Costal Cartilage Fractures and Disruptions in a Rugby Football Player

Abstract

Costal cartilage fracture of the rib cage, or costochondral, is a rare sporting injury. For contact athletes, the instability of the rib cage may lead to potential serious complications, similar to rib fractures or thorax disruption. Most authors recommend initial conservative treatment with surgery reserved for only recalcitrant cases. We report a case of an amateur American male rugby football player who sustained a costal cartilage fracture and disruption involving the anterior left fifth and sixth rib costal cartilages. The case highlights the difficulty in establishing the diagnosis based on clinical examination and standard radiographs alone. Computed tomography was used to assist in diagnosing this destabilizing injury to the rib cage. Costal cartilage fractures and disruptions in athletes are rarely reported in literature and can have serious implications for the athlete's ability to return to play if the rib cage is destabilized.

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CASE REPORT
Costal Cartilage Fractures and Disruptions in a Rugby
Football Player
Victor Lopez, Jr, DO, MA,* Richard Ma, MD,*†Xinning Li, MD,†John Steele, BS,†
and Answorth A. Allen, MD*†
Abstract: Costal cartilage fracture of the rib cage, or costochon-
dral, is a rare sporting injury. For contact athletes, the instability of
the rib cage may lead to potential serious complications, similar to
rib fractures or thorax disruption. Most authors recommend initial
conservative treatment with surgery reserved for only recalcitrant
cases. We report a case of an amateur American male rugby football
player who sustained a costal cartilage fracture and disruption
involving the anterior left fifth and sixth rib costal cartilages. The
case highlights the difficulty in establishing the diagnosis based on
clinical examination and standard radiographs alone. Computed
tomography was used to assist in diagnosing this destabilizing injury
to the rib cage. Costal cartilage fractures and disruptions in athletes
are rarely reported in literature and can have serious implications for
the athlete’s ability to return to play if the rib cage is destabilized.
Key Words: costal cartilage disruption, costochondral fracture, rib
injury, athletic chest wall injury
(Clin J Sport Med 2012;0:1–3)
INTRODUCTION
Fractures or disruptions involving the costal cartilage
are typically high-energy injuries and occur after blunt
trauma.
1–3
The potential for sustaining this type of injury
while participating in sports, however, is likely underrecog-
nized and underreported in literature. In this case report, we
present an amateur rugby football player who sustained costal
cartilage fractures and disruptions involving his left fifth and
sixth ribs. The case highlights the difficulty in establishing the
diagnosis based on clinical examination and standard radio-
graphs alone. Costal cartilage fractures and disruptions in
athletes can have serious implications for the athlete’s ability
to return to play if the rib cage is destabilized. Due to the
precarious location of the injury, it was recommended that the
player not return to collision sports after he recovered due to
the potential of injury to underlying cardiac structures.
CASE REPORT
A 27-year-old amateur American Division II male rugby football
player was injured during an alumni match while attempting to pass
the ball over a defender. The injured player was tackled at his chest
level with both his arms up and above his shoulders. The defending
player made contact with a shoulder tackle into the injured player’s
left upper anterior thorax. The injured ball carrier had to leave the
game and was unable to return to play because of severe left-sided
thoracic pain and difficulty breathing. The player was sent to the
emergency department (ED), where his clinical examination was
notable for significant tenderness to palpation over the left anterior
rib cage. Plain radiographs of the chest and shoulder were inconclu-
sive. The patient was diagnosed with a noncomplex rib sprain and
subsequently discharged home.
After his ED visit, the injured player was evaluated by his home
physician. His clinical examination demonstrated a notable promi-
nence over his left anterior chest wall. Based on the asymmetry that
was present, there was a concern that the player had a structural
injury to his chest wall and a referral was arranged with an
orthopedist. Repeat plain radiographs obtained in clinic failed to
reveal any obvious injuries. A CT scan revealed a mid-substance
costal cartilage fracture of the fifth and sixth ribs directly anterior to
the patient’s cardiac structures (Figure 1).
Due to the patient’s overall improving clinical course, the orthope-
dist recommended conservative management with rest and removal
from competition. The player was pain free by 8 weeks. A CT scan
at 10 weeks after his injury showed evidence of healing at the costal
cartilage fracture sites (Figure 2). One year after the injury, the player
was able to exercise without significant pain in his costal cartilage
injuries; however, he reports occasional clicking at his left chest wall
with certain activities. Due to the precarious location of the player’s
costal cartilage fractures combined with his amateur competition level,
it was recommended that the player refrain from further contact sports
including rugby, where a repeat injury to that area could occur and
place the underlying cardiac structure at risk for injury.
DISCUSSION
The literature on costal cartilage injuries is sparse, and
its true incidence is unknown.
2–5
Most costal cartilage injuries
reported in the literature are in the young male population and
a result of blunt trauma.
2,3
Sports that involve twisting maneu-
vers may predispose athletes to sustain costochondral separa-
tions, which often occur in the relative immobile first and
second ribs.
5,6
These separations are in contrast with fractures
of the costal cartilage, which occur in the lower ribs and
typically result from the direct impact seen in collision sports,
such as hockey and rugby.
5
Rugby may be at increase risk,
given the collisions and lack of protective equipment to
absorb the energy of the impact. Brooks et al
7
reported that
Submitted for publication February 17, 2012; accepted April 4, 2012.
From the *Rugby Research and Injury Prevention Group, New York, New
York; and †Shoulder Surgery and Sports Medicine Service, Hospital for
Special Surgery, New York, New York.
The authors report no conflicts of interest.
Corresponding Author: Victor Lopez, Jr, DO, MA, Rugby Research and
Injury Prevention Group, 118-17 Union Turnpike, Suite 3B, New York,
NY 11375 (vlopezjr@rugbyinjury.org).
Copyright © 2012 by Lippincott Williams & Wilkins
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the incidence of costochondral/sternal injuries was 2.4 per
1000 player-hours in English professional rugby union
match play.
Current imaging modalities used to diagnose costo-
chondral injuries include ultrasound, CT, and magnetic
resonance imaging (MRI).
2,3,5
Unlike rib fractures, costal
cartilage fractures are not visible on radiographs unless it is
strongly calcified.
2
In a retrospective study by Malghem et al,
2
the authors were able to reliably identify all 15 cases of costal
cartilage fractures in their patient series using CT scan. Most
of the fractures in their series were mid-substance in location,
similar to our patient’s fracture. A CT scan also reliably
FIGURE 1. CT scan of the fracture
and disruption to the fifth (above
right) and sixth costal cartilages
(below right). Both costal cartilage
fractures are displaced 100%. The
injured area is located just anterior to
the underlying cardiac structures.
FIGURE 2. Follow-up CT scan
approximately 10 weeks after injury.
New bone formation can be seen at
the site of the fifth (above right
image) and sixth (below right
image) costal cartilage fracture sites,
which represents a healing response.
Lopez et al Clin J Sport Med Volume 0, Number 0, Month 2012
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identifies concomitant injuries such as rib fractures and organ
injuries, which have been reported to occur with sports-
related costal cartilage injuries.
1,4
Ultrasound and MRI have
also been shown to reliably diagnose costal cartilage injuries.
5
The advantage of these modalities over CT is the lack of
additional radiation exposure, which is valuable in the pedi-
atric population and for follow-up imaging.
The literature on outcome and treatment guidance after
costochondral fracture is sparse. Although many of the costal
cartilage fractures presented in the literature are reported to
“heal,”what is unclear from these case series is the healing
rates and quality of healing with this type of injuries. Ques-
tions exist regarding whether cartilage fracture healing would
be as robust as the bony healing that occurs in rib fractures.
8,9
Based on recent experimental animal studies on costal carti-
lage injury, there are questions whether costal cartilages have
the capacity to fully heal.
9
Unlike our case report, we are not
aware of any case series where follow-up imaging is pre-
sented for these injuries.
With regards to return to sport, most athletes with costal
cartilage fractures return once the pain subsides, which may
range from 3 to 12 weeks.
1,5,8,10
The use of protective padding is
encouraged for an additional period for protection until the
injury is fully healed. There is no literature that provides guid-
ance on withholding an athlete from further contact sport par-
ticipation based on this type of injury. Our rationale for
recommending the athlete in this case report to no longer par-
ticipate in contact rugby was based on consideration of his
amateur competition level and the unique location of his costal
cartilage fractures. The fractures involved the fifth and sixth
costochondral cartilages, which are intimately associated with
the underlying cardiac structure. Our athlete’s complaint of
occasional clicking along his chest wall with certain activities
may suggest some residual motion at these costal cartilage
fracture sites despite the bony callus that was seen at the
10-week repeat CT scan. A repeat collision may therefore place
this injured area, and underlying cardiac structure, at risk.
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