Although none of the editors of InsideSurgery.com are treating Pittsburgh Steeler’s quarterback Ben Roethlisberger, we have noted with interest reports that he suffered a dislocation of the sternoclavicular joint and 1st rib injury.
Blunt injuries to this part of the thorax are well-described and well-known to trauma surgeons. The most usual scenario is injury sustained to the sternoclavicular junction and first rib secondary to a motor vehicle accident, such as an unrestrained driver hitting the steering wheel. This injury is also sometimes seen in falls from a significant height.
Diagnosis, treatment, and management of these injuries requires clinical acumen and close follow-up. The diagnosis over the last several years has evolved and is fairly straight forward in a tertiary care center.
Generally, the rib dislocation can be seen on a standard AP or PA chest radiograph. If a bone displacement is seen, care is taken to inspect for any signs of a possible injury to one of the underlying great vessels of the ascending aorta or aortic arch. The most lethal injury is a tear or transection of the aorta, but injury to the inominate vein, brachiocephalic trunk or proximal subclavian artery has been described. These injuries are generally suspected if there is a widened mediastinum on plain film.
Most patients then receive a spiral computed tomography scan, usually with intravenous contrast to ascertain if there has been intimal disruption of the aorta, which apparently from reports Roethlisberger did not have. This study is also used to screen for concominant rib fractures (which occur in over 20% of cases with first rib fractures), pulmonary contusion, pneumothorax, bronchial disruption, tracheal disruption, and esophageal disruption.
Even in the very rare instance of an isolated first rib fracture with sternoclavicular joint dislocation without any other acute injuries, significant morbidity and mortality exist. If there has not been vascular injury acutely and there is avoidance of further blunt trauma during the healing phase, the risk of vascular injury in the post-injury period remains small. The main problems in the post injury period are management of the significant pain associated with the injury and the almost universally occurring respiratory compromise.
Patients usually report close to 10/10 pain with this injury even with the liberal use of narcotics and typically attempt to lessen pain by splinting in their respiratory motion and avoiding ambulation. This leads to atelectasis with subsequent development of pneumonia. Over 50% of patients with significant pain from rib fracture develop pneumonia.
Most large trauma centers have developed rib fracture protocols where patients are kept in a monitored setting, attended to by respiratory therapists every 2-4 hours who closely measure respiratory status and measure vital capacity. Regional anesthesia for awake, non-intubated patients is sometimes offered as is local injection. Most patients are also given sleep aids as this injury is usually sufficiently painful as to interfere with sleep.
Recovery from the injury is variable, depending on the underlying health and age of the patient, but is typically of several months duration for complete healing.
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