Bilateral first rib fractures--case report and review.

104 From the time that they were originally described in 1869, first rib fractures have been a source of anxiety to attendant doctors. 1 First rib fractures are associated with major thoracic trauma and predispose to injury of the subclavian vessels, brachial plexus and mediastinal structures. These complications invariably follow unilateral first rib fractures. In contrast, bilateral first rib fractures (BFRFs) may follow less significant thoracic trauma, suggesting that the mechanism of injury may be different. Furthermore, these injuries have rarely been reported to cause serious complications. The following report illustrates this point. A 28-year-old man presented to Stanger Hospital after being run over by a motor vehicle. The injuries were confined to the thorax, with abrasions along the upper thorax posteri-orly. Surgical emphysema was present over the left chest with marked tenderness along the lower ribs suggesting fractures. The patient was fully conscious and normotensive; breath sounds were decreased on the left. Abdominal examination was normal. Examination of the limbs revealed no neuro-vascular deficits. Baseline blood investigations were normal. The chest radiograph showed BFRFs, fractures of the 5th-9th ribs on the left side, and bilateral surgical emphy-sema. Management entailed analgesia (including rib blocks) and close observation of respiratory function. The patient was discharged 5 days later. On review a month later he was found to be in good health; specifically, there were no upper-limb neurovascular deficits or neuropathies. Discussion The mechanism of injury in BFRF remains unclear. Some authors suggest that it is a relatively benign condition and emphasise that clinical endeavours should be directed at associated injuries, especially of the spinal cord; others suggest that BFRF is a harbinger of major thoracic trauma and mandate urgent investigation to exclude the possibility of injury to the great vessels. The rarity of BFRF leads one to the conclusion that there can be no rules regarding the investigation of this injury; investigations are based on knowledge of the anatomical structures at risk of injury. Extrapolating management guidelines for BFRF from experience with unilateral first rib fractures seems to be logical and is based on the premise that unilateral fractures, while not common, occur more often than BFRFs. Confounding this comparison is the notable rarity of significant intra-thoracic (especially great-vessel) injury in the documented reports of BFRF. Perhaps this is because of a more even distribution of the chest violence along the components of the thoracic inlet. Regardless of the hypothesis, documented …