Rib Series Research Articles

Unexpectedly Complicative Course of a Rib Series Fracture in Patient with Chilaiditi Syndrome

Unexpectedly Complicative Course of a Rib Series Fracture in Patient with Chilaiditi Syndrome

Electrochemically active microorganisms sense charge transfer resistance for regulating biofilm electroactivity, spatio-temporal distribution, and catabolic pathway

Charge transfer resistance (CTR) is a key operating parameter for regulating energy harvesting efficiency, electrochemically active biofilms (ECABs) development, and microbial diversity and metabolism in microbial fuel cell (MFC). However, the response behaviors in terms of electroactivity, spatio-temporal distribution, and catabolic pathway of mixed-culture ECABs when being exposed to different CTR have not been well understood. Herein, we comprehensively investigated the effects of CTR on the characteristics of ECABs by varying external resistance in MFC. Specifically, R3-500 exhibited short ECABs maturation (∼8 d), high energy output (∼0.37 W m−2, ∼0.4 mA cm−2), low internal resistance (∼355 Ω) when ECABs was mature, and highly efficient and stable operation. Exopolysaccharides and extracellular DNA play critical roles in cells attachment on electrode surface and development a steady biofilms skeleton. The electron transfer rate was controlled by biofilm resistance (Rfilm, > 90% of total internal resistance), and a typical two-layer ECABs structure (inner dead layer and outer live layer) colonized on carbon fiber, with the dead-cells bearing inner layer as the major resistance causing increased Rfilm. Metagenomics analysis revealed that R3-500 facilitated the proliferation and co-existence of electricigens (e.g., Geobacter), and putative electric-syntrophy bacteria (e.g., Trichococcus), building a syntrophic relationship for potential interspecies electron/message exchange. Furthermore, the key functional genes families associated with cell activity (such as ftsZ, and rps/rpl series), electron transfer (such as torC, rib series, and pilA), and energy metabolism (hdr, mcr, fwd/fmd, and ntp) were upregulated (1.33–6.67-fold) in R3-500. Together these insights into ECABs’ behaviors by regulating CTR are of potential significance to help to sustain the long-term, highly active operation in bioelectrochemical systems.

Delayed onset acute massive haemothorax after traumatic rib fractures-A Case Report

Rib fractures are common injuries that frequently necessitate intensive care admission for pain management, respiratory support, in addition to managing possible complications. The most common complications of rib fractures are pain, haemothorax, pneumothorax, pulmonary contusions and lacerations, vascular injuries, and intra-abdominal organ injury. After a high impact road traffic accident, a polytrauma 26-year-old Irish gentleman presented with right-sided posterior rib series fractures (from 8th to 12th rib), lung contusion, hepatic laceration, pelvic ring crush injury and urinary bladder disruption. Resuscitation and emergency management including suprapubic catheterisation and external pelvic fixation were performed successfully. Although complications of multiple rib fractures were excluded clinically and radiologically on admission, the patient developed acute massive haemothorax 5 days after the primary injury which has been managed appropriately. This incident raises the concern that haemothoraces and pneumothoraces can occur late after the original injury and high level of suspicion associated with follow-up chest x-ray images are essential in patients with rib fractures. Keywords: Polytrauma, Rib fracture, Haemothorax.

One-View Chest Radiograph for Initial Management of Most Ambulatory Patients with Rib Pain.

Rib series are frequently ordered for ambulatory patients who complain of rib pain or have suffered chest trauma. However, the utility of rib series has been questioned in previous studies. The objective of this study was to compare the efficacy of rib series to a single view posteroanterior chest radiograph in the clinical management of most ambulatory patients with rib pain. We reviewed all rib series for rib pain performed between January 1, 2016 and December 31, 2016, excluding patients with suspected bony metastasis, chest or rib deformities, and follow-up studies for prior rib series. We recorded any follow-up imaging and/or surgical intervention within 30 ± 7 days, fracture diagnosis, and complications relating to rib fractures. One thousand seven hundred ninety-one rib series were performed during the study period. Of these, 1168 (65.2%) rib series were performed because of trauma as reported in the clinical indication (trauma cohort). Six hundred twenty-three (34.8%) of the rib series were performed for clinical indications which did not specify acute trauma (nontrauma cohort). There were 323 (17.9%) rib series that resulted in a fracture diagnosis and 95 (5.3%) that resulted in a possible fracture diagnosis. There were 50 (2.8%) effusions, 7 (0.4%), pneumothoraces, and 1 (0.1%) hemothorax detected. Two patients, 1 each from the trauma and nontrauma cohorts, underwent subsequent intervention during the follow-up period. In both cases, the findings which led to the subsequent intervention could be seen on the initial posteroanterior chest radiograph. Single-view chest radiograph provides sufficient information for the clinical management of ambulatory patients with rib pain.

Chest Injury-football

HISTORY: 17 year old high school football wide receiver presented with left back and rib pain. He sustained a hit in that region during a football game the night before. He was taken out of the game due to pain and difficulty breathing which ultimately kept him from finishing the game. After the game he continued to have pain for which he took a muscle relaxant that he had from a previous injury and over the counter pain medication with minimal pain relief. The pain persisted through the night and into the following morning. His pain was worse with deep breathing and any pressure on his chest. He denied any shortness of breath, dyspnea with exertion, cough, wheezing or hemoptysis. PHYSICAL EXAMINATION: Appeared in no acute distress, Ecchymosis over the posterior lateral aspect of left lower ribs with tenderness to palpation, No crepitus, No palpable deformity, Symmetric chest expansion, posterior rib/back pain reproduced with deep inspiration, Equal bilateral breath sounds, No hyper-resonance to percussion, Normal respiratory rate, Negative anterior posterior compression test, Positive lateral compression test, Full AROM of the back DIFFERENTIAL DIAGNOSIS: Rib fracture, Pneumothorax, Pulmonary contusion, Pulmonary embolism TEST AND RESULTS: X-ray Rib series: Small left apical pneumothorax involving approximately 20% of the hemi thorax. Suspected nondisplaced fractures involving the posterolateral left eighth and ninth ribs with small linear lucencies within these regions. Chest CT scan: Small left-sided pneumothorax approximately 20%. No acute osseous injury. FINAL WORKING DIAGNOSIS: Pneumothorax TREATMENT AND OUTCOMES: The patient was sent to ER after being seen in clinic to expedite getting a CT scan done after the X-rays. After the CT scan was obtained it was decided by the ED to admit the patient for observation. He obtained a subsequent x-ray that evening 12 hours after is initial which showed a slightly smaller left apical pneumothorax. He was discharged the next day. Repeat chest x-ray done three days after discharge showed improving pneumothorax. Patient was seen in clinic 2 weeks after his discharge from the hospital and was started on a graded exercise program with repeat x-ray at 1 week after clinic visit showed resolution of pneumothorax. He returned to full game play at 4 weeks after his initial injury.

Evaluation of Relationship between Radiation Dose and Image Quality according to Source to Image Receptor Distance in Rib Series Radiography

Evaluation of Relationship between Radiation Dose and Image Quality according to Source to Image Receptor Distance in Rib Series Radiography

Number of positive radiographic findings in pediatric trauma patients.

Conventional radiography is frequently performed in pediatric patients in whom fractures and dislocations are suspected. However, until now, the rate of positive findings of the most commonly performed radiographic examinations in pediatric patients is unknown. The aim of this study was to evaluate the number of positive findings in the 20 most frequently requested standard radiographic examinations in pediatric patients in a level 1 trauma center systematically. A transversal cohort study was conducted at a level 1 trauma center in Germany (2008-2014). In a statistical pre hoc analysis, a sample size of 200 images of each standard radiograph was determined. The picture archiving and communication system (PACS) was searched for radiographic examinations in patients under 18years. The following fracture rates for the investigated 20 most common examinations were found: 70.5% clavicle, 54.5% forearm, 53% wrist, 41.5% elbow, 30.5% lower leg, 20% hand, 18.5% finger, 12.5% toe, 12% forefoot, 11.5% ankle, 9% shoulder, 6.5% patella, 5.5% foot, 4% knee, 2% conventional rib series, 1.5% lumbar spine, 1% Towne view, 0.5% skull, 0% cervical spine, and 0% odontoid. Differences in the mean age of analyzed pediatric trauma patients in correlation to different standard radiographs were found. In our study, a relevant amount of different standard radiographs revealed a low fracture rate. Therefore, indications for X-ray should be checked properly and alternative procedures should be discussed with the patient and the parents. Clinical decision rules should be developed and pathways have to be implemented to minimize radiation exposure, waiting time, and costs.

Fractures de côtes non traumatiques

Non-traumatic rib fractures are probably greatly undercounted, although they are the second more frequent peripheral fractures in osteoporotic patients. They can be ascribed to 5 categories: 1) osteoporotic either primary, or, mostly, secondary (especially to corticosteroid intake, hyperparathyroidism, or anorexia nervosa in youngest): those osteoporotic rib fractures are five times less costly than hip fractures; 2) stress fractures, which occur mostly in addicts of rowing, golf and throwing sports; 3) pathological fractures (tumours); 4) osteomalacia, whose diagnosis can already be highly suspected on imaging; 5) rib fractures following forgotten or undisclosed traumatisms, like in alcoholism, chronic coughing, or in Silverman’ syndrome in abused children. In this last context, differential diagnosis with osteogenesis imperfecta is complicated, but rib fractures very rarely herald osteogenesis imperfecta, while they are the more frequent fractures observed in Silverman's syndrome. X-rays can fail to show rib fractures, even when using rib series, so that CT-scan is the mainstay of imaging in difficult cases. However, ultrasound seems also very efficient when performed by trained operators. No specific complications have been reported following non-traumatic and non-tumoral rib fractures. Treatment relies on analgesia, but proposed techniques have yet to be validated.

Diagnostic accuracy of the inverted grayscale rib series for detection of rib fracture in minor chest trauma

Study objectiveTo assess whether inverted grayscale rib series, used alone or as an additional imaging modality, improves diagnostic accuracy of rib fractures of emergency medicine (EM) residents in minor chest trauma. MethodsTwenty readers, including 5 junior and 5 senior EM residents and 10 fourth-year medical students, independently reviewed 110 patients' radiographs during 3 sessions. Session 1 used conventional grayscale rib series, session 2 used inverted grayscale rib series, and session 3 used both conventional and inverted grayscale images. The McNemar test was used to compare the sensitivities and specificities of the diagnostic methods, and to compare their sensitivities and specificities for detecting more than 3 rib fractures. Interobserver agreement was assessed using Cohen κ analysis. ResultsFor senior EM residents, there was no difference in sensitivity (P = .283) and accuracy (P = .888) between conventional rib series and the double-modality method. For junior EM residents and medical students, the double modality offered higher diagnostic sensitivity (P < .001, P = .001) and accuracy (P = .006, P = .002) than did conventional radiography. In cases with more than 3 rib fractures, who required specialist trauma care, the double modality provided greater sensitivity and accuracy among junior EM residents (P = .035 and P = .035, respectively) and medical students (P = .010, P = .010) than did conventional radiography. ConclusionsIn the diagnosis of rib fractures, the combined use of conventional and inverted grayscale rib series increases the diagnostic accuracy of less biased readers by conventional grayscale image like junior EM residents and medical students.

Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography.

BackgroundRib series (RS) are a special radiological technique to improve the visualization of the bony parts of the chest.ObjectivesThe aim of this study was to evaluate the diagnostic accuracy of rib series in minor thorax trauma.MethodsRetrospective study of 56 patients who received RS, 39 patients where additionally evaluated by plain chest film (PCF). All patients underwent a computed tomography (CT) of the chest. RS and PCF were re-read independently by three radiologists, the results were compared with the CT as goldstandard. Sensitivity, specificity, negative and positive predictive value were calculated. Significance in the differences of findings was determined by McNemar test, interobserver variability by Cohens kappa test.Results56 patients were evaluated (34 men, 22 women, mean age =61 y.). In 22 patients one or more rib fracture could be identified by CT. In 18 of these cases (82%) the correct diagnosis was made by RS, in 16 cases (73%) the correct number of involved ribs was detected. These differences were significant (p = 0.03). Specificity was 100%, negative and positive predictive value were 85% and 100%. Kappa values for the interobserver agreement was 0.92-0.96. Sensitivity of PCF was 46% and was significantly lower (p = 0.008) compared to CT.ConclusionsRib series does not seem to be an useful examination in evaluating minor thorax trauma. CT seems to be the method of choice to detect rib fractures, but the clinical value of the radiological proof has to be discussed and investigated in larger follow up studies.

Clinical Significance of Conventional Rib Series in Patients with Minor Thoracic Trauma

Conventional rib series (RS) represent a dedicated radiographic technique to visualize the bony parts of the chest wall. The method is commonly used to evaluate minor thoracic trauma, frequently in combination with chest radiographs (CRs). The aim of this study is to asses the clinical relevance of rib fractures diagnosed by RS in minor thoracic trauma. Retrospective study of 669 patients who received RS for the evaluation of minor thoracic trauma. 405 of the 669 patients received an additional CR. Radiological reports were classified into fracture versus no fracture. Patients were divided into four groups depending on the clinical follow-up. The findings of RS and CR were analyzed using the McNemar test. The statistical significance between the results of the radiographic examinations and the clinical follow-up was analyzed by the Chi-Square test and the Kruskal-Wallis test. We included 669 patients (61.4 % men, 38.6 % women, median age: 51 years, range: 13 - 92 years). Analyzing the reports of 669 patients who received RS, 157 (23.5 %) patients were diagnosed with at least one fractured rib while no fracture was found in 512 (76.5 %) patients. Considering the 157 patients with fractured ribs, 73 (46.8 %) had a single fracture, 38 (24.4 %) and two fractures and 45 (28.8 %) had more than two fractures. When assessing the 405 CRs, we detected 69 (17 %) fractures while the corresponding RS of the same patients revealed 87 (21.5 %) fractures (p < 0.05). Concerning all patients with rib fractures, 63.1 % received medical therapy, while 64.5 % of those patients without a radiologically documented fracture also received therapy (p = 0.25). Our results suggest a limited clinical value of detected rib fractures based on RS. Despite being superior compared to CR in diagnosing rib fractures, the results from RS seem to have no significant influence on further clinical management and therapeutic measures. Minor thoracic trauma should be evaluated by CR to exclude fracture-associated complications such as hemo- and pneumothorax.

The diagnostic utility of rib series in assessing rib fractures

Rib series rarely add information to the posteroanterior (PA) film for the diagnosis of rib fractures. In this investigation, we evaluated the utility of rib X-rays using turnaround time (TAT), radiation exposure, and cost-efficiency as the key parameters. This investigation was conducted from January 2008 to December 2012. We included patients who had rib series performed for suspected rib fractures. TAT for patients was calculated from the time exam was ordered by the emergency department (ED) physician/staff to time the report was finalized by the attending radiologist. Effective radiation dose for rib series was calculated as a summation of radiation dose from the standard rib series images for each patient. Cost-efficiency was determined based on the number of interventions that took place as a result of a complicated study. Our investigation consisted of 422 patients, 208 females aged (57 ± 20.8) and 214 males aged (48 ± 17.3). A total of 74(17.5 %) abnormal findings were noted, out of which only 1(0.23 %) underwent management change. The mean turnaround time for patients undergoing rib series had a value of 133.5 (±129.8) min as opposed to a single chest PA of 61.8(± 64) min. Average effective radiation dose for a rib series was 0.105 (±0.04) mSv, whereas average effective radiation dose of a single chest PA was 0.02 mSv. Dedicated rib series has a low-yield diagnostic value as it pertains to management change. The overall impact on patient care based on our findings is small when compared to the risks associated with prolonged TAT, repeated exposure to radiation, and extensive medical costs.

Complications in Pediatric Spine Surgery Using the Vertical Expandable Prosthetic Titanium Rib

Multicenter retrospective study of 54 children. To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

Usefulness of Reformatted CT Rib Series in Patients with Thoracic Trauma

Usefulness of Reformatted CT Rib Series in Patients with Thoracic Trauma

Hemoptysis in a Varsity Collegiate Football Athlete

HISTORY: A 19-year-old varsity football player sustained a hit to the chest while blocking. During pre-season practice, he was struck in the right side of his anterior chest wall by an opponent's helmet. He developed immediate pleuritic pain and hemoptysis, but denied shortness of breath. He was evaluated immediately by the athletic trainer and subsequently by the team physician. PMH: prior history of pneumonia, no asthma. SH: recreational alcohol use, denies cocaine/other drugs PHYSICAL EXAMINATION: Alert and oriented in no distress. Coughing up blood tinged sputum. HR 100, regular, RR 16, O2 saturation 100% on room air. No cyanosis. No accessory muscle use. No hoarseness. Bronchial breath sounds in the upper airway but lungs were otherwise clear throughout. No crepitus around his neck. Minimal non-focal tenderness with AP and lateral compression over the right side of his chest. Cardiac exam and remainder of examination within normal limits. DIFFERENTIAL DIAGNOSIS: Pulmonary contusion Pneumothorax Pneumomediastinum Pulmonary embolism Rib fracture Hemothorax TEST AND RESULTS: Athlete was stable but given persistent hemoptysis and symptomatology was sent to the ER. CT scan: significant R sided upper lobe pulmonary contusion. No pneumothorax, rib fracture, or pneumomediastinum. FINAL WORKING DIAGNOSIS: R upper lobe pulmonary contusion, complicated by costochondritis TREATMENT AND OUTCOMES: On follow up, he had hemoptysis daily for one week. He was held out of activity for two weeks after the hemoptysis resolved. Repeat limited CT scan showed almost complete resolution of the contusion. He was cleared to resume cardiovascular activity. He gradually increased his activity to sport specific non-contact activities and finally return to light contact. One month after his injury, he returned to full contact sport. He sustained a second injury to the right anterior chest wall that resulted in pain and mild shortness of breath, but no further hemoptysis. His physical exam was significant for R sided chest wall tenderness at the sternocostal border and tenderness with AP and lateral rib compression. Repeat CXR and rib series were normal. He was allowed to continue with cardiovascular and sport specific non-contact activities. He returned to full contact activity 9 weeks after his initial injury.

The material properties of acellular bone in a teleost fish

Several lineages of teleost fishes have independently derived skeletons composed solely of acellular bone, a tissue without obvious advantages over bone that has osteocytes in the matrix. There is no consensus for the functional role of acellular bone, as factors such as salinity, activity level and gross morphology have been shown to be poor predictors of acellularity. We used a three-point bending method to test the hypothesis that the material stiffness (elastic modulus) of acellular bone is higher than that of cellular bone, which could be evidence that material properties were a selective pressure in the evolution of this unusual skeletal material. The acellular ribs of Myoxocephalus polyacanthocephalus are curved, hollow beams that decrease in size both distally and posteriorly along the rib series. First and second moments of area decreased distally and caudally in all individuals. Young's modulus (E) ranged from 3.67 to 8.40 GPa, with a mean of 6.48 GPa. The flexural stiffness (EI) differed significantly between ribs, and the hollow cylinder morphology increased the flexural stiffness by 12.0% over a solid, circular cross-section rod with the same area. Contrary to our expectations, acellular bone is not stiffer by virtue of fewer lacunae but instead falls at the very low end of the range of stiffness seen in cellular bone. There remains the possibility that other properties (e.g. fatigue resistance, toughness) are higher in acellular bone.

Pulmonary Contusion in a College Football Athlete

HISTROTY: An 18 year old, collegiate football athlete sustained a blow to his anterior chest wall by another player's helmet. Initially, he described having the wind knocked out of him and left, anterior chest wall soreness, but no difficulty breathing. Over the next 12 hours, he developed mild dizziness, nausea and worsening chest pain, followed by shortness of breath and hemoptysis. Upon office evaluation the next day, he reported only anterior chest wall tenderness and pleuritic chest pain with cough and deep inspiration. PHYSICAL EXAMINATION: Vitals: BP: 118/64; HR: 64 bpm; RR: 12; Pulse Ox: 98% on room air GENERAL: 6'2“ 200lb male in no distress Neck: No tracheal deviation, JVD or sub-cutaneous emphysema Chest: No deformity or ecchymosis; tender to palpation over the inferior half of his sternum and medial aspects of ribs 9–12 PULMONARY EXAM: Breath sounds clear to auscultation bilaterally and present throughout all lung fields Cardiac: Regular rate and rhythm; no murmur, gallop or rub Abdomen: Mild LUQ ttp; nl bowel sounds Musculoskeletal: No obvious orthopedic injuries or scoliosis. No gross motor deficits. DIFFERENTIAL DIAGNOSIS: Pulmonary Contusion / Laceration Pneumothorax / Hemothorax Rib fracture/ Flail chest /Sternal fracture Cardiac Contusion Splenic Laceration TEST AND RESULTS: AP & Lat CXR with Left Rib Series: Clear lung fields bilaterally, no rib or sternal fracture CT chest: Right traumatic pneumatocele with adjacent focal area of surrounding ground glass airspace consolidation suggestive of hemorrhage. FINAL WORKING DIAGNOSIS: Pulmonary contusion with traumatic pneumatocele TREATMENT and OUTCOMED: The patient was withheld from play and given strict instructions to seek medical attention if symptoms worsen. Repeat CT at three weeks demonstrated resolution of the pulmonary contusion and a small residua density in the right paravertebral region. He was allowed to progress as tolerated and allowed to return to football at 4 weeks having an uneventful remainder of the season. He is to have a repeat CT at 6 months to confirm complete resolution of pneumatocele.

Blunt chest trauma: utility of radiological evaluation and effect on treatment patterns

Minor chest wall trauma is a common complaint in the emergency department (ED) (Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib fractures in elderly patients: mortality and morbidity. Can J of Surgery 2002;45(1):43-6; Lee RB, Bass SM, Morris JA, Mackenzie EJ. Three or more rib fractures as an indicator for transfer to a level I trauma center. J Trauma 1990;30:689-94; Dubinsky I, Low A. Non–life-threatening blunt chest trauma: Appropriate investigation and treatment. Am J Emerg Med 1997;15(3):240-3). Up to 50% of rib fractures may be missed on standard x-ray (Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9; Palvanen M, Kannus P, Niemi S, Parkkari J. Hospital-treated minimal-trauma rib fractures in elderly Finns: long-term trends and projections for the future. Osteoperosis International). Little consensus exists among emergency physicians with respect to the workup of minor blunt chest trauma. The purpose of this study was to evaluate the accuracy of emergency physicians in interpreting rib radiographs and to determine if that interpretation resulted in any variance in treatment patterns. Our study is a retrospective study of 271 charts from a community-based teaching hospital from August 2000 to August 2002. Patients were excluded if they suffered major trauma. The treatment rendered was categorized. Categories included over-the-counter medication, nonsteroidal anti-inflammatory drugs, narcotics, and muscle relaxants. The overall χ 2 calculation showed no differences between the fractured group and the no fracture group ( P = .072). From this, it can be concluded that there were no between-group differences in drugs prescribed based on whether a fracture was diagnosed by the ED physician. Indicating that the interpretation of the rib series does not influence the physicians treatment plan.

Musculoskeletal Injury- Football

HISTORY A college football quarterback sustained a chest wall injury during a hit that occurred while he scrambled with the ball. During the second quarter of an early season game, he was hit on his right shoulder/neck region with his head laterally bent to the left. He did not present to the trainers with an injury or pain during the game. The next morning he presented at the training room with a chief complaint of right anterosuperior chest wall pain. Pain was worse with inspiration, right arm cocking, anterosuperior chest wall pressure, and left lateral bending. He denied any numbness, tingling, loss of sensation, radiation of pain, weakness, or change in upper extremity temperature or color. There was no neck pain but he did have some mild right trapezius pain. PHYSICAL EXAMINATION He appeared comfortable and in no acute distress. Upper extremity appeared symmetric bilaterally with no evidence of swelling or discoloration. On palpation, he had right-sided chest wall tenderness just inferior to the clavicle. Pain was exacerbated with AP compression of the chest. There was no tenderness over the clavicle or AC joint. Shoulder and arm had full range of motion. He had mild pain with the right arm abducted at 90 degrees and fully externally rotated. His strength was 5/5 and symmetric bilaterally with testing of upper extremity. His light touch sensation was intact in all dermatomes and his radial pulses were 2+ and symmetric. Neck exam revealed no tenderness and full range of motion. Pain increased with left lateral bending and left rotation of the neck. Auscultation of the lungs revealed clear breath sounds which were equal and normal sounding bilaterally. DIFFERENTIAL DIAGNOSIS Chest wall contusion Rib fracture Rib synchondrosis injury Pulmonary contusion Clavicle fracture Sternoclavicular dislocation TESTS AND RESULTS Right rib series radiographs: non-displaced right first rib fracture no clavicle fracture or other bony abnormality Posterior to anterior and lateral chest radiographs: non-displaced right first rib fracture clear lung fields normal cardiac silhouette midline trachea Chest CT scan with three dimensional reformatted images from helical CT scanner unicortical first rib fracture FINAL/WORKING DIAGNOSIS Traumatic isolated unicortical right first rib fracture TREATMENT AND OUTCOMES No contact in practice. Protective equipment modified to increase protection of first rib. Shoulder and neck range of motion and strength exercises. Discussed risks regarding close proximity of important structures. Returned to full contact and was able to start game one week after the initial injury almost completely symptom free.

Musculoskeletal Injury- Football

HISTORY A college football quarterback sustained a chest wall injury during a hit that occurred while he scrambled with the ball. During the second quarter of an early season game, he was hit on his right shoulder/neck region with his head laterally bent to the left. He did not present to the trainers with an injury or pain during the game. The next morning he presented at the training room with a chief complaint of right anterosuperior chest wall pain. Pain was worse with inspiration, right arm cocking, anterosuperior chest wall pressure, and left lateral bending. He denied any numbness, tingling, loss of sensation, radiation of pain, weakness, or change in upper extremity temperature or color. There was no neck pain but he did have some mild right trapezius pain. PHYSICAL EXAMINATION He appeared comfortable and in no acute distress. Upper extremity appeared symmetric bilaterally with no evidence of swelling or discoloration. On palpation, he had right-sided chest wall tenderness just inferior to the clavicle. Pain was exacerbated with AP compression of the chest. There was no tenderness over the clavicle or AC joint. Shoulder and arm had full range of motion. He had mild pain with the right arm abducted at 90 degrees and fully externally rotated. His strength was 5/5 and symmetric bilaterally with testing of upper extremity. His light touch sensation was intact in all dermatomes and his radial pulses were 2+ and symmetric. Neck exam revealed no tenderness and full range of motion. Pain increased with left lateral bending and left rotation of the neck. Auscultation of the lungs revealed clear breath sounds which were equal and normal sounding bilaterally. DIFFERENTIAL DIAGNOSIS Chest wall contusion Rib fracture Rib synchondrosis injury Pulmonary contusion Clavicle fracture Sternoclavicular dislocation TESTS AND RESULTS Right rib series radiographs: non-displaced right first rib fracture no clavicle fracture or other bony abnormality Posterior to anterior and lateral chest radiographs: non-displaced right first rib fracture clear lung fields normal cardiac silhouette midline trachea Chest CT scan with three dimensional reformatted images from helical CT scanner unicortical first rib fracture FINAL/WORKING DIAGNOSIS Traumatic isolated unicortical right first rib fracture TREATMENT AND OUTCOMES No contact in practice. Protective equipment modified to increase protection of first rib. Shoulder and neck range of motion and strength exercises. Discussed risks regarding close proximity of important structures. Returned to full contact and was able to start game one week after the initial injury almost completely symptom free.