Ian Hunt – Modern Management of Chest, Rib and Sternal Injuries in the Elite Athlete – Injury Rehab Network

The third Injury Rehab Network event of 2024 with BASRaT featured a presentation from Mr Ian Hunt, Consultant Thoracic Surgeon. The online event took place on the evening of Tuesday 5th March with 220 sports rehabilitation practitioners in attendance.

Mr Hunt discussed chest injuries in elite athletes. The recording is available to watch here.

Ian Hunt 275px

Mr Ian Hunt, Consultant Thoracic Surgeon

Mr Hunt is a thoracic (chest) surgeon who specialises in chest wall problems. He is regarded as a leading expert on congenital chest (pectus) deformities and injuries to the chest, ribs, and sternum. He sees patients from all around the world.

Mr Hunt was appointed as a consultant thoracic surgeon at St George’s Hospital in 2009, having trained in London, UK, Canada, and the USA. He was the head of thoracic surgery for 7 years and is currently the lead for thoracic trauma for the Southwest London and Surrey trauma network.

He has been actively involved in clinical management, research, training, and education. He regularly consults with professional sports teams in managing chest wall problems. He is the medical director of the ‘rib injury clinic’.

Modern management of chest, rib, and sternal injuries in the elite athlete

Mr Hunt’s presentation considered the initial diagnosis and management of common chest wall injuries and treatment with an emphasis on return-to-play protocols.

Rugby tackle

Learning Objectives

Mr Hunt summarised the learning objectives from this presentation, including, “Consider the initial diagnosis and management of common chest wall injuries and treatment with an emphasis on return to play protocols.”

Consider types of injury (anatomy)
Identify symptoms and signs (clinical features)
Consider investigations
Become familiar with treatments, protocols and prognosis (return to play)

Overview

In the overview, Ian reviewed the types and sports/ activities associated with chest injuries, emphasising their broad spectrum, which ranges from minor to life-threatening. He highlighted injuries resulting from direct impact to the chest, commonly seen in contact sports and martial arts.

The discussion also covered injuries from significant acceleration/ deceleration, such as those occurring in motorsports and skiing. Additionally, he touched upon repetitive injuries/ stress fractures encountered in activities like golf and rowing and the effects of lack of external protection/ body armour, particularly relevant to contact sports.

Ian noted that the majority of his work is associated with rugby injuries.

Bony Thoracic Skeleton

In his presentation, Mr Hunt delved into the anatomy of the bony thoracic skeleton, with Ian focusing on the thoracic components, including the Sternum, Ribs, and what he termed the ‘Complex rib’, referring specifically to the chondral (cartilage) aspects. He also addressed miscellaneous conditions related to this anatomy, such as slipped rib syndrome, Costochondritis, and Tietze’s syndrome, providing a comprehensive overview of the structural elements and potential issues within the thoracic region.

6-Step Return to Play (RTP) Progression

Mr Hunt described the stages for injured athletes to return to play:

Back to regular activities (school/ work)
Light aerobic activity
Moderate aerobic activity
Heavy, non-contact activity
Practice and full contact
Competition

Manubrium

In his discussion on Manubrium injuries, Ian explored the unique nature of injuries to the manubrium, highlighting its status as a compact bone positioned at the chest’s upper portion. He noted that injuries here are uncommon and typically result from high impact and direct force.

Regarding the management of Manubrium injuries, Mr Hunt emphasised the importance of ongoing clinical assessments aligned with radiological findings. For Manubrial fractures, he pointed out indicators such as tenderness, clicking or popping noises indicating instability, and the progression of symptoms. When addressing the First rib fracture, he distinguished between acute and chronic conditions, focusing on neurological, vascular, and muscular power aspects. In terms of muscular issues, specifically the Pectoralis hematoma +/- tear, signs include swelling and progression of the condition.

Additionally, Mr. Hunt outlined the initiation of Return to Play (RTP) protocols, considering factors like pain, tenderness, range of motion (ROM), and stability, with ultrasound assessments possibly playing a role in evaluating the latter.

Sternal Injuries & Associated Soft Tissue Injury

In his examination of Sternal Injuries & Associated Soft Tissue Injury, Mr Hunt delved into the conditions commonly accompanying sternal injuries, stressing the importance of clinical suspicion. Key concerns include Pneumothorax, Haemothorax, Cardiac Arrhythmia, Lung contusions, and Barotrauma. He emphasised the critical role of radiological assessment in diagnosing these conditions. Mr Hunt also highlighted the significance of early intervention in managing such injuries, underlining its importance in successful recovery and patient care.

Manubriosternal Joint

Ian provided an in-depth look at the Manubriosternal Joint, also referred to as the ‘angle of Louis’, which is the articulation between the upper two parts of the sternum. He detailed that this is a secondary cartilaginous joint and explained how it can be injured through acceleration/ deceleration movements or direct trauma. Additionally, Ian discussed the joint’s susceptibility to conditions both acutely and chronically, including inflammatory conditions and degenerative conditions, highlighting the complexities and vulnerabilities associated with this particular joint.

Chest X Ray

Sternum

Mr. Hunt explored injuries to the Sternum, the robust bone located at the centre of the chest, noting a high incidence of such injuries typically resulting from a direct high-impact blow or a flexion-compression mechanism. He outlined the critical aspects of clinical suspicion for sternal injuries, which include sudden, sharp pain in the central chest that intensifies with deep breathing or coughing and may be accompanied by swelling, bruising, or deformity.

In terms of diagnostic approaches, Ian discussed radiological evaluations, including chest X-rays, which, while useful, may be insensitive for detecting sternal injuries and are often complemented by Chest CT scans, particularly in the sagittal view, which might include 3D reconstruction for enhanced detail.

Mr Hunt categorised the management of Sternal injuries into acute and chronic phases. Acute management focuses on the degree of injury and monitoring for complications, while chronic management addresses deformity and pain. Conservative treatment for nondisplaced injuries includes observation, rest, ice application, and Return to Play (RTP) based on a timeline of 6-12 weeks, integrating analgesia, restricted activities, thoracic mobility exercises, and light resistance strength and conditioning (S&C). He also mentioned the potential for serial imaging to assess stability and prognosis.

Moreover, Ian evaluated surgical options for sternal injuries, differentiating between acute and chronic conditions. He detailed the limited role of closed reduction, the applicability of Open Reduction with Internal Fixation (ORIF), and the increasing offer of Fusion of the Manubriosternal Joint (MSJ), highlighting technical developments in the field.

Xiphisternal Joint

Mr. Hunt provided insights into the Xiphisternal Joint, identifying it as a fibrous joint situated at the bottom of the rib cage, central in the chest. He noted that injuries to this joint are rare, but it remains susceptible to inflammatory and degenerative conditions, indicating the specific health issues that can affect this less commonly injured part of the thoracic anatomy.

Xiphisternum

Ian delved into the Xiphisternum, describing it as costal cartilage of variable length that is nonetheless susceptible to injury from direct impacts or indirect stress/ avulsion events. Mr. Hunt further analysed injuries to the Xiphisternum, noting that they are often rare or undiagnosed, typically musculoskeletal in origin and frequently associated with a history of direct injury. He highlighted the condition as part of a “cluster of peri-sternal chondritis/ costochondritis syndrome” and introduced Xyphoidalgia (Xiphodynia) as a syndrome characterised by pain and tenderness to the lower sternum/upper abdomen, often accompanied by associated prominence of the Xiphoid process. This prominence can be induced by weight loss or exercise, with pain exacerbated by activities like bending, twisting, or performing ‘crunches’.

Mr. Hunt also discussed conservative and surgical options for managing Xiphisternum injuries. Conservative measures include restriction or alteration of activities, analgesia, and local anaesthetic and steroid injections. Meanwhile, surgical options may be considered in extreme cases, particularly when associated with prominence, where excision of the xiphisternum might be performed.

Thoeraic Skeleton

Ribs

Rib anatomy

Mr Hunt provided a detailed description of Rib anatomy, categorising the ribs into distinct groups based on their physical characteristics and connections:

True ‘Vertebrosternal’ ribs (01-07):
- These ribs articulate with the spine posteriorly at the Costovertebral joint.
- Anteriorly, they connect with the costal cartilage at the Costochondral junction, forming the costal cartilage itself.
- They also articulate with the sternum anteriorly via the Sternocostal joint.
False ‘Vertebrochondral’ ribs (08-10):
- These ribs articulate with the spine posteriorly at the Costovertebral joint.
- Anteriorly, they connect with the chondral rib above to form the costal arch, contributing to the structure of the rib cage.
- There is an increasing recognition of anatomical variations, including ‘pseudo-floating’ ribs, also known as slipped rib syndrome.
False floating ‘Vertebral’ ribs (11-12):
- These articulate with the spine posteriorly at the Costovertebral joint but have no anterior articulation.
- They are pointed at their anterior ends, with the 12th rib being notably shorter, adding to the diversity of rib structures and potential areas for injury or medical concern.

Injuries to ribs

Ian addressed rib injuries, highlighting their status as the most common type of chest injury. He noted that their incidence is often underestimated and that management is typically supportive. However, he pointed out an increasing role for specialist intervention in these cases. Ian emphasised that the number of rib fractures is proportional to the severity of the injury and underscored the importance of being aware of potential underlying ‘internal injuries’. He also drew attention to the recognition of ‘complex’ rib injuries, particularly those affecting the anterior cartilaginous part of the ribs, underscoring the complexity and varied nature of rib-related trauma.

Rib Fractures (01-03):

These are considered rare fractures but are gaining recognition as isolated injuries, particularly in specific sports contexts, due to direct high-impact forces and severe force.
The severity of these fractures can vary significantly, with potential complications including neurovascular issues.
Management is usually conservative, focusing on rest and a Return to Play (RTP) protocol that includes restrictions on specific activities, particularly lifting and thoracic mobility exercises.
Surgical correction is rare due to access issues but may be considered in acute cases involving neurovascular compromise or chronic conditions characterised by persistent pain, typically through open reduction and internal fixation.

Rib Fractures (04-10):

These represent a common injury type, usually resulting from a direct blow or an indirect crushing force, typically occurring anterior to their angle and being quite variable.
Features of these fractures include whether they are single or multiple (potentially leading to flail chest), displaced or non-displaced, and the presence of any underlying injuries.
Diagnosis relies on clinical suspicion marked by localised, intense sharp pain that worsens with deep breathing, coughing, or changes in position, alongside imaging techniques like chest X-ray, CT, dynamic chest wall ultrasound, and MRI to confirm the fracture and assess for complications.

Management:

Early Management (Simple): Focuses on avoiding complications like atelectasis or direct lung injury, typically involving conservative measures such as pain management (NSAIDs, neuropathic painkillers, lidocaine patches, muscle relaxants), setting realistic expectations, and adhering to an RTP protocol. The use of chest binders or rib straps may also be considered.
Early vs. Late Management: Surgical options might be required to address complications, non-union, mal-union, or persistent pain, with possible interventions including reduction, internal fixation (ORIF), or rib segment excision.
Management (Complex): In more severe cases, early surgical intervention may be necessary to manage complications, significant displacement, or ventilation issues, with late surgery focusing on resolving chronic pain or mal/ non-union situations.

Complex Injuries to Ribs

Ian provided an in-depth analysis of complex rib injuries, focusing on their characteristics, diagnostic methods, and management strategies:

Characteristics:

Complex rib injuries primarily affect the anterior and anterolateral chest and involve the costal (hyaline cartilage), which has different properties compared to bone, being more flexible, soft, and pliable, with age-related changes.
These injuries significantly impact the mechanics of breathing and often involve junctional ‘joint’ injuries.

Radiological Assessment:

For diagnosing these injuries, MRI is preferred over CT due to its superior detailing of cartilage injuries.
Dynamic Ultrasound Scans are highlighted for their usefulness but noted as operator-dependent. They are crucial for diagnosis and assessing prognosis, particularly regarding healing and stability.

Types of Junctional ‘Joint’ Rib Injuries:

Sternocostal and Costochondral disruptions, which may involve subluxation, dislocation, and possibly fractures.
Injuries to the Costal Arch/Margin and Interchondral fractures, including fractures through the cartilaginous plate or at the articulation of the chondral junction of the rib above.

Diagnosis:

Emphasises clinical suspicion based on symptoms such as localised, sharp, intense pain that worsens with deep breathing, coughing, or changes in position, alongside possible swelling, bruising, deformity, and clicking or popping sounds.
Diagnostic tools include chest X-rays (though not sensitive), Chest CT with reconstruction, Chest MRI, and Dynamic chest wall ultrasound, each with specific roles in confirming the injury and excluding complications.

Management of Complex Rib Injuries:

The degree of disarticulation is crucial in determining management options, differentiated into acute (early) vs chronic (late)
Conservative management includes rest, ice, analgesia, restriction of activities, and Return to Play protocols, which may be accelerated depending on the situation, alongside guidelines for aerobic, static, strength, and conditioning, as well as resistance exercises.
Surgical options may be considered, such as Open Reduction and Internal Fixation (ORIF), the role of primary repair, or excision of the cartilage component, particularly when conservative methods do not provide relief or in the presence of severe disarticulation.

Ian’s detailed approach underscores the complexity of these injuries and the importance of a nuanced, personalised approach to treatment, weighing the benefits and drawbacks of conservative vs surgical options based on individual cases.

Chest Pain

Miscellaneous chest problems

In the section on Miscellaneous Chest Problems, Mr Hunt addressed various conditions that do not fit neatly into the categories of direct trauma or specific anatomical injuries:

Inflammatory Conditions:
- Costochondritis: An inflammation of the cartilage that connects a rib to the sternum, causing chest pain akin to that of a heart attack. It’s a common cause of chest pain in children and adolescents.
- Tietze’s Syndrome: Similar to costochondritis but often with swelling at the costosternal joint, leading to chest pain that can be sharp and intensified with movement or deep breathing.
Degenerative Conditions:
- Arthritis of Chest ‘Joints’: This encompasses degenerative changes in the sternocostal, costochondral, and costovertebral joints, leading to chronic chest pain and stiffness, which are typically exacerbated by certain movements or physical activity.
Mechanic/Neuropathic Conditions:
- Slipped Rib Syndrome: This occurs when a rib slips away from its usual position, leading to back pain, chest pain, or abdominal pain. It often goes undiagnosed and is a result of weak ligaments that allow the rib to move abnormally.

These conditions, while not always directly related to physical injury, can cause significant discomfort and impact on quality of life, requiring a varied approach to diagnosis and treatment.

Slipped Rib Syndrome:

Ian discussed the presentation, diagnosis, and management of slipped rib syndrome, a condition characterised by excessive rib tip movement leading to pain in the lower chest or upper abdomen, often due to intercostal nerve impingement.

Presentation:

Pain typically originates in the lower chest or upper abdomen, exacerbated by specific movements like twisting, bending, or deep breathing. It’s often intermittent and sharp due to excessive rib tip movement but can turn into a dull ache after triggering activities.
There might be a clicking or popping sensation, with pain alleviation achieved by resting, avoiding certain activities, or stretching out the rib cage.

Background:

Common in individuals with a history of trauma, hypermobility, and connective tissue disorders (e.g., Ehlers-Danlos Syndrome (EDS)), and can occur unilaterally more often than bilaterally.
The syndrome affects individuals of any age and is frequently underdiagnosed or not recognised.

Symptoms:

Pain, often intermittent and sharp, is triggered by certain movements or activities but can also manifest as a dull ache.
Possible clicking or popping sensation associated with rib movement.

Signs:

Tenderness over the lower anterior ribs and excessive rib tip movement.
The ‘Hook’ manoeuvre can help diagnose the pain by reproducing the excessive movement of the rib tips.

Investigations:

Dynamic Ultrasound (DUS) is pivotal and requires an experienced operator. It shows excessive rib tip movement, compression of the intercostal nerve, and possible reduction in abdominal wall muscle bulk or contractility.

Management of Slipped Rib Syndrome:

Conservative Treatment: Involves rest, temperature management, analgesia, activity restriction, and targeted physical therapy, focusing on isometric ‘core’ abdominal activities to stabilise the lower ribs, progressing to isotonic/dynamic activities.
Advanced treatments like steroid injections, radiofrequency (RF) ablation, or cryotherapy can be considered.
Surgical Options: May include targeted rib tip excision or stabilisation techniques like suture techniques, ‘spacers’ for stenting ribs, or vertical absorbable plates, particularly when conservative measures are ineffective.

Ian’s approach underlines the importance of recognising slipped rib syndrome due to its potential to be overlooked, ensuring accurate diagnosis through appropriate imaging and physical examination, and adopting a tailored management strategy ranging from conservative to surgical options based on individual patient needs and responses to treatment.

Summary/ key points

The key points covered by Mr. Hunt in his comprehensive review of chest, rib, and sternal injuries are summarised as follows:

Various Types of Chest Injury: Identification and understanding of the diverse range of chest injuries, including those affecting the ribs, sternum, and costal cartilage.
Conservative vs Surgical Management Options: A detailed analysis of treatment strategies, distinguishing between conservative approaches and the conditions necessitating surgical intervention.
Management of Underlying and Life-Threatening Injuries: Emphasis on the critical importance of managing not only the primary injury but also any associated life-threatening complications.
Investigations and Imaging Techniques: Exploration of diagnostic tools and imaging techniques such as X-rays, CT scans, MRIs, and dynamic ultrasounds to accurately assess and diagnose chest injuries.
Simple vs Complex Injuries: Differentiation between simple injuries, which typically require less intensive treatment, and complex injuries, which may demand more elaborate management strategies.
Deformity, Displaced/ Non-Displaced: Discussion on the significance of identifying deformities and distinguishing between displaced/ disarticulation and non-displaced injuries for appropriate management.
Non/Mal-Union: Highlighting potential complications of rib and sternal fractures, such as non-union and mal-union, and the implications for treatment and recovery.
Pain: Pain is considered a major symptom in chest injuries, affecting both diagnosis and treatment approaches.
Miscellaneous Rib Injuries: Review of less common rib-related conditions such as slipped rib syndrome, Tietze’s syndrome, and costochondritis.
Return to Play – 6-Step Progression: A structured approach to safely returning athletes to their sport following chest injuries, emphasising a gradual, step-wise progression based on clinical milestones and patient recovery.

These points reflect the breadth of Mr. Hunt’s expertise in the area of thoracic injuries, highlighting the importance of a thorough and nuanced approach to diagnosis, management, and rehabilitation.

Q&A

Ian kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Mr Hunt to the questions

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