Chest Wall Lesion

DIFFERENTIAL DIAGNOSIS

Common

• Acute Rib Fracture
• Healing Rib Fracture
• Rib Metastases

Less Common

• Chest Wall Metastases
• Hematoma
• Lipoma
• Elastofibroma Dorsi
• Fibroma
• Carcinoma, Male Breast
• Gynecomastia
• Accessory Breast
• Prominent Xiphoid Process
• Prominent or Floating Rib
• Costochondritis
• Accessory Muscle
• Lymphatic Malformation
• Vascular Malformation
• Stress Rib Fracture
• Abscess
• Sternoclavicular Joint Arthropathy
• Thyroglossal Duct Cyst

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

• US is very useful for chest wall lesions as structures are superficial

Retroscapular region is only area not accessible
• For rib fractures, examine around painful area only
• Ask patient to place finger over most painful area

Caveat: US is less helpful in unconscious, uncooperative patients and young children
• No need to examine all ribs

Helpful Clues for Common Diagnoses

• Acute R ib Fracture

History of trauma with localized tenderness

Sharp break in superficial bone cortex

– ± displacement or angulation

– ± adjacent soft tissue swelling or hypoechoic hematoma

– Wide break in cortex or cortical irregularity suggests pathologic fracture

Typically, fractures are vertically aligned to each other

– Check adjacent ribs alongside rib fracture

US will detect 10x more rib fractures than radiography

– Also able to accurately detect fractures of costal cartilage or costochondral junction

US is more accurate than radiography at detecting pneumothorax

– Pneumothorax seen as loss of normal to-and-fro respiratory motion at pleural surface on real-time scanning over least dependent portion of hemithorax
• Healing R ib Fracture

Fracture margin is less sharp and more rounded

Progressive bridging callus

– Initially hypoechoic mass alongside fracture

– Progressive ossification of callus with ↑ echogenicity and ↑ acoustic shadowing

– After ~ 2 months, only ossified cortical bump remains without visible fracture line

– Cortical contour will take from months to years to remodel to normal

US can accurately discriminate between acute and nonacute rib fracture
• Rib Metastases

Common site of skeletal metastases

Lung, kidney, hepatocellular carcinoma, and bowel are all common primary sites

Usually multiple

– Randomly located as opposed to linear vertical location of rib fractures

Can be detected only if cortex is disrupted

– Metastases usually originate in medullary canal prior to infiltrating cortices

US has low sensitivity for detecting early rib metastases

If cortex disrupted, US accurate at distinguishing metastatic from traumatic fracture

Bone destruction

– Irregular thinning or loss of echogenic superficial cortex of rib

– ± soft tissue mass at site of bony destruction

Helpful Clues for Less Common Diagnoses

• Chest Wall Metastases

Feature of advanced malignancy

Muscle metastases relatively uncommon, possibly due to

– Destruction of tumor cells by muscle motion

– Muscle pH inhospitable to tumor cells

– Muscle limits accumulation of tumoral lactic acid that induces tumor neovascularity in other tissues
• Hematoma

Due to trauma, anticoagulation, strenuous and prolonged coughing, vascular malformation

Often within pectoralis or intercostal muscles

Mildly echogenic mass ± concentric layering liquefaction ± marginal hyperemia
• Lipoma

Similar appearances to lipoma elsewhere

Hypoechoic, well-defined soft tissue mass with fine echogenic striations
• Elastofibroma Do rsi

Uncommon; benign, slow-growing, connective tissue tumor

– Subscapular area (99%); more common in elderly and in females (60%); frequently bilateral

– More common in persons who perform manual labor

– Tumor composed of abnormal elastic fibers

– Generally regarded as fibroblastic reactive process or pseudotumor

Large, well-circumscribed tumor

Alternating bands of hypoechoic (fat) and hyperechoic (fibrous) tissue

Usually only minimal hyperemia

– Can occasionally be difficult to distinguish from surrounding muscle
• Fibroma

Hypoechoic subcutaneous nodule with well-defined or ill-defined border
• Carcinoma, M ale Breast

Multilobulated cystic pattern more common than mixed cystic-solid pattern

Ill-defined more common than well-defined margin

Mildly hypervascular, mainly peripheral
• Gynecomastia

Growth of glandular tissue in male breast

Pseudogynecomastia = ↑ fat in male breast

Most cases are idiopathic

Identifiable causes include

– Congenital anorchia, Klinefelter syndrome

– Hermaphroditism, adrenal carcinoma

– Liver disorders, drugs (spironolactone, cimetidine, estrogen derivatives)

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Tags: Diagnostic Ultrasound Musculoskeletal

Apr 9, 2020 | Posted by admin in MUSCULOSKELETAL IMAGING | Comments Off

DIFFERENTIAL DIAGNOSIS

Common

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

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Chest Wall Lesion

Chest Wall Lesion

Less Common

Helpful Clues for Common Diagnoses

Helpful Clues for Less Common Diagnoses

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Chest Wall Lesion

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