the first rib

Wednesday, January 18, 2012

It’s not good to be an interesting patient. Only a couple of things can be going on. Either the diagnosis is so rare that lots of doctors and nurses want to be able to see it with their own eyes, or there is something bad that can happen because of the injury or illness and doctors are scrambling to look for potential complications. First rib injuries are exceedingly rare in contact sports, so it should come as no surprise that Tim Tebow has becoming interesting again.

When the chest wall is injured, pain is the consequence that will cause the majority of complications. We breathe like a bellows sucking air into the lungs causing them to expand. If that the ribs can’t swing out because of pain, breathing becomes shallow and the lung isn’t able to completely inflate. A dark, warm place without much air movement sets the perfect conditions for developing an infection. Fever, cough and shortness of breath are the signs of pneumonia.

Any chest can lead to a collapsed (pneumothorax) or bruised lung (pulmonary contusion). However, not all ribs are created equal and the set of potential complications depend upon what part of the rib cage is damaged. The lower ribs protect the organs in the upper part of the abdomen and broken lower ribs can also cause damage to the liver, spleen and diaphragm. And then there is the first rib.

The first rib is located deep within the body protected on all sides by the thick muscles of the neck and by the collarbone in front and the shoulder blade in back. It has a weak spot where there is a groove within the bone to allowing the subclavian artery and vein to pass into the arm. As well, there are numerous muscles that are anchored and constantly tugging on it. For that reason first rib stress fractures are not that uncommon, especially in sports that emphasize upper arm movement like rowing, tennis, gymnastics, weightlifting and baseball. But traumatic fractures are rare. It takes a lot of force to overcome all the protection and for that reason, the patient who acutely injures a first rib fracture becomes very interesting.

Looking for complications means returning to basics and understanding anatomy. It comes as no surprise that the subclavian artery and vein can be torn with a first rib injury since they run through a groove in the bone. Tearing a major blood vessel is life threatening since they tend to bleed uncontrollably. Complication number two has to do with the brachial plexus or the bundle of nerves that connects the nerves in the arm to the spinal cord. Tearing or even bruising part or all of the plexus can lead to significant loss of arm function. And of course, the first rib also protects the top part of the lung so pulmonary contusion and pneumothorax are still possibilities.

Rib fractures may or may not be seen on plain x-rays of the chest. If there is a high suspicion for first rib injury, a CT scan may be needed to look at not only the rib, but also the blood vessels and the lung tissue. If brachial plexus damage is a concern, an MRI might be needed.

It seems that Mr. Tebow did not have any of the major disasters that can accompany a first rib fracture but that did not stop his doctors from worrying about those potentials. It’s OK when doctors worry about their patients but it’s never good to be interesting.

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