From the Guidelines
When a patient presents with a traumatic first rib fracture, it is essential to thoroughly assess for associated injuries, particularly vascular injuries to the subclavian vessels, as the presence of a first rib fracture has been linked to an increased likelihood of injury to these vessels [@23@]. In evaluating a patient with a traumatic first rib fracture, several key areas of assessment are crucial to identify potential complications and associated injuries.
- Vascular injuries: The presence of a first rib fracture increases the likelihood of injury to the adjacent subclavian and innominate vessels [@25@]. Therefore, checking pulses, blood pressure in both arms, and looking for signs of bleeding or hematoma is vital.
- Pulmonary complications: Rib fractures, including those of the first rib, are associated with pulmonary complications such as pneumothorax, hemothorax, and pulmonary contusion [@2@, @5@, @6@]. Chest auscultation and imaging should be performed to evaluate for these conditions.
- Brachial plexus injury: Assessing upper extremity strength, sensation, and reflexes can help identify potential brachial plexus injury, which may be associated with first rib fractures.
- Tracheal or esophageal injury: Checking for subcutaneous emphysema, dysphagia, or voice changes can help identify potential tracheal or esophageal injury.
- Thoracic outlet syndrome: Signs of arm pain or numbness should be evaluated as they may indicate thoracic outlet syndrome.
- Associated fractures: Palpation and imaging should be used to assess for associated clavicle or scapular fractures.
- Comprehensive trauma assessment: Given the high-energy nature of the injury, a thorough assessment to rule out injuries to other body systems, including head, spine, and abdominal injuries, is necessary. The use of CT angiography may be warranted if vascular injury is suspected, especially given the association between first rib fractures and subclavian vessel injuries [@23@].
From the Research
Associated Injuries with Traumatic First Rib Fracture
In the presence of a traumatic first rib fracture, several other injuries should be checked for, including:
- Vascular injuries, such as subclavian artery damage 1, 2, 3, 4
- Brachial plexus injuries 1, 2, 5, 3
- Thoracic injuries, such as pneumothorax or hemothorax 2, 5, 3
- Abdominal injuries 2, 5
- Cardiac injuries 2
- Head injuries, including traumatic brain injuries 2, 3
- Orthopedic injuries, such as fractures of the clavicle, scapula, or long bones 2, 3, 4
- Neurologic lesions, such as Horner's syndrome 2
- Post-traumatic thoracic outlet syndrome 2
Mechanisms of Injury
The mechanisms of injury that can lead to a traumatic first rib fracture include:
- Posteriorly directed trauma to the upper thorax or shoulder girdle 1
- Direct blow to the sternum and anterior chest wall 1
- Blow fracturing the clavicle 1
- Strong sudden contraction of the scalenus anticus muscle 1
- High-energy trauma, such as motor vehicle accidents 5, 3, 4
Importance of Early Detection and Management
Early detection and management of associated injuries are crucial to prevent further complications and improve patient outcomes 1, 2, 5, 3, 4. Computed tomography scan thorax can be useful in diagnosing first rib fracture and associated injuries 4.