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Radiology Quiz Case 1: Diagnosis

Radiology Quiz Case 1: Diagnosis Diagnosis: First rib pseudarthrosis The computed tomogram showed that the hypoplastic first ribs were fused to the second ribs by means of an osseous projection from the second rib that formed a pseudojoint with the first rib. Rib anomalies are common, occurring in 1.4% of young men in a large series in which chest radiographs were studied in military recruits. Cervical ribs are the most commonly encountered abnormality, although estimates of their incidence vary widely, from 0.2% to 8%.1 They may produce thoracic outlet syndrome owing to pressure on the brachial plexus, subclavian artery, or subclavian vein,2 as well as a palpable mass in the supraclavicular fossa. Other congenital rib anomalies include forked ribs, hypoplastic ribs, and fused ribs. The first and second ribs are most likely to be congenitally fused. Pseudarthrosis is uncommon and reflects the development of an irregular jointlike fusion between 2 ribs. This deformity may be congenital or acquired. Congenital pseudarthrosis relates to a persistent defect between separate ossification centers, whereas acquired pseudarthrosis relates to a healed acute fracture or a healed stress fracture.3 Whether congenital or posttraumatic, pseudarthrosis appears as a lucent line through the midportion of a rib, with dense sclerotic borders, similar to a healing fracture. Previous descriptions of symptomatic pseudarthrosis are predominantly limited to case reports and case series. Pseudarthrosis of a cervical rib has been described in association with thoracic outlet syndrome.4 Pseudarthrosis of the first rib in adolescents has been described in overhead throwing athletes, with a hypothesized mechanism of chronic stress leading to a fatigue fracture.5 In a recent surgical series of neurogenic thoracic outlet syndrome related to rib anomalies, accrued over 26 years, anomalous first ribs were resected in 7 of 46 cases.2 Of these 7, only 2 involved the spontaneous development of symptoms; in the other 5 cases, the symptoms were related to automobile crashes. We report an unusual case of pseudarthrosis of a hypoplastic first rib that produced a palpable mass in the supraclavicular fossa. In this case, the abnormality was likely congenital, as the contralateral first rib was also hypoplastic and fused to the second rib and there was no history of trauma or repetitive stress. No immediate treatment was indicated, as the patient was otherwise asymptomatic. However, continued clinical follow-up was recommended, with consideration of surgery should the symptoms of thoracic outlet syndrome develop. Return to Quiz Case. References 1. Guttentag AR, Salwen JK. Keep your eyes on the ribs: the spectrum of normal variants and diseases that involve the ribs. Radiographics. 1999;19(5):1125-114210489169PubMedGoogle Scholar 2. Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg. 2002;36(1):51-5612096257PubMedGoogle ScholarCrossref 3. Brower AC, Woodlief RM. Pseudarthrosis at the first sternocostal synchondrosis. AJR Am J Roentgenol. 1980;135(6):1276-12776779540PubMedGoogle Scholar 4. Sabapathy SR, Venkatramani H, Bhardwaj P. Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome. J Hand Surg Am. 2010;35(12):2018-202121074954PubMedGoogle ScholarCrossref 5. Mithöfer K, Giza E. Pseudarthrosis of the first rib in the overhead athlete. Br J Sports Med. 2004;38(2):221-22215039264PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1: Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 138 (7) – Jul 1, 2012

Radiology Quiz Case 1: Diagnosis

Abstract

Diagnosis: First rib pseudarthrosis The computed tomogram showed that the hypoplastic first ribs were fused to the second ribs by means of an osseous projection from the second rib that formed a pseudojoint with the first rib. Rib anomalies are common, occurring in 1.4% of young men in a large series in which chest radiographs were studied in military recruits. Cervical ribs are the most commonly encountered abnormality, although estimates of their incidence vary widely, from 0.2% to 8%.1...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.138.7.684
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: First rib pseudarthrosis The computed tomogram showed that the hypoplastic first ribs were fused to the second ribs by means of an osseous projection from the second rib that formed a pseudojoint with the first rib. Rib anomalies are common, occurring in 1.4% of young men in a large series in which chest radiographs were studied in military recruits. Cervical ribs are the most commonly encountered abnormality, although estimates of their incidence vary widely, from 0.2% to 8%.1 They may produce thoracic outlet syndrome owing to pressure on the brachial plexus, subclavian artery, or subclavian vein,2 as well as a palpable mass in the supraclavicular fossa. Other congenital rib anomalies include forked ribs, hypoplastic ribs, and fused ribs. The first and second ribs are most likely to be congenitally fused. Pseudarthrosis is uncommon and reflects the development of an irregular jointlike fusion between 2 ribs. This deformity may be congenital or acquired. Congenital pseudarthrosis relates to a persistent defect between separate ossification centers, whereas acquired pseudarthrosis relates to a healed acute fracture or a healed stress fracture.3 Whether congenital or posttraumatic, pseudarthrosis appears as a lucent line through the midportion of a rib, with dense sclerotic borders, similar to a healing fracture. Previous descriptions of symptomatic pseudarthrosis are predominantly limited to case reports and case series. Pseudarthrosis of a cervical rib has been described in association with thoracic outlet syndrome.4 Pseudarthrosis of the first rib in adolescents has been described in overhead throwing athletes, with a hypothesized mechanism of chronic stress leading to a fatigue fracture.5 In a recent surgical series of neurogenic thoracic outlet syndrome related to rib anomalies, accrued over 26 years, anomalous first ribs were resected in 7 of 46 cases.2 Of these 7, only 2 involved the spontaneous development of symptoms; in the other 5 cases, the symptoms were related to automobile crashes. We report an unusual case of pseudarthrosis of a hypoplastic first rib that produced a palpable mass in the supraclavicular fossa. In this case, the abnormality was likely congenital, as the contralateral first rib was also hypoplastic and fused to the second rib and there was no history of trauma or repetitive stress. No immediate treatment was indicated, as the patient was otherwise asymptomatic. However, continued clinical follow-up was recommended, with consideration of surgery should the symptoms of thoracic outlet syndrome develop. Return to Quiz Case. References 1. Guttentag AR, Salwen JK. Keep your eyes on the ribs: the spectrum of normal variants and diseases that involve the ribs. Radiographics. 1999;19(5):1125-114210489169PubMedGoogle Scholar 2. Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg. 2002;36(1):51-5612096257PubMedGoogle ScholarCrossref 3. Brower AC, Woodlief RM. Pseudarthrosis at the first sternocostal synchondrosis. AJR Am J Roentgenol. 1980;135(6):1276-12776779540PubMedGoogle Scholar 4. Sabapathy SR, Venkatramani H, Bhardwaj P. Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome. J Hand Surg Am. 2010;35(12):2018-202121074954PubMedGoogle ScholarCrossref 5. Mithöfer K, Giza E. Pseudarthrosis of the first rib in the overhead athlete. Br J Sports Med. 2004;38(2):221-22215039264PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Jul 1, 2012

Keywords: diagnostic radiologic examination,radiology specialty

References