Case

A 60 year old male patient comes to your clinic complaining of midline pain inferior to the sternum and just medial to the edge of the anterior costal margin. The pain is constant but worse when inhaling, especially deeply. Upon physical exam, you note that heart and lung sounds are normal. Upon obtaining a patient history, you learn that one week ago, the patient underwent cardiopulmonary resuscitation (CPR) after a minor heart attack.

Question 2/3 - What do you think has happened?

Click on your selected option(s) below  (correct = 2, over-thinking = 3+)

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Not quite. A rib fracture is technically where the bone of the rib has fractured. Ribs are bony lateral and posteriorly then transitioning to costal cartilage before attaching to the sternum.

Incorrect. Ribs are counted from superior to inferior, so rib #2 attaches at the manubriosternal angle, a location more superior to the described position.

Correct!  A fracture of the costal cartilage of rib 7 close or at the attachment to the sternum could be perceived as the midline pain described by the patient. Also, due to the articulation of the costal cartilage with the sternum, you could also have the pain increase with respiration, particularly upon taking a deep breath.

Incorrect. Rib #10 is a 'false rib', where the costal cartilage attaches to the rib above (#9).  The cartilage of rib #9 in turn attaches to the cartilage of rib #8, which in turn attaches to rib #7. So a rib #10 costal cartilage fracture would be lateral and inferior to the described location. 

Correct! This is the most likely cause of a constant midline pain at that location and it is not uncommon when performing a CPR to fracture the xiphoid process (or indeed a rib). Deep inspiration puts tension on the diaphram and anterior abdominal wall which could cause movement of the xiphoid process and pain. 

Incorrect. The manubrium is the most superior part of the sternum where the clavicles articulate. The pain is described as coming from the inferior end of the sternum.