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      Cough-Induced Multiple, Bilateral, Asymmetrical Rib Fractures in a Scoliosis Patient: A Case Report

      case-report

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          Abstract

          Cough-induced rib fractures represent infrequent complications of strenuous and prolonged coughing, mostly provoked by respiratory tract infections, with localized chest pain being the most indicative component of the clinical picture. This paper reports a case of a 27-year-old female patient who presented with four cough-induced rib fractures following the contraction of an upper respiratory tract infection. The unique character of this case is provided by the young age of the patient, the presence of multiple and bilaterally located rib fractures, and the absence of predisposing factors related to her bone physiology. Furthermore, three of the four fractures were revealed on the left side, where a scoliotic sinistro-convex thoracic curvature is described. Following conservative treatment, the patient experienced a complete resolution of symptoms and favorable clinical outcomes. Even in the seemingly low-risk category, the diagnosis of cough-induced rib fractures should be taken into consideration, and their correlation to pre-existing rib deformities, such as the ones secondary to scoliosis, should be thoroughly investigated.

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          Most cited references7

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          Cough-induced rib fractures.

          To define the demographic, clinical, and radiological features of patients with cough-induced rib fractures and to assess potential risk factors. For this retrospective, single-center study, we identified all cases of cough-induced rib fractures diagnosed at the Mayo Clinic in Rochester, Minn, over a 9-year period between January 1, 1996, and January 31, 2005. Bone densitometry data from patients' medical records were analyzed, and T scores were used to classify patients into bone density categories. The mean +/- SD age of the 54 study patients at presentation was 55+/-17 years, and 42 patients (78%) were female. Patients presented with chest wall pain after onset of cough. Rib fracture was associated with chronic cough (> or =3 weeks' duration) in 85% of patients. Rib fractures were documented by chest radiography, rib radiography, computed tomography, or bone scan. Chest radiography had been performed in 52 patients and revealed rib fracture in 30 (58%). There were 112 fractured ribs in 54 patients. One half of patients had more than one fractured rib. Right-sided rib fractures alone were present in 17 patients (26 fractured ribs), left-sided in 23 patients (35 fractured ribs), and bilateral in 14 patients (51 fractured ribs). The most commonly fractured rib on both sides was rib 6. The fractures were most common at the lateral aspect of the rib cage. Bone densitometry was done in 26 patients and revealed osteopenia or osteoporosis in 17 (65%). Cough-induced rib fractures occur primarily in women with chronic cough. Middle ribs along the lateral aspect of the rib cage are affected most commonly. Although reduced bone density is likely a risk factor, cough-induced rib fractures can occur in the presence of normal bone density.
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            Rib stress fractures.

            The ribs are an uncommon site of stress fracture. Typical locations are the first rib anterolaterally, the fourth through ninth ribs laterally and posterolaterally, and the posteromedial upper ribs. Muscular forces are predominantly responsible for these fractures. This article reviews the mechanisms of injury in various activities and illustrates the scintigraphic appearance of rib stress fractures.
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              Rib stress fractures in elite rowers. A case series and proposed mechanism.

              K Karlson (2015)
              The potential cause of stress fractures of the rib in elite rowers was examined by a retrospective review of 14 fractures in 10 patients. Fractures occurred on the antero- to posterolateral aspects of ribs 5 through 9 and were most often associated with long-distance training and heavy load per stroke. A review of the literature yields striking similarities between these stress fractures and fractures caused by cough. It is suggested that actions of the serratus anterior and external oblique muscles on the rib cause stress fracture because of the repetitive bending forces in both rowing and coughing. A technique involving less use of both muscles through a truncated arm pull-through and a decreased layback position at the end of the stroke, and equipment changes to decrease length of the lever arm, should yield a decreased risk of rib stress fractures in rowing.

                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                22 November 2023
                November 2023
                : 15
                : 11
                : e49251
                Affiliations
                [1 ] Department of Anatomy and Embryology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, ROU
                [2 ] Department of Orthopedic Surgery and Traumatology, Dr. Fogolyán Kristóf Emergency County Hospital, Sfântu Gheorghe, ROU
                [3 ] Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, ROU
                [4 ] Department of Radiology, Emergency County Hospital Târgu Mureș, Târgu Mureș, ROU
                [5 ] Department of Orthopedic Surgery and Traumatology, Emergency County Hospital Târgu Mureș, Târgu Mureș, ROU
                [6 ] Department of Aesthetic Medicine, The Ghanem Clinic, London, GBR
                Author notes
                Article
                10.7759/cureus.49251
                10744169
                38143673
                8f045f12-5a79-4187-80d1-cb4946ff442f
                Copyright © 2023, Incze-Bartha et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 November 2023
                Categories
                Radiology
                Orthopedics

                thoracic pain,scoliosis,multiple rib fractures,rib deformities,cough

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