Stress Fractures of the Ribs and Upper Extremities: Causation, Evaluation, and Management

Abstract

Stress fractures are common troublesome injuries in athletes and non-athletes. Historically, stress fractures have been thought to predominate in the lower extremities secondary to the repetitive stresses of impact loading. Stress injuries of the ribs and upper extremities are much less common and often unrecognized. Consequently, these injuries are often omitted from the differential diagnosis of rib or upper extremity pain. Given the infrequency of this diagnosis, few case reports or case series have reported on their precipitating activities and common locations. Appropriate evaluation for these injuries requires a thorough history and physical examination. Radiographs may be negative early, requiring bone scintigraphy or MRI to confirm the diagnosis. Nonoperative and operative treatment recommendations are made based on location, injury classification, and causative activity. An understanding of the most common locations of upper extremity stress fractures and their associated causative activities is essential for prompt diagnosis and optimal treatment.

Unusual chest wall pain caused by thoracic disc herniation in a professional baseball pitcher

“…The physical findings of this case mimicked these injuries, except for the hypoesthesia of the left side of the chest. Pain due to a rib fracture may radiate along the distribution of the intercostal nerve, but sensory disturbances, such as hypoesthesia, are rare 23) . Immediate MRI and/or ultrasound evaluation are usually indicated to identify injured abdominal core muscles or rib fractures in professional baseball players for whom minimizing time spent on the Disabled List is important 21,24) .…”

Imaging of rib stress fractures in elite rowers: the promise of ultrasound?

“…Radiography has limited use in diagnosing rib stress fractures, as demonstrated by previous studies 7. During the initial stages of fracture, sensitivity may be as low as 10%, and only reach 30%–70% throughout follow-up, once callus formation is present 19 20.…”

“…During the initial stages of fracture, sensitivity may be as low as 10%, and only reach 30%–70% throughout follow-up, once callus formation is present 19 20. However callus formation can occur more than 3 weeks after symptom onset, limiting the usefulness of radiography in the early detection of rib stress fractures 7. Furthermore, even when present, stress fracture findings, like cortical thickening, are subtle and may be overlooked on imaging, even with dedicated rib views 7.…”

“…However callus formation can occur more than 3 weeks after symptom onset, limiting the usefulness of radiography in the early detection of rib stress fractures 7. Furthermore, even when present, stress fracture findings, like cortical thickening, are subtle and may be overlooked on imaging, even with dedicated rib views 7. In addition, radiography entails ionising radiation, and the average effective radiation dose for posterior-anterior and lateral views, has been reported as 0.1 mSv, with reported doses between 0.05 and 0.24 mSv 21.…”

“…During physical examination, the clinician should also thoroughly assess the chest and abdomen in order to rule out a non-musculoskeletal origin of rib pain 7. Patients may experience tenderness along the midaxillary line of the chest wall 16.…”