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A 37 year old man with mild learning disability and a history of previous neuroleptic use was admitted for investigation of a 1 year history of dystonia. On admission he had severe axial and limb dystonia with opisthotonus. Following extensive investigation for other causes of dystonia, a diagnosis of tardive dystonia secondary to neuroleptic exposure was made.
A routine chest radiograph revealed bilateral first rib fractures (fig 1). Such fractures are extremely rare because the first ribs are deeply placed and well protected by the shoulder girdle, lower neck musculature, and clavicles,1 and almost always occur in the context of severe, generalized trauma. However, rare cases of non-traumatic first rib fractures caused by sudden violent contraction of the neck muscles or repeated muscular pulling, for example during sporting activities, have been described.2 Traumatic first rib fractures typically occur at the subclavian groove where the subclavian artery crosses the thinnest portion of the rib, often causing injury to adjacent vascular, pulmonary, or mediastinal structures. By contrast, non-traumatic fractures rarely injure adjacent structures and conservative management is indicated.
The patient reported here had no history of previous trauma, and had no abnormal physical signs in the chest, nor any distal neurovascular deficit in the arms. We propose that the bilateral first rib fractures in this case resulted from tension on the scalene muscles during repetitive, violent opisthotonic spasms. To our knowledge, this is a unique neurological cause of bilateral first rib fractures.
Competing interests: none declared
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