From the time that they were originally described the first rib fractures have been a source of anxiety to attending doctors. First rib fractures are fairly common injuries and are frequently associated with massive trauma to other parts of body including the thorax, head and abdomen. The most common associated injuries pneumothorax, haemothorax, pulmonary contusion, a flail chest and myocardial contusion occasionally with a haemopericardium.

1. Dislocation of the First Costovertebral Articulation on One Side
and Fracture of First Rib on Another Side

2. Dislocation of the first costovertebral articulation on one side and
fracture of first rib on another side
Pankaj Kumar*
ABSTRACT
Costovertebral dislocation of first rib on one side and first rib fracture on other side is a rare injury. We are elaborating
the diagnosis and its presentation.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Costovertebral subluxation, First rib, Fracture
INTRODUCTION
From the time that they were originally described the first
rib fractures have been a source of anxiety to attending
doctors. First rib fractures are fairly common injuries and
are frequently associated with massive trauma to other parts
of body including the thorax, head and abdomen. The most
common associated injuries pneumothorax, haemothorax,
pulmonary contusion, a flail chest and myocardial contu-
sion occasionally with a haemopericardium. Local injuries
more directly related to the first rib fracture include trauma
of the brachial plexus injuries, Horner syndrome and tear of
the subclavian artery. In contrast, bilateral first rib fractures
may follow less significant thoracic trauma, suggesting that
the mechanism of injury may be different. We were report-
ing one case of costovertebral dislocation of first rib one
side and fracture of another rib on another side. This type
of injuries had not been reported in literature.
CASE REPORT
A 35 year’s old man presented to Apollo Reach Hospital
after being fall from height. The injuries were confined to
the supraorbital region and thorax. The patient was fully
conscious and normotensive. Abdominal examination was
normal. Examination of limbs revealed no neurological
deficits but there was Horner syndrome. The chest radio-
graph showed costovertebral dislocation of right rib and
fracture of left rib (Figs. 1 and 2). Management entailed
analgesics and close observation of respiratory function.
The patient was discharged at 7 days of admission. On
review a month later he was found to be good health;
specifically, there were no upper limb neurovascular deficit
or neuropathies.
DISCUSSION
The costovertebral articulations consist of two gliding type
synovial joints, the costocentral and the costotransverse.
When subjected to severe trauma, these joints may be sub-
luxed or dislocated. The costotransverse joint is more likely
of the two to be injured. The first costotransverse joint is
especially vulnerable because of its unique position at the
top of the rib cage.1
The first rib attaches at the sternum,
turns at the base of the cervical spine and inserts at the T1
vertebral junction. The brachial plexus is intimately situated
around the first rib, with the C7 and C8 nerve roots actually
surrounding the rib on their way to becoming the cords of
the brachial plexus. The first rib, like any other joint, can
subluxate, usually in a superior and outward position. With
some practice, a clinician can feel the first rib as it is more
superiorly displaced in the cervical space. This may be
Apollo Reach Hospital, Karimnagar, India.
*
North Avenue, Plot No-6, Beside Apollo Reach Hospital, Karimnagar 505001, India. Tel.: þ91 9618123678, email: drpankaj06@yahoo.co.in
Received: 19.8.2012; Accepted: 22.9.2012; Available online 29.9.2012
Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.09.002
Apollo Medicine 2012 December
Volume 9, Number 4; pp. 343e344
Case Report

3. significant in that many patients with neck pain difficult to
resolve may actually have a first-rib subluxation, promoting
a restricted cervical movement that is resistant to adjustments
of the cervical themselves. A proper evaluation of the neuro-
logical system is the only way to know which side to address
as primary. But for those just starting out in the fun world of
neurology, knowing about the first rib may very well make
all the difference in those difficult cases no one else has
been able to solve.2
Pain and dysaesthesia affecting the
neck and upper limb is a common isolated complaint, which
may be accompanied by paresis and vasomotor and trophic
changes of the arm and hand. The peripheral nerves
supplying the upper limb may be vulnerable to entrapment
at a number of points along their course through the cervical
root canals, the thoracic outlet and the axilla. The major
arteries and veins serving the upper limb are closely related
to the nerve structures at the thoracic outlet and symptoms of
ischaemia and/or venous obstruction may accompany the
neurological findings, or present in isolation. A comprehen-
sive account of the compressive syndromes of the thoracic
outlet is given in the excellent monograph by Lord and
Rosati (1971).3
Cervical ribs (Halsted and Reid, 1916)4
have long been recognized as a source of nerve and/or
vascular compression; though the association of their pres-
ence with signs of neurovascular entrapment is not a simple
one. Cervical ribs (Halsted and Reid, 1916)4
have long been
recognized as a source of nerve and/or vascular compression,
though the association of their presence with signs of neuro-
vascular entrapment is not a simple one. Injuries to the first
rib synchondrosis are uncommon in sport. The potential for
serious complications following posterior displacement is
similar to that seen with posterior sternoclavicular joint dislo-
cation. Conservative treatment is invariably effective with
a return to sport in 4e6 weeks.5
Treatment options for dis-
placed costochondral injuries are poorly described in the
literature. They include conservative treatment or closed
reduction under general anaesthesia. If open reduction and
fixation is necessary, the risk of migration of fixation devices
should be considered.6
CONFLICTS OF INTEREST
The author has none to declare.
REFERENCES
1. Christensen EE, Dietz GW. Injuries of the first costovertebral
articulation. Radiology. 1980 Jan;134(1):41e43.
2. Romero DC, DACNB Edgar. Vascular concomitants secondary
to 1st rib subluxation. Dynamic Chiropractic. June 4, 2007;vol.
25(Issue 12).
3. Lord Jr JW, Rosati LM. Thoracic outlet syndrome. Clin Symp.
1971;23(2):1e32.
4. Halsted WS, Reid MR. An experimental study of circum-
scribed dilatation of an artery immediately distal to a partially
occluding band and its bearing on the dilatation of the subcla-
vian artery observed in certain diseases of cervical rib. J Exp
Med. 1916;24:271e286.
5. Kemp SPT, Targett SGR. Injury to the first rib synchondrosis in
a rugby footballer. Br J Sports Med. 1999;33:131e133.
6. Lyons FA, Rockwood Jr CA. Migration of pins used in opera-
tions on the shoulder. J Bone Joint Surg Am. 1990;72:
1262e1267.
Fig. 1 Inferior subluxation of first rib on right side and fracture
of first rib on left side.
Fig. 2 Subluxation of first rib fracture on right side and fracture
of first rib on left side.
344 Apollo Medicine 2012 December; Vol. 9, No. 4 Kumar

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