mystery of yawning
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La parakinésie brachiale oscitante
Yawning: its cycle, its role
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Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
 
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
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8 avril 2012
J Emerg Med.
2012;43(2):e 119-121

Juvenile First Rib Fracture Caused by Morning Stretching

Lee SJ, Yie K, Chon SB.

Emergency Medicine and Respiratory Center of Kangwon National University Hospital and School of Medicine, Kangwon National University, Chuncheon, South Korea.

Chat-logomini

 
 
Abstract
 
First rib fractures are very rare, being primarily associated with external blunt trauma. Related conditions, such as sudden contraction of the neck muscle, stress fractures, and fatigue fractures, have been reported sporadically. These fractures are mostly related to repetitive or explosive physical training. However, anatomical relationships and related injury mechanisms may cause first rib fractures without repetitive sports activity. To present a case of juvenile first rib fracture caused by morning stretching without sports activity. We present a rare case report of juvenile atraumatic first rib fracture.
 
Physicians should be aware that even morning stretching with yawning can cause a first rib fracture in children. Awareness is important for early recognition, and proper management is critical for a pain-free return to normal life. An understanding of the mechanism of atraumatic first rib fracture is important.
 
 
INTRODUCTION
 
First rib fractures are very rare, being primarily associated with external blunt trauma. Related conditions, such as sudden contraction of the neck muscles, stress fractures, and fatigue fractures, have been sporadically reported. These fractures are mostly related to repetitive or explosive physical training. However, certain anatomical relationships and related injury mechanisms may cause first rib fractures without repetitive sports activity.
 
CASE REPORT
 
A 13-year-old boy presented to our Emergency Department (ED) with a sudden sharp, stabbing pain in the left shoulder and neck immediately after stretching with a yawn in the morning. His mother said that he woke up with his right arm flexed pointing upward and his left arm outstretched pointing downward. He yawned and turned his head to the right side, and suddenly heard a click in his neck. He had no history of genetic disease, recent trauma, or sports activity. He denied any child abuse and seemed to be well nourished. On physical examination, he had neither muscle atrophy of the shoulder girdle nor asymmetry of the scapular region. Although both shoulders exhibited full range of motion, scapula retraction produced a nagging pain in the left shoulder and medial scapular area. There was minimal supraclavicular tenderness. The pain was relieved somewhat by resting. The patient felt occasional numbness in his left upper limb when it was stretched. The numbness was absent in the normal position. Laboratory findings, including complete blood cell count, electrolytes, hepatobiliary test, renal function test, urine analysis, C-reactive protein, and erythrocyte sedimentation rate, were unremarkable. However, a radiograph of the left ribs revealed a first rib fracture. Because there was no significant neurological or musculoskeletal complication, the patient was treated conservatively and underwent routine follow-up. A nonsteroidal anti-inflammatory drug was prescribed for 3 days and effectively alleviated the pain.
 
He was advised to avoid any physical activity, including participating in physical education classes at school. A nerve conduction study was performed the next day in the Neurology outpatient department; it did not reveal any abnormal electrophysiological finding. Two months later, the fracture site had healed with callus formation, and the numbness associated with limb stretching had completely disappeared.
 
Atraumatic isolated first rib fracture in juveniles is uncommon. It can be caused by sudden muscular pulls, fatigue, or stress fractures, or heavy mechanical loading on the first rib. The diagnosis is made by obtaining a careful history, finding focal tenderness (although it was not severe in this case) on physical examination, and performing plain radiography. Identifying concomitant neurovascular injury and controlling the pain and complications is not complex in most cases. However, the mechanism of injury should be determined in each case. Some possible mechanisms of juvenile atraumatic first rib fracture follow. Matsumoto et al. suggest that simultaneous eccentric muscle contraction of the scalenus anterior, scalenus medius, and serratus anterior can cause the first rib to fracture (1). Anatomically, the scalenus muscles and the serratus muscle insert on the superior and inferior surfaces of the first rib, respectively. Contraction of the scalenus anterior pulls the lateral portion of the first rib proximally and posterolaterally, whereas contraction of the scalenus medius pulls the medial portion of the first rib proximally and medially. On the other hand, the serratus anterior pulls the first rib posterolaterally and inferiorly. Simultaneous contraction of these muscles can exert a shearing force at the groove of the subclavian artery, which is the thinnest portion of the first rib. This situation may not be associated with repetitive use of the upper extremity; it can be seen with "heading" actions, especially in laterally bending heading of a soccer player, with coughing, and with nervous tics in children. Although there is no published report identical to our case, we believe that the cause of first rib fracture in our patient was by this mechanism.
 
It has been theorized that chronic repetitive muscle action at a younger age also can be a cause of stress fractures of the first rib. Vigorous sports activity and respiratory distress require maximum increase in the capacity of the thoracic cavity with forced inspiration using accessory breathing muscles such as the serratus and scalenus. Children carrying heavy schoolbags using only one strap are at higher risk for this situation. In adults, on the other hand, pseudoarthrosis formation of the costomanubrial joint of the first rib results in limitation of "bucket handle" motion during respiration, and this is assumed to be associated with reduced "buffer power" during muscular impacts, and predisposes to stress fracture (6). Finally, child abuse must be considered, especially in young individuals presenting with first rib fractures. The possible mechanisms involved in child abuse could be direct impact force, compressive force, shaking, or acute axial load (slamming), the latter two of which cause indirect fractures.
 
For an accurate diagnosis, considering the possibility of first rib fracture along with thorough history-taking and physical examination are most important in children who have a complaint of pain in the shoulder or neck. It usually can be visualized on anteroposterior chest or shoulder radiographs, mainly in the region of the groove for the subclavian artery. Controversies exist regarding the need for additional imaging in this type of injury. Although it may not be necessary for the diagnosis, computed tomography scan is useful to delineate the anatomy of the fracture, to rule out pathologic lesions, and to confirm healing at follow-up. Bone scans can assist in determining the acuity of the fracture.
 
Generally, symptomatic treatment with activity modification for 4-6 weeks and pain control should suffice, but any hidden neurovascular injury should be identified. The timing of the patient's return to physical activities depends on symptoms. Late complications that require surgical decompression such as brachial plexus palsy, thoracic outlet syndrome, and Homer syndrome, are rare but possible due to extensive callus formation .
 
CONCLUSION
 
Physicians should be aware that even morning stretching with yawning can cause a first rib fracture in younger patients. Awareness is important for early recognition, and proper management is critical for a pain-free return to normal life. An understanding of the mechanism, associated findings, and prognosis of atraumatic first rib fracture is important.