[Stress fractures of the first rib].

Among the many patients who present to chest clinics and casualty departments with thoracic pain of obscure origin there are a few in whom the cause is immediately apparent from the initial chest radiograph. We present two examples in young women, who were found to have sustained a stress fracture of the first rib during the course of fairly mild but unaccustomed exertion. Case reports Case 1 A 21-year-old woman presented to an accident and emergency department complaining that she had had an ache in her left shoulder and above the left clavicle for the previous two days. The pain was continuous but worse on inspiration. Clinical examination showed nothing abnormal and she was not dyspnoeic or cyanosed, nor did she have tachycardia or evidence of deep vein thrombosis. An electrocardiogram was normal. A chest radiograph showed a transverse fracture of the distal end of the first rib (fig la). Direct questioning revealed that although she had not sustained direct trauma to her shoulder she had been lifting her 2-year-old daughter using the left arm immediately before the onset of the pain, whereas she would normally have used the right arm for this purpose. It was concluded that a stress fracture of the first rib was the cause of her pain. The left arm was immobilised in a broad sling for one week and she made a rapid and uneventful recovery. A later radiograph showed callus formation at the site of the original fracture (fig lb), confirming the initial diagnosis. Case 2 A 14-year-old girl was referred to the chest clinic by her general practitioner with a three-week history of pain in the region of the left shoulder and scapula. The pain was worse on deep inspiration. Clinical examination showed nothing abnormal but the chest radiograph showed a fracture of the first rib on the left side (fig 2). Inquiry revealed that she had been working on her father's allotment immediately before the onset of the pain. The work was strenuous and unaccustomed and had consisted mainly in an attempt to rake some hard, compacted soil. Investigations (including serum calcium, phosphate, and alkaline phos-phatase estimations; liver function tests; full blood count; and ESR) all gave results within normal limits. She was treated with analgesics. Subsequently she failed to attend for review but was reported to be well and pain free. Fig 2 Case 2: fracture ofthe left first rib. Fig …