Isolated open comminuted fracture of the first rib.

In the emergency department, open isolated rib fractures are rarely seen. There is scarce literature related to open isolated first rib comminuted fracture. We report a 33-year-old male who presented with an isolated open first rib comminuted fracture following a road traffic accident. He did not have any neurovascular or major organ injuries and was managed successfully with conservative treatment.

Introduction

An isolated first rib fracture with open wound following trauma is rarely seen in the emergency room. Many case reports have been published on closed first rib fracture following trauma and repetitive stress injury. According to our knowledge, there is scarcity of literature with an isolated open fracture of the first rib. Here we are presenting a case of isolated open first rib comminuted fracture following a road traffic accident.

Case Report

A 33-year-old male presented to our emergency department with a history of fall from the motorcycle while riding a two-wheeler and sustained injury to the right upper chest. The patient was taken to a nearby hospital for first aid and then referred to our institute for further management. At triage, his vitals were stable. On further assessment, airway was patent, and a cervical collar was applied. There was no respiratory distress and oxygen saturation was maintained at 98% at room air. There was a laceration near the right side of the suprasternal notch, of size 4 cm length × 1.5 cm breadth × bone depth, with the surrounding abrasion of size approximately 15 cm × 2 cm extending from the left side of the lower neck up to the right upper chest [Figure 1]. There was no vascular or neurological deficit in the right upper limb. No disability and distracting injuries were noted.

Figure 1

Open wound in the chest

Immediately, eFAST was done at emergency medicine; no free fluid was noted in the abdomen and chest and there was no hemopneumothorax. Chest X-ray was taken and it showed a comminuted fracture of the right first rib with mild subcutaneous emphysema [Figure 2]. There was no associated pneumothorax or hemothorax. C-spine X-ray was normal. Since the wound was open in nature, the first dose of intravenous antibiotic was given at emergency medicine. Primary suturing was done after cardiothoracic consultation. The patient was kept under observation and discharged after 24 h with analgesics and antibiotics. The patient was contacted after 1 week and he had no complications.

Figure 2

X-ray chest showing comminuted first rib fracture (arrow)

Discussion

The first rib is the broadest of all ribs and tightly curved. It is surrounded by muscular structure from the shoulder joint and neck. Compared with other ribs, first rib fracture is very rare.[1] It is most often associated with other injuries. Five mechanisms have been categorized to cause first rib fracture such as posteriorly direct trauma, indirect trauma through anterior chest or sternum, a force applied laterally through clavicle, violent muscle contraction, and due to unidentifiable cause.[2]

The subclavian vessel crosses over the first rib at its groove, which is the weakest point to get broken.[3] Therefore, in case of first rib fracture, injury to the subclavian vessels should be considered. Brachial plexus injuries were also common following fracture of the first rib. Isolated closed first rib fracture without any associated complication was documented.[45]

Our patient had an open comminuted fracture and there was no other injury found. Distal pulses were palpable in both upper limbs, and there was no motor or sensory deficit.

In conclusion, open isolated first rib fracture is very rare and comminuted fracture is uncommon. The patient should be examined for other major injuries in case of first rib fracture. Extensive work-up is needed only if the patient has signs or symptoms suggestive of other systemic injuries.

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Conflicts of interest

There are no conflicts of interest.