Chest wall – underappreciated structure in sonography. Part II: Non-cancerous lesions

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VOLUME 17 , ISSUE 71 (March 2017) > List of articles

Chest wall – underappreciated structure in sonography. Part II: Non-cancerous lesions

Andrzej Smereczyński / Katarzyna Kołaczyk / Elżbieta Bernatowicz

Keywords : anomalies, fractures, inflamed ribs, sternum, sternoclavicular joints, scapula

Citation Information : Journal of Ultrasonography. Volume 17, Issue 71, Pages 275-280, DOI: https://doi.org/10.15557/JoU.2017.0040

License : (CC BY-NC-ND 4.0)

Received Date : 18-November-2016 / Accepted: 20-December-2016 / Published Online: 29-December-2017

ARTICLE

ABSTRACT

The chest wall is a vast and complex structure, hence the wide range of pathological conditions that may affect it. The aim of this publication is to discuss the usefulness of ultrasound for the diagnosis of benign lesions involving the thoracic wall. The most commonly encountered conditions include sternal and costal injuries and thoracic lymphadenopathy. Ultrasound is very efficient in identifying the etiology of pain experienced in the anterior chest wall following CPR interventions. Both available literature and the authors’ own experience prompt us to propose ultrasound evaluation as the first step in the diagnostic workup of chest trauma, as it permits far superior visualization of the examined structures compared with conventional radiography. Sonographic evaluation allows correct diagnosis in the case of various costal and chondral defects suspicious for cancer. It also facilitates diagnosis of such conditions as degenerative lesions, subluxation of sternoclavicular joints (SCJs) and inflammatory lesions of various etiology and location. US may be used as the diagnostic modality of choice in conditions following thoracoscopy or thoracotomy. It may also visualize the fairly common sternal wound infection, including bone inflammation. Slipping rib syndrome, relatively little known among clinicians, has also been discussed in the study. A whole gamut of benign lesions of thoracic soft tissues, such as enlarged lymph nodes, torn muscles, hematomas, abscesses, fissures, scars or foreign bodies, are all easily identified on ultrasound, just like in other superficially located organs.

Graphical ABSTRACT

The chest wall is a vast and complex structure where a whole range of pathological conditions may be encountered, with post-traumatic sternal and costal injuries and lymphadenopathy of thoracic lymph nodes being the largest group(110). The objective of the present study is to discuss the usefulness of sonography in the diagnostics of noncancerous lesions of the chest wall.

  1. Developmental anomalies are mostly found in children and young adults(9,1116). The most common defects are sternal and costal variations, present in approximately one third of patients in this age group(12). The conditions encountered in the anterior chest wall include asymptomatic malformations manifesting as chondral, costal or sternal asymmetry, such as aplasia, hypoplasia, fused ribs or cartilages, increased angularity of the costal cartilage or rib, rib clefts, supernumerary costal cartilages and ribs (Fig. 1). Sometimes, spiked ends of the floating ribs may cause localized pain on rapid movements of the trunk (Fig. 2). Such anomalies are easily identified on ultrasound(9,17). More serious thoracic deformations, however, such as pectus carinatum or pectus excavatum compressing blood vessels and the respiratory tract, frequently with concomitant kyphoscoliosis, require volume imaging modalities, such as CT or MRI(1113). In the sternum, the most common developmental variations include elongated or forked xiphoid process. Persistent developmental fissures or foramina may also be present (Fig. 3). Less frequently, suprasternal bones (ossicles) are found over the suprasternal notch(16,17). Congenital malformations of the scapula range from its complete absence to hypoplasia and partial duplication. Sometimes, the spine of the scapula may be improperly fused with the acromion, or the coracoid process improperly joined with the scapula. Congenital elevation of the scapula (Sprengel deformity) is commonly accompanied by anomalies in cervicothoracic vertebrae(1820). Muscular defects tend to be less frequent. They may manifest as aplasia, hypoplasia or hypertrophy of a given muscle or muscle set, or even the presence of additional muscles. Poland syndrome is a well-known anatomical deformity, involving unilateral underdevelopment or absence of the chest muscle, typically with coexisting ipsilateral cutaneous syndactyly(2123).

  2. Post-traumatic conditions of the chest wall are frequent, and they are easily identified on ultrasound. Blunt chest trauma typically results with rib fractures, which account for at least 50% of all chest injuries(3). Only 10–60% of rib injuries are visible on plain film radiography(2,6,79,24). Sonography is especially helpful in diagnosing occult fractures where no direct injury occurred, where bone dislocation is absent, or where it is costal cartilage that is fractured(2,4,7,25). Breaks show on ultrasound as linear cortical discontinuity (Fig. 4), sometimes with a very slight, step-like, dislocation present. When the discontinuity is more prominent, there may be an acoustic shadow visible deep to its posterior border, customarily referred to as the lighthouse or chimney phenomenon (Fig. 5). An additional sign may be the presence of a hematoma at the anterior contour of the break (Fig. 6). Ultrasound is also used to check for the formation of a fibrocartilage callus (Fig. 7). It also helps to detect potential coexisting injuries, such as a pleural hematoma, pneumothorax or pulmonary contusion(5,6,8,9,24). Ultrasound is more efficient than conventional radiography in the detection of sternal fractures following different types of trauma (Fig. 8)(9,26-29). The identification of sternal and costal injuries caused by CPR intervention may be particularly interesting (Fig. 9)(26), as in such cases the pain in the anterior chest wall experienced by the patient tends to be misattributed to cardiac etiology, posing a diagnostic challenge for the clinician. The large majority of sternal fractures occur in its body, with the sonographic features of sternal trauma being similar to those found in rib fractures. A prompt diagnosis of fracture may be misguided when the cartilage between the manubrium and the sternal body or between the body and the xiphoid process is intact (Fig. 10). Also, the rare longitudinal or horizontal fissures present in the sternum due to developmental anomalies should be kept in mind in such cases to avoid misinterpretation(16). Ultrasound is very helpful in diagnosing abnormalities of the sternoclavicular joints. All anterior or posterior subluxations of the sternoclavicular ends, which are very challenging to diagnose with plain film radiography, are easily identified on ultrasound (Fig. 11)(30-33). Intraoperative ultrasound is also extremely valuable as a tool able to confirm whether closed reduction has been successful or not(30). Ultrasound findings of fracture-separation of the growth plate of the clavicular epiphysis in a 3 year-old boy have also been reported(34). Additionally, there have been isolated case reports of identification of a scapular fracture on ultrasound(35,36). The modality is also useful for visualizing post-traumatic chest wall or pleural cavity hematomas. Similarly, the value of sonographic examination has been demonstrated for the diagnosis of pneumothorax(3,6,8,9).

  3. US may be by the imaging modality of choice in complications of the chest wall following thoracoscopy and thoracotomy. The prevalence of sternotomy complications has been estimated at 0.5-5%(37-39). The fairly common infected sternotomy wound with purulent drainage, including inflamed bone, is quite easy to diagnose on ultrasound (Fig. 12), even though the diagnosis of these complications involving anterior mediastinum is traditionally performed with CT(37). Additionally, ultrasound permits an accurate diagnosis of sternal instability due to the absence of proper bone healing following sternotomy(40).

  4. Degenerative lesions in the sternoclavicular or sternocostal joints are easy to find on ultrasound, as they present with narrowed joint space and marginal osteophytes, accompanied by distended joint capsule(9) (Fig. 13).

  5. Inflammatory responses in rheumatic diseases quite commonly involve chondral, osseous and articular elements of the chest, yet they are rarely the subject of sonographic investigation (Fig. 14)(41-44). The listed studies are concerned with the so-called Tietze syndrome (osteochondritis), characterized by the inflammation of the cartilage of one or more of the upper ribs (costochondral junction). In this condition, sonographic features may be elusive, commonly limited to the heterogeneity of the cartilage, leading to the occurrence of an acoustic shadow. The most characteristic lesions show thickened cartilage with hazy-looking borders and accompanying edema of the adjacent soft tissue. Another rare condition of similar location is SAPHO (synovitis-acne-pustulosis-hyperostosis-osteotitis), yet as to date, ultrasound has not found its application in this disease entity(45,46).

    Infectious lesions in the chest wall are uncommon, and when present tend to be situated in the sternoclavicular joints. They account for approximately 1% of all joint infections and typically affect drug users(9,44,47). Chest wall tuberculosis is a rare, yet occasionally encountered entity, which involves the thoracic skeleton (Fig. 15).

    According to Meuwly et al. (5,48), the slipping rib syndrome is not as much a rare, as relatively poorly recognized condition. It manifests by pain experienced in the vicinity of the costal arch, e.g. when coughing or lifting heavy objects. It results from costochondral hypermobility, whereby an inferiorly located cartilage slips onto a superiorly located one, causing nerve irritation in this area. The 7 upper sets of ribs are strongly connected directly to the sternum through sternocostal joints, whilst cartilages of rib 8, 9 and 10 are joined to each other by bands of loose fibrous tissue. This is where roof tile-like arrangement of cartilages may occur. The Valsalva maneuver performed by the patient during an ultrasound exam helps to induce such a setup, facilitating correct diagnosis. A linear transducer should then be placed in a position transverse to the course of the last cartilages(5,48) (Fig. 16).

  6. Noncancerous soft tissue lesions of the chest wall, such as enlarged lymph nodes, injured muscles, hematomas, abscesses, fissures, scars or foreign bodies are easily identified on ultrasound, just like other superficially located structures and organs(5,6,8,9,24,44,49,50).

Summary

Based on the literature of the subject and the authors’ own experience, ultrasound may safely be assumed as the modality of choice for the diagnosis of a wide range of noncancerous pathological conditions involving the chest wall.

Fig. 1

Comparative sonogram of costal arches. Costal cartilages (c), thicker on the left side (L)

JoU-2017-0040-g001.jpg
Fig. 2

End of rib 11, pointed like a spike (arrow), compresses adjacent soft tissues, causing localized pain

JoU-2017-0040-g002.jpg
Fig. 3

Ventrally deviated xiphoid process (arrow), which caused the patient’s concern

JoU-2017-0040-g003.jpg
Fig. 4

Fracture of right rib 4 without dislocation (arrow)

JoU-2017-0040-g004.jpg
Fig. 5

Dislocated rib fracture, causing chimney phenomenon on ultrasound (arrows)

JoU-2017-0040-g005.jpg
Fig. 6

Hematoma (arrow) visible at the break

JoU-2017-0040-g006.jpg
Fig. 7

External fibrocartilage callus on healing rib (arrow,) 30 days after rib fracture

JoU-2017-0040-g007.jpg
Fig. 8

Double fracture of the sternal body (arrows) caused by seat belt compression

JoU-2017-0040-g008.jpg
Fig. 9

Double fracture of the sternal body caused by CPR

JoU-2017-0040-g009.jpg
Fig. 10

The site where the manubrium and the sternal body are joined (arrow) – occasionally misdiagnosed as fracture

JoU-2017-0040-g010.jpg
Fig. 11

Anterior subluxation of the sternal end of the right clavicle. Arrows indicate dislocation distance

JoU-2017-0040-g011.jpg
Fig. 12

Sternal wound infection after sternotomy. Extensive sternal bone destruction where metal sutures were placed (arrows)

JoU-2017-0040-g012.jpg
Fig. 13

Marked degenerative lesions in sternoclavicular joints. Arrows indicate marginal osteophytosis

JoU-2017-0040-g013.jpg
Fig. 14

Destructive lesions accompanied by ossification found at the interface of the manubrium and the sternal body (arrow) in a patient suffering from ankylosing spondylitis

JoU-2017-0040-g014.jpg
Fig. 15

Extensive rib destruction caused by TB found in a 54-year old female farmer

JoU-2017-0040-g015.jpg
Fig. 16

Slipping rib syndrome. Comparative sonogram showing dislocation of right rib 8 slipping towards rib 7 (R), revealed during Valsalva maneuver . No such effect was demonstrated on the left side while performing the same maneuver (L).

JoU-2017-0040-g016.jpg

Conflict of interest

Authors declare no financial or personal links t any persons or organizations that may adversely affect the content of this publication or claim rights thereto.

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FIGURES & TABLES

Fig. 1

Comparative sonogram of costal arches. Costal cartilages (c), thicker on the left side (L)

Full Size   |   Slide (.pptx)

Fig. 2

End of rib 11, pointed like a spike (arrow), compresses adjacent soft tissues, causing localized pain

Full Size   |   Slide (.pptx)

Fig. 3

Ventrally deviated xiphoid process (arrow), which caused the patient’s concern

Full Size   |   Slide (.pptx)

Fig. 4

Fracture of right rib 4 without dislocation (arrow)

Full Size   |   Slide (.pptx)

Fig. 5

Dislocated rib fracture, causing chimney phenomenon on ultrasound (arrows)

Full Size   |   Slide (.pptx)

Fig. 6

Hematoma (arrow) visible at the break

Full Size   |   Slide (.pptx)

Fig. 7

External fibrocartilage callus on healing rib (arrow,) 30 days after rib fracture

Full Size   |   Slide (.pptx)

Fig. 8

Double fracture of the sternal body (arrows) caused by seat belt compression

Full Size   |   Slide (.pptx)

Fig. 9

Double fracture of the sternal body caused by CPR

Full Size   |   Slide (.pptx)

Fig. 10

The site where the manubrium and the sternal body are joined (arrow) – occasionally misdiagnosed as fracture

Full Size   |   Slide (.pptx)

Fig. 11

Anterior subluxation of the sternal end of the right clavicle. Arrows indicate dislocation distance

Full Size   |   Slide (.pptx)

Fig. 12

Sternal wound infection after sternotomy. Extensive sternal bone destruction where metal sutures were placed (arrows)

Full Size   |   Slide (.pptx)

Fig. 13

Marked degenerative lesions in sternoclavicular joints. Arrows indicate marginal osteophytosis

Full Size   |   Slide (.pptx)

Fig. 14

Destructive lesions accompanied by ossification found at the interface of the manubrium and the sternal body (arrow) in a patient suffering from ankylosing spondylitis

Full Size   |   Slide (.pptx)

Fig. 15

Extensive rib destruction caused by TB found in a 54-year old female farmer

Full Size   |   Slide (.pptx)

Fig. 16

Slipping rib syndrome. Comparative sonogram showing dislocation of right rib 8 slipping towards rib 7 (R), revealed during Valsalva maneuver . No such effect was demonstrated on the left side while performing the same maneuver (L).

Full Size   |   Slide (.pptx)

REFERENCES

  1. Saito T,Kobayashi H,Kitamura S,Ultrasonographic approach to diagnosing chest wall tumors Chest 1988 94 1271 1275
    [CROSSREF]
  2. Griffith JF,Rainer TH,Ching AS,Law KL,Cocks RA,Metrweli C,Sonography compared with radiography in revealing acute rib fracture AJR Am J Roentgenol 1999 173 1603 1609
    [CROSSREF]
  3. Wicky S,Wintermark M,Schnyder P,Capasso R,Denys A,Imaging of blunt chest trauma Eur Radiol 2000 10 1524 1538
    [CROSSREF]
  4. Malghem J,Vande Berg B,Lecouvet FE,Maldague B,Costal cartilage fractures as revealed on CT and sonography AJR Am J Roentgenol 2001 176 429 432
    [CROSSREF]
  5. Meuwly JY,Gudinchet F,Sonography of the thoracic and abdominal walls J Clin Ultrasound 2004 32 500 510
    [CROSSREF]
  6. Mathis G,Thoraxsonography – part 1: Chest wall and pleura Praxis 2004 93 615 621
    [CROSSREF]
  7. Smereczyński A,Gałdyńska M,Bojko S,Lubiński J,Kliniczna przydatność ultrasonografii w wykrywaniu złamań żeber Ultrasonografia 2008 33 28 32
  8. Dietrich CF,Mathis G,Cui XW,Ignee A,Hocke M,Hirche TO,Ultrasound of the pleurae and lungs Ultrasound Med Biol 2015 41 351 365
    [CROSSREF]
  9. Lee RK,Griffith JF,Ng AW,Sitt JC,Sonography of the chest wall: A pictorial essay J Clin Ultrasound 2015 43 525 537
    [CROSSREF]
  10. Carter BW,Benveniste ME,Betancourt SL,de Groot PM,Lichtenberger JP,Amini B,Imaging evaluation of malignant chest wall neoplasms Radiographics 2016 36 1285 1306
    [CROSSREF]
  11. Donnelly LF,Taylor CNR,Emery KH,Grody AS,Asymptomatic, palpable, anterior chest wall lesions in children: is cross-sectional imaging necessary? Radiology 1997 202 829 831
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  12. Donnelly LF,Frush DP,Abnormalities of the chest wall in pediatric patients AJR Am J Roentgenol 1999 173 1595 1601
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  13. Donnelly LF,Use of three-dimensional reconstructed helical CT images in recognition and communication of chest wall anomalies in children AJR Am J Roentgenol 2001 177 441 445
    [CROSSREF]
  14. Glass RB,Norton KI,Mitre SA,Kang E,Pediatric ribs: a spectrum of abnormalities Radiographics 2002 22 87 104
    [CROSSREF]
  15. Kryger M,Kosiak W,Batko T,Żebro dwudzielne – diagnostyka z wykorzystaniem ultrasonografii Opis przypadku. J Ultrason 2013 13 446 450
    [CROSSREF]
  16. Yekeler E,Tunaci M,Tunaci A,Dursun M,Acunas G,Frequency of sternal variations and anomalies evaluated by MDCT AJR Am J Roentgenol 2006 186 956 960
    [CROSSREF]
  17. Trinavarat P,Riccabona M,Potential of ultrasound in the pediatric chest Eur J Radiol 2014 83 1507 1518
    [CROSSREF]
  18. Williams MS,Developmental anomalies of the scapula – the “omo”st forgotten bone Am J Med Gent 2003 120A 583 587
    [CROSSREF]
  19. Simanovsky N,Hiller N,Simanovsky NH,Partial duplication of the scapula Skeletal Radiol 2006 35 696 698
    [CROSSREF]
  20. Silva RT,Hartmann LG,Laurino CT,Biló JP,Clinical and ultrasonographic correlation between scapular dyskinesia and subacromial space measurement among junior elite tennis players Br J Sports Med 2010 44 407 410
    [CROSSREF]
  21. Fokin AA,Robicsek F,Poland’s syndrome revisited Ann Thorac Surg 2002 74 2218 2225
    [CROSSREF]
  22. Watfa W,di Summa PG,Raffoul W,Bipolar latissimus dorsi transfer through a single incision: first key-step in Poland syndrome chest deformity Plast Reconstr Surg Glob Open 2016 4 e847.
    [CROSSREF]
  23. Sferlazza SJ,Cohen MA,Poland’s syndrome: a sonographic sign AJR Am J Roentgenol 1996 167 1597.
    [CROSSREF]
  24. Chan SS,Emergency bedside ultrasound for the diagnosis of rib fractures Am J Emerg Med 2009 27 617 620
    [CROSSREF]
  25. Lee WS,Kim YH,Chee HK,Lee SA,Ultrasonographic evaluation of costal cartilage fractures unnoticed by the conventional radiographic study and multidetector computed tomography Eur J Trauma Emerg Surg 2012 38 37 42
    [CROSSREF]
  26. Smereczyński A,Gabriel J,Złamania mostka w obrazach USG Pol Przegl Radiol 1996 61 216 218
  27. Jin W,Yang DM,Kim HC,Ryu KN,Diagnostic values of sonography for assessment of sternal fractures compared with conventional radiography and bone scans J Ultrasound Med 2006 25 1263 1268
    [CROSSREF]
  28. You JS,Chung YE,Kim D,Park S,Chung SP,Role of sonography in the emergency room to diagnose sternal fractures J Clin Ultrasound 2010 38 135 137
    [PUBMED]
  29. Racine S,Drake D,BET 3: Bedside ultrasound for the diagnosis of sternal fracture Emerg Med J 2015 32 971 972
    [CROSSREF]
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