Isolated Bilateral First-Rib Fractures/Izole Bilateral Birinci Kosta Kirigi

Headnote

ABSTRACT

Introduction: Bilateral fractures of the first rib are extremely rare and usually associated with either multiple rib fractures or serious traumatic injuries. In many cases, first rib fracture is related to seri- ous trauma of the intrathoracic, head, and cervical spine, includ- ing neurovascular injuries. We present a case report of isolated bilateral first rib resulting from fracture following falling down from approximately 3 meters in height.

Case Report: A 52-year-old woman, with Glasgow coma scale score 15, fell down 2 hours ago and was admitted to the emer- gency department. Patient's vital signs were stable. Breath and heart sounds and pulse examinations in the bilateral carotid ar- teries and upper extremities were not determined to be aberrant. The cervical spine radiographic figures were obtained as intact; however, the bilateral first ribs were fractured by direct radiog- raphy and thoracal computerized tomography. There were no other pathological findings related to the patient.

Conclusion: The first rib is deeply placed and protected by the shoulder girdle and muscles, the fracture of which remains the rarest of all rib fractures. We know that potential life-threatening injuries occur with only first-rib fracture; so, we think that the po- tential risk of that trauma is too high in the case of bilateral first- rib fractures. Our patient was fortunate.

Keywords: Bilateral rib fractures, isolated fracture of the first rib

Received: 25.11.2012 Accepted: 20.03.2013

ÖZET

Giris: Bilateral birinci kosta kirigi son derece nadirdir ve genel- likle birden fazla kosta kirigi veya ciddi travmatik yaralanmalarla birliktedir. Birçok vakada birinci kosta kirigi intratorasik ciddi ya- ralanmalarla, ciddi nörovasküler yaralanmalari içeren bas ve sevi- kal vertebra travmalariyla iliskilidir. Biz yaklasik 3 metre yüksekten düsen ve izole olarak bilateral birinci kostasi kirilan bir olgu su- nuyoruz.

Olgu Sunumu: Elli iki yasinda kadin, acile gelmeden 2 saat önce düsmüs, glasgow koma skoru 15'di. Hastanin vital bulgulari sta- bildi. Akciger, kalp sesleri, bilateral üst ekstremite ve karotis arter nabiz muayenelerinde bir anormallik tespit edilmedi. Servikal ver- tebra radyografik olarak intakti, ancak direkt radyografi ve torakal bilgisayarli tomografide bilateral birinci kosta kirigi mevcuttu. Hastada baska herhangi bir patolojik bulguya rastlanilmadi.

Sonuç: Birinci kosta derin yerlesimlidir, omuz kusagi ve kaslar ta- rafindan korunur, kirilmasi tüm kosta kiriklari içerisinde nadirdir. Biliyoruz ki birinci kosta kirigi hayati tehdit eden yaralanmalarla beraberdir, bu yüzden bilateral kosta kirigi olan vakalarda potan- siyel riskin yüksek oldugunu düsünüyoruz. Bizim hastamiz sans- liydi.

Anahtar Kelimeler: Bilateral kosta kirigi, izole birinci kosta kirigi

Gelis Tarihi: 25.11.2012 Kabul Tarihi: 20.03.2013

Introduction

Bilateral fractures of the first rib are extremely rare and usually associated with either multiple rib fractures or serious traumatic injuries (1-5). In many cases, traumatic fractures of the first rib occur together with serious intrathoracic, head, and cervical spine (C-spine) as well neurovascular injuries (4). Violent muscular contraction and chronic stress are the nontraumatic causes (1).

We present a case of isolated bilateral first rib fracture because of falling down from 3 meters in height.

Case Report

A 52-year-old woman who fell down 2 hours ago was admitted to the emergency department. On arrival in the Emergency Department, her Glasgow Coma Scale score was 15. Her vital signs included blood pressure of 140/80 mm Hg, pulse rate 92 beats/min, respiratory rate 16 breaths/min, and oxygen saturation 96% without oxygen supply. Skin abrasions were seen between the neck and right shoulder with inspection. The patient was suffering from pain with palpation of the lower cervical spine in the physi- cal examination, and her complaint was increasing by lifting her right shoulder. She had normal pulses in the bilateral carotid arteries and upper extremities as well as normal breath and heart sounds on listening to the chest with a stethoscope. The assessment of the cranial nerve was normal. The C-spine radiographies were normal, but isolated, bilateral first-rib fractures were established on the chest radiograph (Fig. 1) and thoracal computerized tomography (Fig. 2). There was no other radiologic finding. She was managed conser- vatively at the thoracic surgery service and discharged 5 days after admission without any complications.

Discussion

The first rib is deeply placed and protected by the shoulder girdle and muscles, and fracture of the first rib remains the rarest of all rib fractures (4). In many cases, traumatic fractures of the first rib occur together with serious intrathoracic, head, and C-spine as well neuro- vascular injuries (4). The incidence of first-rib fracture could hardly be defined due to its rarity but has been estimated at between 0.001% and 0.005% in reviewing chest radiographies of healthy young Navy personnel and in patients who were screened for tuberculosis (4). The weakest point of the first rib is at the groove for the subclavian artery, which is also the thinnest portion of the first rib (4, 6).

The mechanism of first-rib injury in motor vehicle accidents seems to be a violent contraction of the scalene muscles brought on by the sudden forward movement of the head and neck (4, 7). Associated complica- tions include delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, and thoracic outlet syndrome (4). Horner's syn- drome also has been reported to result from first-rib fracture (4, 5, 8, 9).

Conclusion

Accurate diagnosis of first-rib fracture can often be made by chest radiography. Recognition of potentially life-threatening injuries as- sociated with first-rib fractures is essential.

Hasta Onami: Yazili hasta onami bu çalismaya katilan hastadan alin- mistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir - H.Ç.; Tasarim - H.Ç.; Denetleme N.G.; Kaynaklar - H.Ç., M.Y.; Malzemeler - O.B.; Veri toplanmasi ve/veya islemesi - H.Ç., O.B.; Analiz ve/veya yorum - H.Ç., M.Y.; Literatür taramasi - H.Ç., M.Y.; Yaziyi yazan - H.Ç., M.Y.; Elestirel Inceleme - N.G., O.B.

Çikar Çatismasi: Yazarlar herhangi bir çikar çatismasi bildirmemislerdir.

Finansal Destek: Yazarlar bu çalisma için finansal destek almadiklari- ni beyan etmislerdir.

Informed Consent: Written informed consent was obtained from the patient who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - H.Ç.; Design - H.Ç.; Supervision - N.G.; Funding H.Ç., M.Y.; Materials - O.B.; Data Collection and/or Pro - cessing - H.Ç., O.B.; Analysis and/or Interpretation - H.Ç., M.Y.; Litera- ture Review H.Ç., M.Y.; Writing - H.Ç., M.Y.; Critical Review N.G., O.B.

Conflict of Interest: No conflict of interest was declared by the au- thors.

Financial Disclosure: The authors declared that this study has re- ceived no financial support.

References

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