Abnormal ribs

Published on 23/05/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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CHAPTER 9 Abnormal ribs

9.1 Rib fractures 144

9.2 Metastatic deposits 146

9.1 Rib fractures

Note how there is increased whiteness over the left side of the chest. On close inspection you can see that the posterior ribs have a step in their alignment – these are fractures affecting the 5th, 6th, 7th and 8th ribs.

Your examination of the chest X-ray is not completed until you have looked carefully at the ribs. They should be of a uniform density with smoothish, unbroken edges. The main abnormalities to look for are old and new fractures and metastases.

1. New fractures. Look along the edges of each rib. A new fracture will be seen as a break in the edge. Once you have spotted a fracture look for more information. Look at the position of the fracture. A fracture of any of the first three ribs is unusual and implies tremendous force. Look for other fractures. A line of fractures suggests a traumatic injury whereas fractures scattered throughout the ribs may suggest repeated injury (as in an alcoholic) or underlying bony weakness (as in malignant disease). Look at the density of the ribs and compare them in your mind to other X-rays you have seen. If the ribs are less white than usual this suggests underlying decrease in bone density. Finally look for the complications of rib fractures – surgical emphysema, pneumothorax and haemothorax. Remember also that damage to the lower three ribs may result in hepatic, splenic or renal injury.

2. Old fractures. Again look along the edges. The callus formation that follows a fracture will cause the rib to expand at this point. You need to look carefully – sometimes callus formation can simulate a lung mass.

Diagnosis of rib fractures

Rib fractures can be missed on a chest X-ray. The diagnosis is therefore clinical and the chest X-ray is usually performed to look for potential complications.

9.2 Metastatic deposits

Look carefully at this film. The lungs are overexpanded. Note the destruction of the posterior part of the cortex and the medulla of the right 5th rib with an associated ill-defined soft tissue mass (arrow). This is a lytic metastasis.

Metastatic lesions in the ribs will tend to look like dark holes. Scan the ribs carefully for evidence of metastasis. Secondaries start in the medulla and spread outwards with very little reaction around them so you are literally just looking for a dark hole. Sometimes the underlying lung markings create the impression of a metastasis in the overlying rib. If you spot a dark hole in the rib then look carefully at its edge. Compare the outline to the underlying lung markings. If they overlap then the metastasis may be deceptive. If you see bone metastases check carefully to see whether there is an associated fracture.

Look carefully at the other bones, which may contain similar pathology.

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