Costal cartilage fractures as revealed on CT and sonography

Bioengineering Full-scale auricles using 3D-printed external scaffolds and decellularized cartilage xenograft

Reconstruction of the human auricle remains a formidable challenge for plastic surgeons. Autologous costal cartilage grafts and alloplastic implants are technically challenging, and aesthetic and/or tactile outcomes are frequently suboptimal. Using a small animal "bioreactor", we have bioengineered full-scale ears utilizing decellularized cartilage xenograft placed within a 3D-printed external auricular scaffold that mimics the size, shape, and biomechanical properties of the native human auricle. The full-scale polylactic acid ear scaffolds were 3D-printed based upon data acquired from 3D photogrammetry of an adult ear. Ovine costal cartilage was processed either through mincing (1 mm3) or zesting (< 0.5 mm3), and then fully decellularized and sterilized. At explantation, both the minced and zested neoears maintained the size and contour complexities of the scaffold topography with steady tissue ingrowth through 6 months in vivo. A mild inflammatory infiltrate at 3 months was replaced by homogenous fibrovascular tissue ingrowth enveloping individual cartilage pieces at 6 months. All ear constructs were pliable, and the elasticity was confirmed by biomechanical analysis. Longer-term studies of the neoears with faster degrading biomaterials will be warranted for future clinical application. STATEMENT OF SIGNIFICANCE: Accurate reconstruction of the human auricle has always been a formidable challenge to plastic surgeons. In this article, we have bioengineered full-scale ears utilizing decellularized cartilage xenograft placed within a 3D-printed external auricular scaffold that mimic the size, shape, and biomechanical properties of the native human auricle. Longer-term studies of the neoears with faster degrading biomaterials will be warranted for future clinical application.

The True-Blue technique: Enhanced chondral assessment of the chest wall

There is a growing understanding and identification of costal cartilage injuries, however, diagnosis of these injuries remains difficult. We present a novel radiodensity based coloring technique, termed the True-Blue technique, to manipulate 3D CT imaging and more accurately diagnose costochondral injuries.

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

Management of a Flail Chest Caused by Multiple Costosternal Fractures: A Case Report

Costochondral separation is a rare consequence of blunt thoracic trauma and can lead to life-threatening complications such as a flail chest. The diagnosis of costochondral separation remains challenging due to the obscurity of the condition on chest radiographs. Surgical rib fixation is a viable treatment option and research regarding its effectiveness and long-term benefits is promising but still evolving. Here, we discuss a case of flail chest caused by multiple costosternal fractures definitively managed with surgical rib fixation.

[Costal Cartilage Injury Using MRI: A Case Report]

A magnetic resonance imaging (MRI) scan was performed to rule out a sternal fracture in a woman in 30s. Short tau inversion recovery (STIR) coronal showed no signal change in the sternum but increased signal from the mediastinum to the anterior thoracic region. We could not detect significant findings until midway through the examination. T₂-weighted fat-suppressed images revealed a suspected left first costal cartilage injury at the end of the examination. In addition, three-dimensional gradient-recalled echo (3D GRE) T₁-weighted fat-suppressed images clearly revealed a lesion area with a high signal intensity in the costal cartilage and a low signal intensity in the surrounding tissue, and we diagnosed costal cartilage injury definitely. In case of MRI for posttraumatic chest pain, T₁-weighted fat-suppressed images with 3D GRE may be useful for the detection of lesion area.

Bilateral costal cartilage fractures sustained in the gym during repeated bench press exercises

Costal cartilage fractures are common in high-energy blunt chest trauma but are frequently missed on imaging evaluation and accordingly underreported in the literature. In this report, we describe a case of a 32-year-old male who sustained bilateral costal cartilage fractures following repeated blunt trauma in the gym sustained during bench press exercises. The patient presented with a painful "clicking" of a rib in and out of place while bending or turning sideways. Initial chest X-ray and computed tomography (CT) imaging were reported negative for fractures; however, a closer inspection of the CT image revealed bilateral costal cartilage fractures. As the patient's symptoms improved over time, a conservative approach to treatment with regular analgesia and advice to avoid external impact on the fracture sites was adopted. This unique case highlights an unusual mode of trauma and diagnostic complexity of costal cartilage fractures.

Articular Findings on Chest Computed Tomography: An Algorithmic Approach for Radiologists

ABSTRACT

Chest computed tomography (CT) is one of the most frequently performed imaging studies. Incidental osseous and articular findings are commonly encountered in chest CTs in daily practice. The spectrum of findings is broad, varying from benign to malignant, and interpretation of these incidental musculoskeletal findings could be challenging for radiologists. In this review, we provide a systematic algorithmic approach for the diagnosis of common articular findings seen on chest CT with recommendations for appropriate follow-up evaluation.

Costal cartilage fractures in blunt polytrauma patients - a prospective clinical and radiological follow-up study

Purpose

To assess the healing of costal cartilage fractures (CCFX) in patients with blunt polytrauma with follow-up imaging and clinical examination. Effect on physical performance and quality of life (QoL) was also evaluated.

Methods

The study group comprised twenty-one patients with diagnosed CCFX in trauma CT. All the patients underwent MRI, ultrasound, ultra-low-dose CT examinations, and clinical status control. The patients completed QoL questionnaires. Two radiologists evaluated the images regarding fracture union, dislocation, calcifications, and persistent edema at fracture site. An attending trauma surgeon clinically examined the patients, with emphasis on focal tenderness and ribcage mobility. Trauma registry data were accessed to evaluate injury severity and outcome.

Results

The patients were imaged at an average of 34.1 months (median 36, range 15.8–57.7) after the initial trauma. In 15 patients (71.4%), CCFX were considered stable on imaging. Cartilage calcifications were seen on healed fracture sites in all the patients. The fracture dislocation had increased in 5 patients (23.8%), and 1 patient (4.8%) showed signs of a non-stable union. Four patients (19.0%) reported persistent symptoms from CCFX.

Conclusion

Non-union in CCFX is uncommon but may lead to decreased stability and discomfort. Both clinical and radiological examinations play an important part in the post-traumatic evaluation of CCFX. CT and MRI visualize the healing process, while dynamic ultrasound may reveal instability. No significant difference in QoL was detected between patients with radiologically healed and non-healed CCFX. Post-traumatic disability was mostly due to other non-thoracic injuries.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10140-022-02066-w.

Pediatric chest wall masses: spectrum of benign findings on ultrasound

A palpable finding along the chest wall is a frequent indication for pediatric US. Accurate identification of benign lesions can reassure families and appropriately triage children who need follow-up, cross-sectional imaging, or biopsy. In this pictorial essay, we review chest wall anatomy, illustrate US techniques and discuss key US imaging features of common benign lesions and normal variants.

Costal cartilage fracture: A commonly missed thoracic injury in trauma patients

In this report, we describe a case of a 43-year-old male who sustained a displaced mid chondral costal cartilage fracture along with multiple ipsilateral rib fractures following a jet ski collision. Costal cartilage fractures (CC) are commonly missed on imaging evaluation, and accordingly underreported in the literature. High-energy blunt chest trauma represents the most common mechanism for CC injuries. Computed Tomography (CT) is the modality of choice to diagnose CC fractures along with the associated cardiopulmonary and abdominal injuries in polytrauma patients. There is currently no consensus with respect to the management of CC fractures. Further research is required to explore the long-term impact of CC fractures on thoracic cage stability.

Ultrasonographic evaluation of costal cartilage for microtia reconstruction surgery

PURPOSE

Autogenous costal cartilage grafts have gained the golden standard method in microtia reconstruction. Right now, there was no useful method to assess the quality of costal cartilage before microtia reconstruction surgery. The purpose of this study was to evaluate the role of ultrasonography in assessing costal cartilage in patients who were ready to do microtia reconstruction surgery.

METHODS

A prospective controlled study was conducted to collect 65 patients who underwent microtia reconstruction and underwent ultrasonography of costal cartilage before operation. The results of costal cartilage calcification and honeycombed phenomenon measured by ultrasonography were compared with those during operation. The age-specific patterns in calcification and honeycombed phenomenon were explored.

RESULTS

According to the results of ultrasonography, the positive rate of calcification was 10.9% in patients under 18 years old, while 80% in patients over 18 years old. The positive rate of honeycombed phenomenon was 2.8% in patients under 12 years old, 42.9% in patients between 12 and 18 years old, and 25% in patients over 18 years old. Compared with intraoperative results, the accuracy rate of ultrasonography for calcification was 100%. The accuracy rate for honeycombed phenomenon was 83.3%.

CONCLUSION

Ultrasonography has high accuracy rate in assessing the calcification and honeycombed phenomenon of the costal cartilage, which was of vital importance for microtia reconstruction. The quality of costal cartilage changed with the age.

ACR Appropriateness Criteria® Rib Fractures

Rib fractures are the most common thoracic injury after minor blunt trauma. Although rib fractures can produce significant morbidity, the diagnosis of injuries to underlying organs is arguably more important as these complications are likely to have the most significant clinical impact. Isolated rib fractures have a relatively low morbidity and mortality and treatment is generally conservative. As such, evaluation with standard chest radiographs is usually sufficient for the diagnosis of rib fractures, and further imaging is generally not appropriate as there is little data that undiagnosed isolated rib fractures after minor blunt trauma affect management or outcomes. Cardiopulmonary resuscitation frequently results in anterior rib fractures and chest radiographs are usually appropriate (and sufficient) as the initial imaging modality in these patients. In patients with suspected pathologic fractures, chest CT or Tc-99m bone scans are usually appropriate and complementary modalities to chest radiography based on the clinical scenario. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Ultrasound and bone: a pictorial review

The assessment of bone mainly relies on standard radiographs, CT, MRI, and bone scintigraphy depending on the anatomic region complexity and clinical scenario. Ultrasound (US), due to different acoustic impedance between soft tissues and the bone cortex, only allows the evaluation of the bone surfaces. Nevertheless, US can be useful in the evaluation of several bone disorders affecting the limbs as a result of its tomographic capabilities and high definition. This pictorial review article summarises our clinical experience in adults and reviews the literature on US bone examination. We first present the US appearance of normal bone and the main congenital anatomic variations, after which we illustrate the US findings of a variety of bone disorders. Although US has limits in bone assessment, its analysis must be a part of every musculoskeletal US examination.

Prevelance of the costal cartilage fracture on the computerised tomography in chest trauma

INTRODUCTION

Radiography remains limited in costal cartilage injuries, and sonography, CT and MR imaging turns out to be more sensitive in the detection of cartilage injuries. This study aims to determine the frequency of costal cartilage fractures detected in the CT images of the patients with high energy chest trauma and to evaluate the association of costal cartilage fracture with the complications of trauma.

METHODS

The CT images of 93 patients aged 18-91 years with a trauma admitted to the Emergency Department of the State Hospital between February 2019 and June 2019 were studied retrospectively. Thorax CT images of 93 patients who presented to the emergency department with blunt chest trauma with AIS > 2 were retrospectively investigated by a radiologist with a board certificate who had 15 years of experience in the field.

RESULTS

Costal cartilage fracture was identified in 39 of 93 patients with severe chest trauma. Among the 93 chest trauma patients admitted to the emergency department between February and June 2019, the prevalence of costal cartilage was calculated as 41.93%. Note that the most common costal cartilage fractures in the study group were identified in the 6th, 7th, 8th and 1st costal cartilages. Another significant relationship (p = 0.007) was found between costal cartilage calcification and cartilage fracture.

CONCLUSION

Costal cartilage fractures frequently occur in blunt thoracic trauma with multiple rib fractures and are of clinical importance as they lead to the instability of chest wall. The incidence of cartilage fractures increases in elderly patients with costal cartilage calcification.

Analysis of the advantages of 3D printing in the surgical treatment of multiple rib fractures: 5 cases report

Background

Rib fractures account for a fairly high proportion of chest injuries, ranging from 55 to 80%. The most common mechanisms of injury include: traffic accident, extrusion and falls from significant heights. Besides, the surgical treatment of multiple rib fractures has been accepted by more and more medical professionals. We reported 5 clinical cases of patients with multiple rib fractures undergoing open reduction and internal fixation using 3D printing technology.

Case presentation

Retrospective analysis of 5 clinical cases of multiple rib fractures from January 2017 to August 2018 in our hospital. A preoperative CT thin slice scan was used to reconstruct the 3D model according to the scanning results, and 3D printing technology was adopted to prepare the rib model. Preoperative reconstruction of the rib’s normal shape and lock plate for the shaped ribs was created according to reconstructed model. For multiple fractures especially patients with severely deformed rib shape, it is suggested to intraoperative shape directly to the metal bone plate fixed on the ribs on both ends of the fracture line, in order to establish a basic support frame. The other various fracture section can be fixed on the lock plate respectively. Postoperative chest radiographs of the 5 patients showed that the internal fixations were in good and natural shape. The thoracic contour was well formed and symmetrically with the contralateral side.

Conclusion

Making the rib model and the pre-shaped titanium alloy rib locking plate using 3D printing technology, provided a more minimally invasive and precisely individualized treatment for some rib fracture operations.

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

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.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma

Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallée lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. ^© RSNA, 2017.

Sonographic diagnosis of a radiographically occult displaced fracture of a costal cartilage

We report the case of a 22-year-old athlete who sustained a blunt thoracic trauma to the right chest causing a costal cartilage fracture. Plain radiographs revealed no abnormalities while sonographic (US) examination performed a week later because of persistent pain led to the diagnosis of a displaced fracture of the right tenth costal cartilage. A follow-up US examination confirmed the healing of the fracture and allowed the patient to return to competitive sport activity. We recommend the use of US in patients with persisting pain after thoracic trauma with negative plain radiographs of the ribs to rule out radiographically occult costal cartilage fractures. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:605-607, 2017.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ² and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. ^© RSNA, 2017.

Thoracic wall trauma-misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging

Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the "gold-standard" for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way.

Simple X-ray versus ultrasonography examination in blunt chest trauma: effective tools of accurate diagnosis and considerations for rib fractures

Simple radiography is the best diagnostic tool for rib fractures caused by chest trauma, but it has some limitations. Thus, other tools are also being used. The aims of this study were to investigate the effectiveness of ultrasonography (US) for identifying rib fractures and to identify influencing factors of its effectiveness. Between October 2003 and August 2007, 201 patients with blunt chest trauma were available to undergo chest radiographic and US examinations for diagnosis of rib fractures. The two modalities were compared in terms of effectiveness based on simple radiographic readings and US examination results. We also investigated the factors that influenced the effectiveness of US examination. Rib fractures were detected on radiography in 69 patients (34.3%) but not in 132 patients. Rib fractures were diagnosed by using US examination in 160 patients (84.6%). Of the 132 patients who showed no rib fractures on radiography, 92 showed rib fractures on US. Among the 69 patients of rib fracture detected on radiography, 33 had additional rib fractures detected on US. Of the patients, 76 (37.8%) had identical radiographic and US results, and 125 (62.2%) had fractures detected on US that were previously undetected on radiography or additional fractures detected on US. Age, duration until US examination, and fracture location were not significant influencing factors. However, in the group without detected fractures on radiography, US showed a more significant effectiveness than in the group with detected fractures on radiography (P=0.003). US examination could detect unnoticed rib fractures on simple radiography. US examination is especially more effective in the group without detected fractures on radiography. More attention should be paid to patients with chest trauma who have no detected fractures on radiography.

Core Injuries Remote from the Pubic Symphysis

The core, or central musculoskeletal system of the torso, is essential for participating in sports and other physical activities. Core injuries are commonly encountered in athletes and active individuals. The importance of the midline pubic plate and rectus abdominis-adductor aponeurosis for core stability and function is discussed in the literature. This review article examines other important core injuries remote from the pubic symphysis, relevant clinical features, and preferred approaches to imaging. Several specific syndromes encountered in the core are reviewed. By protocoling imaging studies and identifying pathology, radiologists can add value to the clinical decision-making process and help guide therapeutic options.

Emergency Thoracic US: The Essentials

Acute thoracic symptoms are common among adults visiting emergency departments in the United States. Adults with these symptoms constitute a large burden on the overall resources used in the emergency department. The wide range of possible causes can make a definitive diagnosis challenging, even after clinical evaluation and initial laboratory testing. In addition to radiography and computed tomography, thoracic ultrasonography (US) is an alternative imaging modality that can be readily performed in real time at the patient's bedside to help diagnose many thoracic diseases manifesting acutely and in the trauma setting. Advantages of US include availability, relatively low cost, and lack of ionizing radiation. Emergency thoracic US consists of two main parts, lung and pleura US and focused cardiac US, which are closely related. Acoustic mismatches among aerated lungs, pleura, chest wall, and pathologic conditions produce artifacts useful for diagnosis of pneumothorax and pulmonary edema and help in detection of subpleural, pleural, and chest wall pathologic conditions such as pneumonia, pleural effusion, and fractures. Visual assessment of cardiac contractility and detection of right ventricular dilatation and pericardial effusion at focused cardiac US are critical in patients presenting with acute dyspnea and trauma. Additional US examinations of the inferior vena cava for noninvasive volume assessment and of the groin areas for detection of deep venous thrombosis are often performed at the same time. This multiorgan US approach can provide valuable information for emergency treatment of both traumatic and nontraumatic thoracic diseases involving the lungs, pleura, chest wall, heart, and vascular system. Online supplemental material is available for this article. (©)RSNA, 2016.

Chondral Rib Fractures in Professional American Football: Two Cases and Current Practice Patterns Among NFL Team Physicians

BACKGROUND

Although a recognized and discussed injury, chondral rib fractures in professional American football have not been previously reported in the literature. There currently exists no consensus on how to identify and treat these injuries or the expected return to play for the athlete.

PURPOSE

To present 2 cases of chondral rib injuries in the National Football League (NFL) and discuss the current practice patterns for management of these injuries among the NFL team physicians.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Two cases of NFL players with chondral rib injuries are presented. A survey regarding work-up and treatment of these injuries was completed by team physicians at the 2014 NFL Combine. Our experience in identifying and treating these injuries is presented in conjunction with a survey of NFL team physicians' experiences.

RESULTS

Two cases of rib chondral injuries were diagnosed by computed tomography (CT) and treated with rest and protective splinting. Return to play was 2 to 4 weeks. NFL Combine survey results show that NFL team physicians see a mean of 4 costal cartilage injuries per 5-year period, or approximately 1 case per year per team. Seventy percent of team physicians use CT scanning and 43% use magnetic resonance imaging for diagnosis of these injuries. An anesthetic block is used acutely in 57% and only electively in subsequent games by 39%.

CONCLUSION

A high index of suspicion is necessary to diagnose chondral rib injuries in American football. CT scan is most commonly used to confirm diagnosis. Return to play can take up to 2 to 4 weeks with a protective device, although anesthetic blocks can be used to potentially expedite return.

CLINICAL RELEVANCE

Chondral rib injuries are common among NFL football players, while there is no literature to support proper diagnosis and treatment of these injuries or expected duration of recovery. These injuries are likely common in other contact sports and levels of competition as well. Our series combined with NFL team physician survey results can aid team physicians in identifying these injuries, obtaining useful imaging, and counseling players and coaches and the expected time of recovery.

The effect of factors other than age upon skeletal age indicators in the adult

CONTEXT

Estimation of adult age from skeletal remains is problematic due to the weak and variable relationship between age indicators and age.

OBJECTIVES

To assess the proportion of variation in age indicators that is associated with factors other than age and to attempt to identify what those factors might be.

METHODS

The paper focuses on frequently used adult bony age markers. A literature search (principally using Web of Science) is conducted to assess the proportion of variation in age indicators associated with factors other than age. The biology of these age markers is discussed, as are factors other than age that might affect their expression.

RESULTS

Typically, ∼60% of variation in bony age indicators is associated with factors other than age. Factors including inherent metabolic propensity to form bone in soft tissue, vitamin D status, hormonal and reproductive factors, energy balance, biomechanical variables and genetic factors may be responsible for this variation, but empirical studies are few.

CONCLUSION

Most variation in adult skeletal age markers is due to factors other than age; dry bone study of historic documented skeletal collections and high resolution CT scanning in modern cadavers or living individuals is needed to identify these factors.

Pseudarthrosis of the cartilaginous part of the first rib is a common incidental finding on chest CT

PURPOSE

The cartilaginous parts of the first rib are usually articulating with sternal manubrium via a synchondrosis. With advancing age, there is progressive calcification of the rib cartilage. Pseudarthrosis of this calcified cartilage have been described in a study on anatomic specimen, but there are no systematically studies examining the anatomy of the cartilaginous parts of the first rib in vivo or using computed tomography (CT).

MATERIAL AND METHODS

A retrospective study of 60 chest CT scans of patients without history of trauma was performed and 120 first ribs were examined. In all patients, the grade of calcifications of the first rib was determined (no calcifications/some calcifications/severe and at least on one side contiguous calcification of the cartilage) and the presence of pseudarthrosis was noted.

RESULTS

Pseudarthrosis was found in 39/120 ribs (32.5%). The occurrence of pseudarthrosis was significantly more common in patients with severe calcifications (54%) in contrast to patients with no or minor calcifications (6.1%).

CONCLUSIONS

Pseudarthrosis of the first rib is a common finding in patients with severe calcifications. Radiologists should be aware of this frequent incidental finding, that should not be mistaken for pathology in CT imaging after trauma.

Sonography of occult rib and costal cartilage fractures: a case series

OBJECTIVE

The purpose of this case series is to describe the use of diagnostic ultrasound (US) in the detection of occult rib and costal cartilage fractures presenting as chest wall pain to a chiropractic clinic.

CLINICAL FEATURES

Three patients presented with chest wall pain and tenderness. Two of the patients presented with acute chest wall injury and 1 carried a previous diagnosis of rib fracture after trivial trauma 2 months earlier.

INTERVENTION AND OUTCOMES

Diagnostic US was selected as a non-ionizing imaging tool for these patients after negative digital radiography studies. All fractures were considered isolated as there was no associated injury, such as pneumothorax. Both of the acute cases were followed up to complete healing (evidence of osseous union) using US. All patients eventually achieved pain-free status.

CONCLUSION

In these cases, US was more sensitive than radiography for diagnosing these cases of acute rib and costal cartilage fractures. Early recognition of rib injury could avoid potential complications from local manipulative therapy.

Costal cartilage fractures and disruptions in a rugby football player

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 the literature and can have serious implications for the athlete's ability to return to play if the rib cage is destabilized.

Imaging of football injuries to the upper extremity

Imaging of football players is unique in many ways. Familiarity with mechanisms of injury, position of the player, and the need for rapid diagnosis and reporting will help radiologists when dealing with these athletes. Although plain radiographs are typically the first imaging modality used, MR imaging has become the cornerstone on which diagnoses and treatment decisions are based. As these athletes become stronger, faster, and more skilled, the ability to accurately assess their injuries becomes even more important, and understanding of the challenges that these patients present becomes critical.

Rib fracture: Different radiographic projections

Background:

Rib fracture is the most common thoracic injury. It is thought to be present in 10% of all traumatic injuries and in almost 40% of patients who sustained severe non-penetrating trauma. There are 12 pairs of ribs. This study reviews various methods of acquisition and reconstruction of radiographic images of traumatic rib fractures in order to determine the optimal views and to simplify rib fracture diagnostics.

Material/Methods:

Eight different plain radiography pictures of ribs were performed with the patient in an erect position. The following projections were obtained in sequence: oblique at 45° or 30° angle on inspiration, oblique at 45° or 30° angle on expiration as well as 45° and 39° projections during slow and fast breathing. All radiographic examinations were performed using a Philips three-phase scanner installed at the Al- Razi Hospital in Jenin, Palestine.

Results:

The results demonstrate that the 45° antero-posterior oblique projection performed on expiration is recommended for diagnostics and interpretation of traumatic rib fractures.

Conclusions:

Conclusion emerging from this study are such that for a 45° oblique view on expiration is recommended for radiographic imaging of patients with clinical signs of fracture, e.g. evaluation of lower rib fractures, while 45° oblique view during fast breathing is recommended for suspected upper rib fractures.

Diffusion-weighted whole-body imaging with background body signal suppression facilitates detection and evaluation of an anterior rib contusion

We report the magnetic resonance imaging (MRI) findings in a 29-year-old woman with anterior chest wall pain following blunt trauma, with special emphasis on the value of diffusion-weighted whole-body imaging with background body signal suppression (DWIBS). Although a rib contusion could be depicted at (fat-suppressed) T2-weighted MRI, anatomical localization and assessment of lesion extent were superior and more straightforward at DWIBS. Thus, this report shows the utility of adding DWIBS to an MRI protocol for anterior chest wall evaluation.

Evaluation by ultrasound of traumatic rib fractures missed by radiography

Rib fractures are the most common (25%) injuries resulting from blunt chest trauma, and are usually revealed on radiographs. Radiography sometimes cannot show fractures, especially those in costal cartilages, except for densely calcified ones. Several authors have recently investigated the role of ultrasound in the detection of rib fractures. We conducted this study to investigate possible rib fractures with ultrasound, determine those overlooked on chest x-ray, and analyze the possible clinical predictors of these insidious rib fractures in minor or mild blunt chest trauma. A total of 20 patients with minor mild blunt chest trauma were enrolled into this study. All radiographs were reviewed by two radiologists who noted rib fractures or other complications. Ultrasonography was performed in the radiology department using a linear transducer by one radiologist. The costal cartilage normally appears relatively hypoechoic compared with the osseous rib. Fractures of the rib, costochondral junction, and costal cartilage were denoted by a clear disruption of the anterior echogenic margin. A total of 20 patients with normal radiological findings, but continuing symptoms were evaluated by ultrasound. The most common etiology of trauma was a fall, as seen in 60% of the patients. None of the rib fractures were identified radiographically. Sonography detected 26 rib fractures in 18 of 20 subjects at presentation. Sonography reveals more fractures than radiography and will reveal fractures in most patients presenting with suspected rib fracture.

Isolated costal cartilage fracture: an unusual cause of an anterior chest mass in a toddler

A 17-month-old boy presented with a palpable anterior chest wall mass and was evaluated by chest radiography, sonography, and MRI. No history of trauma was provided initially. Sonography and MRI showed a costal cartilage fracture with overlying hematoma. Identification of a fracture isolated to the costal cartilage is rare and this is a unique case among children. In the appropriate clinical setting, costal cartilage fractures can be confirmed by sonography alone, and follow-up assessment can be based on clinical evaluation without the need for additional cross-sectional imaging.

Sonography for diagnosis of cervical ribs in children

OBJECTIVE

The purpose of this series was to describe the use of sonography for diagnosis of cervical ribs in children.

METHODS

Two children had hard nonmobile supraclavicular masses that were of clinical concern for malignancy. Both children were first evaluated by sonography.

RESULTS

Sonography showed each mass to be a tubular bony structure with a cartilaginous end. They were thought to represent cervical ribs. This anatomic variant was subsequently confirmed with radiography in 1 case and computed tomography in the other.

CONCLUSIONS

Musculoskeletal sonography may offer a reliable method for diagnosing cervical ribs without the need for ionizing radiation.