admitted and as the patient was hemodynamically stable he was kept under observation for 48 hours. IV analgesics were given to decrease the patient's discomfort. After 48 hours the patient was discharged and followed up on out-patient visits. By the end of the second week the patient was back to his school to continue with his studies.
|Figure 1: Chest x-ray showing bilateral fracture first rib indicated by black arrows|
Click here to view
| Discussion|| |
The fracture of the first rib is considered to be a significantly major injury and that it requires a major force to bring about this fracture as the first rib is very well protected by soft tissues in the lower neck as well as the clavicle and the scapula.  Hence, isolated fracture first rib is a rare phenomenon. Often isolated fractures of the first rib are often seen with or without history of trauma which may not be correlated with the fracture. Non-traumatic bilateral first rib fractures have also been reported.  First rib fractures may be isolated or occur along with other rib or clavicle fractures and are usually located in an anatomically weak area. 
Therefore, many authors in the past discussed the mechanism of this fracture. According to several authors, the mechanism of this fracture has been divided into the three categories:
- As a result of direct chest trauma, usually related to motor vehicular accident,
- In the setting of sporting activities, especially those related to prompt excessive neck muscle contraction as with weight lifting and rowing,
- Medical cases of respiratory compromise that require the excessive use of accessory breathing muscles such as status asthmaticus, pertussis in childhood. ,
The location of the fracture on the rib is also of significance. The subclavian vessels pass over the first rib forming the subclavian groove. The scalenus anterior and the upper slip of the serratus anterior insert on each side of the subclavian sulcus and by exerting opposite traction lead to fracture of the anatomical weak point of the first rib. Furthermore, this type of fractures may even remain silent.  Most authors have rightly designated this type of fracture as fatigue fracture. 
Many authors tried to elaborate pathological fracture of the first rib in few patients, but this suspicion was disproved. In the literature we could not find any data regarding pathological fractures of the first fib.
Even after an extensive research the exact mechanism of injury in bilateral first rib fracture remains questionable. According to some authors, since it is a relatively benign condition clinical endeavors should be directed at associated complications, especially of the thoracic structures and spinal cord. On the other hand, others suggest that bilateral first rib fracture is a hallmark of major thoracic trauma and direct urgent investigation to rule out the possibility of injury to the great vessels.  Keeping in mind the rarity of bilateral first rib fracture, we can draw the conclusion that there cannot be any definite rules regarding the investigation protocol of this injury. We should plan the investigations based on anatomical structures at risk of injury. Although unilateral fractures are uncommon, they are found more often than bilateral first rib fractures.
Nowadays, selective investigations are recommended to define subclavian artery or other major vascular injuries. The common situations where such investigations are warranted are:
- Chest radiograph showing widened mediastinum,
- Upper-extremity absence of pulse,
- Brachial plexus injury and
- An expanding hematoma. ,, After excluding the possibility of major vascular injury, treatment of bilateral first rib fracture should include appropriate analgesics and hot compression only, since cervical collar stabilization is not routinely required.
In our patient although he was involved in a road traffic accident that caused bilateral first rib fractures, he did not have associated vascular, brachial plexus, and mediastinal injuries. He did not have associated clavicular and other rib fractures, nor did he have a hemothorax or pnemothorax.
The mechanism of this injury could probably be due to the fact that although he slipped and fell from his two wheeler, he did so while travelling at a low speed, with the handles of the bike striking him in the region of the first ribs on both sides. This resulted in undisplaced fractures of both first ribs and no other major neurovascular deficit or thoracic injury. At the time of fall the patient may have landed in a very awkward position resulting in excessive neck muscle contraction. This traction type force may have resulted in fracture of these ribs at its weakest point, along the subclavian groove.
| Conclusion|| |
The surgeons who deal with emergency and trauma centers should be aware of this occurrence of bilateral first rib fractures and the consequences it may follow although it is a rare phenomenon. The management needed for this may vary from analgesics and rest to an emergency thoracotomy if a major vessel is involved in the injury. Expedient management with early investigation and thorough hemodynamic monitoring can be life saving for the patient.
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