Unrecognised Rib Fracture Simulating Pleurisy

WITHIN fifteen months three patients with unsuspected rib fracture were referred to Enniskillen Chest Clinic because of chest symptoms. The first rib was fractured in two cases, and the tenth rib in the remaining one. All fractures were on the right side. Two case histories are given: (1) Miss M. McA., aged 32, consulted her doctor because of violent cough and acute chest pain, diagnosed as right-sided dry pleurisy, followed after one week by swelling and joint pains in the lower limbs. Two weeks later, on 3rd February, 1956, an X-ray at the Chest Clinic showed fracture of the tenth rib on the right side, with some displacement of fragments. Callus formation was well marked on a film taken 17th March, 1954. No pulmonary abnormality was present on either film. On questioning, she recalled that she had slipped while pushing a car about the time of the onset of her chest pain. Although she "wrenched herself," no impact was sustained. On 3rd February, 1956, the B.S.R. was normal (7.0 Cutler 1 hour) and the Mantoux test negative to 1 mgm. old tuberculin. The fracture was considered to have been the cause of her symptoms. (2) John L., aged 19, took influenza on 14th March, 1955, for which he spent one week in bed. He had slight cough and sputum. Two weeks after onset he had pain in the right scapular region, at first worse on moving, but later on coughing. This persisted until he was seen at the Chest Clinic on 10th October, 1956, having complained of right infra clavicular pain three-four days previously. On examination, no swelling or tenderness was found, but chest X-ray showed a fracture of the first rib on the right side. B.S.R. was normal (5.0 Cutler 1 hour) and Mantoux positive to 0.1 mgm. old tuberculin. The infra clavicular pain for which he was referred was due to this fracture. Both instances of fracture of the first rib occurred without known cause in right-handed muscular young men. These cases show that unsuspected rib fracture must be borne in mind as a possible, though rare, cause for chest pain associated with cough.