Disclosures: Catherine A. Mills, MD, BA: No financial relationships or conflicts of interest

Case Diagnosis: Costal Cartilage Fracture of the Seventh Rib

Case Description or Program Description: A 35-year-old physically active male presented to the outpatient sports medicine clinic with over one year of rib pain. The pain first started following a posterior chest/back impact when he fell while surfing. He had immediate left anterior chest pain with an associated popping sensation. Multiple plain films were negative for fracture at the time of injury. Pain was persistent despite activity modification and physical therapy. He complained of rib deformity with tenderness to palpation, clicking, and pain with physical activity. Physical exam was significant for left anterior-inferior chest wall deformity and crepitus over the left anterior chest wall with all thoracic movement. MRI of the chest wall demonstrated chronic left seventh rib costal cartilage fracture with malalignment and surrounding edema. Point of care musculoskeletal ultrasound redemonstrated the cartilage defect.

Setting: Sports Medicine Clinic

Assessment/Results: Given the prolonged duration of his pain and mechanical symptoms and the persistent mild displacement of the fracture, he was referred to thoracic surgery for evaluation and management. He underwent rib fixation with plating.

Discussion (relevance): Costal chondral fractures are uncommon, possibly due to underdiagnosis as they are not easily identified on plain imaging. It is suspected that these fractures have a high rate of non-union when managed conservatively. Surgical management results in more rapid healing but is also technically complicated as hardware may need to be affixed to cartilage on both sides of the defect.

Conclusions: Early advanced imaging in suspected cases of rib fracture with negative plain film imaging may help to diagnose and treat costal chondral fractures more efficiently. This case also demonstrates the utility of point of care musculoskeletal ultrasound, as this modality was able to identify the cartilage defect that was not visible on plain film.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rib-crushing-wave/