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Original Report |
1 All authors: Department of Radiology, University of Louvain, St. Luc University Hospital, Hippocrate Ave., 10, B-1200 Brussels, Belgium.
Received May 11, 2000;
accepted after revision July 12, 2000.
Address correspondence to J. Malghem.
Abstract
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CONCLUSION. On CT, fracture was seen as a low-density area through the costal cartilage, with surrounding calcifications present near old fractures, and gas density within the cleft in some cases. On sonography, cartilage fracture appeared as an interruption of the smooth anterior aspect of the cartilage.
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Costal cartilage fractures have rarely been reported in the literature [2, 3]. We report a series of eight patients presenting with 15 costal cartilage fractures diagnosed on CT in all patients and on sonography in three patients.
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CT or sonography was performed because of severe posttraumatic parasternal pain unexplained by radiographic findings, or because of a painful parasternal mass with clinical suspicion of tumor in patients without obvious recent trauma. In one patient, a surgical biopsy had been performed that showed the presence of chondroid tissue with atypical chondrocytes, raising the possibility of a malignant chondroitic tumor. In another patient, a needle biopsy disclosed aspecific hemorrhagic material.
Radiography and CT were available in all eight patients, and sonography in three.
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No fractures were seen on radiography. The diagnosis of costal cartilage fracture was established using CT in all 15 lesions. CT images consistently revealed a focal discontinuity of the costal cartilage, with displacement in five (33%) of 15 lesions (Fig. 2A). Swelling of the neighboring soft tissues was seen in four lesions. Focal surrounding calcifications were visible near three fractures on CT scans obtained several weeks after the presumed causal trauma (Figs. 3A,3B,3C,3D,3E and 4A,4B). In four fractures involving the chondrosternal or chondrocostal junction, fine linear lucencies with a gas density were present in the cartilaginous cleft (Fig. 5A).
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In the three patients who underwent sonography, the abnormalities consisted of a discontinuity in the thin echogenic line corresponding to the anterior aspect of the hypoechogenic cartilage in all six lesions, with a step-off in two lesions (Fig. 2B) and a small hyperechogenic area perpendicular to the cartilage surface in one lesion, corresponding to the gas density observed on the CT image of the same lesion (Fig. 5B).
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Fractures of costal cartilages are not often described in the literature. Occasional illustrations are included in books or reviews discussing chest injuries or costal lesions [4, 6, 7]. We found three reports in the literature describing a total of 15 costal cartilage fractures diagnosed with sonography [2, 3] or CT [8].
In our series, fractures were recognized by visualizing focal interruption in the relatively high costal cartilage density on CT images, or in the linear echogenic anterior margin of the hypoechogenic cartilages on sonography. A significant displacement of the adjacent segments was evident in one third of the lesions and soft-tissue swelling on CT images in four of the 15 lesions. Two additional abnormalities were observed. First, calcifications surrounding the fracture sites were seen in three lesions examined several weeks after the presumed causal trauma. Milgram [7] also observed focal calcifications near a costal cartilage on a histopathologic specimen from a patient engaged in karate who had noticed a lump on his chest cage for several months. Second, a thin area with gas density within the cartilage cleft was seen in four of the six lesions involving the chondrocostal or chondrosternal junctions. This accumulation of gas is probably the result of a vacuum phenomenon in the fracture cleft.
Costal cartilage fractures probably occur more frequently than is currently recognized because of underdiagnosis. Flail chest fractures may involve the chondrocostal or chondrosternal junctions, which cannot be identified radiographically [1]. In a sonographic study of patients with suspected rib fracture, Griffith et al. [3] found that 11% of all fractures were located in the costal cartilage or at the chondrocostal junction.
In our patients, none of the lesions were diagnosed using radiography. CT or sonography was performed either because of unexplained considerable local acute posttraumatic pain, or because of a chronic painful lump without an obvious origin. Chronic symptoms may be caused by the inability of chondrocytes to respond effectively to cartilage fracture [9], contrary to bone cells that generate a neoformative process generally leading to consolidation of bony rib fractures within several weeks. When a chronic fracture of the cartilage is not recognized, the lesion may be misdiagnosed. Histologic analysis of the biopsy can reveal chondroid tissue with atypical cells suggestive of a malignant tumor, as we found in a 46-year-old man with a painful lump in the anterior thoracic chest wall 3 months after an overlooked thoracic trauma (Fig. 4A,4B).
Cartilage fractures in our series were located at the chondrocostal or chondrosternal junction for the first ribs, and the middle region of the other costal cartilages. Most lesions were observed in patients who were relatively young (median age, 27.5 years) and male (6/8). A larger series is needed to determine whether this sex, age, and topographic distribution reflects the true prevalence of these fractures that could result from peculiar mechanical characteristics (i.e., increased risk for cartilage fractures, especially when the bony ribs are strong in young men).
Differential diagnosis includes other painful lesions of the costal cartilage, such as costochondritis and Tietze's and Cyriax's syndromes. Costochondritis and Tietze's syndromes are ill-defined disorders characterized by pain originating from the chondrocostal articulations of the second to fifth ribs, with local swelling in Tietze's syndrome. Pathogenesis is unclear and could be of traumatic origin. Diagnosis of Tietze's syndrome is generally based on clinical findings, although cartilage swelling may be visible on CT [5] or sonography [10]. However, no abnormal findings were found either on CT or sonography in another series [11]. Cyriax's syndrome ("slipping rib syndrome") is a disorder affecting the anterior extremity of the eighth, ninth, and 10th ribs, which articulate with the superjacent ribs and not with the sternum. This syndrome, encountered especially in women around the age of 50 years, seems to be a result of posttraumatic subluxation of these costo—costal articulations. The diagnosis is also based on clinical findings [12]. When the dominant symptom is a focal mass, tumoral or infectious lesions of the chest wall must be also considered [4]. Chondral fracture with soft-tissue swelling can be differentiated from these entities by visualization of the fracture line (the curved multiplanar reformatted CT images are especially helpful in this evaluation), a step-off deformity, and contained gas within the cartilage cleft, which is present in some cases.
In conclusion, our observations show that CT and sonography enable recognition of costal cartilage fractures, a diagnosis often overlooked on radiography. A search for such lesions using CT or sonography is indicated in cases of severe acute posttraumatic parasternal pain, or painful parasternal mass without obvious recent trauma. It is difficult to say whether the costal cartilage fractures, infrequently reported in the literature, are truly exceptional or if they are just underdiagnosed.
Acknowledgments
We thank J. L. Doyen, C. Villers, and C. Lebon for referring patients; P.
Michel and H. Noël for the histologic analysis
of the biopsied specimens; and Françoise
Martin, Martine Millecan, Jocelyne Burion, and Anne Smith for editorial
assistance.
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