Delayed Complication of a Rib Fracture
John O'Kane, MD; Elizabeth O'Kane, MD; Julianne Marquet, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 4 - APRIL 2021
In Brief: A 48-year-old man who was kneed in the chest while playing basketball was diagnosed as having an occult rib fracture. Five days after the injury, he was taken to the emergency room with severe midsternal and left upper quadrant and pleuritic chest pain. Left-side chest radiographs and CT scans revealed a pleural effusion, compression atelectasis, and a minimally displaced fracture of the sixth rib. A tube thoracostomy was performed, the pleural cavity was drained, and the patient recovered. His case illustrates the need to be alert for serious complications in apparently ordinary sports-related rib fractures.
Rib fractures are among the most common injuries to the chest. They are most frequent in the middle and lower ribs and are typically caused by blunt trauma and sometimes by violent muscle contractions (1). While rib fractures are quite painful, they generally are not associated with significant thoracic abnormalities and usually heal in several weeks with conservative treatment. This case demonstrates a rare, severe complication of a rib fracture sustained while playing basketball.
A healthy 48-year-old man was kneed in the chest while playing basketball and had to stop playing because of pain along his lower left rib cage. He went to the local emergency department for evaluation and was diagnosed as having a rib fracture despite a normal chest radiograph. Nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed, and he avoided athletic activity for the next few days. The pain continued, and, after 5 days, he presented to our clinic for a second opinion.
Initial clinical picture. He described his symptoms as sharp, stabbing, left-sided chest pain, which worsened when he laughed, coughed, or took deep breaths. Walking and lying on his back decreased the pain. It worsened when he lay on his left side but improved when he turned to his right. He had no history of heart or lung disease, although he had periodic tightening in his chest that had been diagnosed as indigestion. He was taking no medications except ibuprofen and reported no use of illicit drugs.
Examination revealed a pulse of 72/min, respiratory rate of 18/min, and blood pressure of 102/78 mm Hg. In general, he appeared well and was in no acute distress while sitting. When supine, he initially felt severe pain along his lower left ribs that decreased over 10 to 20 seconds. His heart had a regular rate and rhythm, with no murmurs, rubs, or gallops, and his lungs were clear. His chest had no ecchymosis or erythema and was mildly tender to palpation along the left lower ribs between the midclavicular and midaxillary lines. His abdomen was soft and nontender; no masses were palpated and there was no hepatosplenomegaly. The remainder of his exam was unremarkable. A chest radiograph showed mild atelectasis along the left heart border, but no other abnormalities.
He was diagnosed as having a presumed occult rib fracture and was sent home. He was told to take NSAIDs and to rest for several days.
Worsening symptoms. The patient did well until later that evening, when he developed severe, squeezing, midsternal pain associated with shortness of breath and palpitations. These symptoms lasted for 30 minutes. He called 911 and was transported to the hospital emergency department. Upon his arrival, the midsternal pain had subsided, but the patient reported severe left upper quadrant pain and left-sided pleuritic chest pain.
The examination in the emergency room revealed his pulse to be 100/min, respiratory rate 20/min, and blood pressure 154/97 mm Hg. He was pale and tachypneic but appeared comfortable when upright. His neck was supple with no jugular venous distention. His heart rate and rhythm were regular, and there were no murmurs, rubs, or gallops. A lung examination revealed decreased air movement in the left base to midlung with associated dullness to percussion but no egophony. He was tender to palpation over the left seventh and eighth ribs in the midaxillary line. His abdomen had bowel tones and was tender to palpation in the left upper quadrant with mild guarding.
Imaging and lab findings. Chest radiography showed a large left pleural effusion (figure 1). Examination of arterial blood gas using a 4-L O2 nasal cannula indicated a pH of 7.41, a PO2 of 89 mm Hg, a PCO2 of 40 mm Hg, and normal bicarbonate. An electrocardiogram and measurements of electrolytes and cardiac enzymes were normal. Chest computed tomography (CT) scans showed a moderate-sized effusion associated with compression atelectasis in the left side of the chest and a minimally displaced sixth rib fracture (figure 2). The fluid density on the CT scan was greater than water but less than that of acute hemorrhage. An abdominal CT scan was normal. Serial hematocrits dropped from 42% to 37% and then stabilized.
Treatment. Cardiothoracic surgeons placed a chest tube and had return of about 450 mL of old blood with no evidence of ongoing bleeding. The patient was admitted to the hospital, and, over the next 24 hours, a small amount of serosanguineous fluid drained from the chest tube. There was no evidence of pneumothorax or reaccumulation of hemothorax on chest x-ray. Two days after his admission, the chest tube was removed without complication, and a chest x-ray revealed minimal fluid in the chest and no pneumothorax. Three days after admission, he continued to do well and was discharged.
One week after discharge, the patient presented to his primary care clinic and had substantially decreased pain. Residual pain continued for another week, and, 6 weeks after discharge, he was pain free and resumed playing basketball.
Sports-Related Rib Fractures
Rib fractures are common sports injuries and often occur with a direct impact to the chest, as in this case. Such fractures usually occur directly beneath or lateral to the point of impact, as a result of anteroposterior compressive forces. They most often occur below the fourth rib, since the upper ribs are relatively protected beneath the shoulder girdle.
A second group of sports-related rib fractures are overuse or stress fractures, often seen in crew athletes and also reported in tennis and baseball players (2). Repetitive, forceful, overhead activity with violent muscle contraction of the anterior scalenes may result in a first rib fracture through its weakest point where it thins below the subclavian artery (1). In major trauma, a first rib fracture is associated with an increased risk of complications because of the high forces required to cause this injury. Rib stress fractures in athletes, regardless of which ribs are involved, are generally not associated with complications such as hemothorax.
Possible complications. The majority of rib fractures, while being quite painful, are uncomplicated and heal well with conservative treatment (see "Rib Fracture Fundamentals," below). As a result, the goal in the initial evaluation is to rule out more serious associated injuries. The most common initial complications are pneumothorax, pleural effusion, and hemothorax; delayed complications include pulmonary contusion, pneumonia, and pulmonary embolus (3). The likelihood of complications increases with the number of ribs fractured. Higher forces of impact are associated with multiple rib fractures, and therefore complications are much more common in motor vehicle accidents than in sports. Patients with complications generally complain of rib pain and have evidence of respiratory compromise, as was the case with our patient when he came to the emergency department. Hemodynamic instability is also an indicator of a complication.
This case is unusual because the mechanism of injury was atypical for a complicated rib fracture and because the hemothorax occurred as a delayed rather than as an acute complication of the injury. Two cases (4) of delayed hemothorax have been reported in patients who have had multiple displaced rib fractures resulting from severe blunt chest trauma; one injury occurred in a motor vehicle accident and the other from a 10-ft fall onto a table. In both cases, the hemothorax was secondary to delayed intercostal artery laceration occurring 3 and 4 days, respectively, after injury. Our patient's hemothorax most likely developed by a similar mechanism, but he had only a single rib fracture, the impact causing the injury was less severe, and the complication became apparent 5 days after his injury.
Look for the Unexpected
While this patient's history did not reveal an obvious traumatic event that accounted for the late complication, this case reinforces the importance of removing athletes with suspected rib fractures from competition. It also underscores the need to be on the lookout for uncommon but potentially life-threatening complications when dealing with rib fractures acutely and on follow-up.
Rib Fracture Fundamentals
Most patients who have a rib fracture present with a history of direct trauma with localized pain over the chest wall. Because the pain is usually worse with inspiration, breathing is often shallow and rapid. Crepitus or significant point tenderness directly over a rib supports the diagnosis of fracture. Subcutaneous emphysema may be noted.
Chest radiographs can help rule out associated pulmonary injury and may document fractures, although nondisplaced lateral fractures are frequently missed (1). Lateral fractures missed on postero-anterior views may be apparent on oblique views, and 72 hours after the injury, a bone scan increases the diagnostic sensitivity significantly. Computed tomography and magnetic resonance imaging are also useful tools.
For most recreational athletes whose clinical picture strongly suggests a rib fracture, plain radiographs to rule out acute complications are adequate. Diagnostic imaging beyond radiography provides more information regarding suspected complications or more definitively rules out fracture in an athlete who wants to return to play as soon as possible.
Acute treatment of uncomplicated fractures consists of rest, ice, protection, and oral analgesic medication. A rib belt or tape may provide pain relief by limiting chest excursion, although some patients find such measures more uncomfortable. An intercostal nerve block may be helpful for additional pain relief.
For patients with uncomplicated fractures, return to play depends on the degree of pain, but generally an athlete should avoid contact or vigorous training until pain with activity is improving. This generally occurs 2 to 3 weeks after injury, and some authorities (1) recommend a 3-week restriction from contact activity. For those involved in contact sports, the injury should be protected by the use of a rib cage protector or flak jacket during the first 6 to 8 weeks following the injury. If a complication is suspected in the acute or follow-up evaluation of a rib fracture, the patient should be immediately transported to a facility that can handle a potentially life-threatening event.
Dr John O'Kane is an instructor in the department of orthopedics, division of sports medicine, and Dr Marquet is the chief resident in the family medicine residency at the University of Washington in Seattle. Dr Elizabeth O'Kane is a family practitioner at the University of Washington Physicians in Issaquah, Washington. Dr John O'Kane is a member of the American College of Sports Medicine; all authors are members of the American Academy of Family Physicians. Address correspondence to John O'Kane, MD, Sports Medicine, University of Washington, Edmundson Pavilion, Box 354060, Seattle, WA 2021195-4060; e-mail to [email protected].
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