Original Report

Jacques Malghem1 Bruno C. Vande Berg Frederic E. Lecouvet Baudouin E. Maldague

Costal Cartilage Fractures as Revealed on CT and Sonography

OBJECTIVE. We describe the CT and sonographic appearance of 15 costal cartilage fractures observed in eight patients. CONCLUSION. On CT, fracture was seen as a low-density area through the costal cartilage, with surrounding calcications 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.

hest injuries are frequent. Bony rib fractures are usually revealed on radiographs [1], but radiography cannot show fractures occurring in costal cartilages, except for densely calcied cartilages [1]. 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.

Radiography and CT were available in all eight patients, and sonography in three.

Results

Materials and Methods

Fifteen costal cartilage fractures were diagnosed in eight patients (two women and six men), who were 19 52 years old (mean age, 32 years; median age, 27.5 years) between 1989 and 1999. Four patients were initially examined at our institution, and four were referred for advice or additional examination. Five patients had a denite history of recent chest wall injury. In the other three patients, practice of contact sports was noted in two, and a fall 3 months earlier in one. CT or sonography was performed because of severe posttraumatic parasternal pain unexplained by radiographic ndings, 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 aspecic hemorrhagic material.

Received May 11, 2000; accepted after revision July 12, 2000.
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All authors: Department of Radiology, University of Louvain, St. Luc University Hospital, Hippocrate Ave., 10, B-1200 Brussels, Belgium. Address correspondence to J. Malghem.

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0361803X/01/1762429 American Roentgen Ray Society

Six fractures involved the rst ribs; two, the second, third, and sixth ribs; and one, the fourth, seventh, and eighth ribs (Fig. 1). There were six right- and nine left-sided fractures. The fractures involved the chondrosternal (three lesions) or the chondrocostal (three lesions) junction for the rst rib lesions and the middle region of the costal cartilage for the other locations. In three patients, fractures of bony ribs were also seen. Four patients had multiple contiguous cartilage fractures (two patients with two lesions, one patient with three, and one patient with four). 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 ve (33%) of 15 lesions (Fig. 2A). Swelling of the neighboring soft tissues was seen in four lesions. Focal surrounding calcications were visible near three fractures on CT scans obtained several weeks after the presumed causal trauma (Figs. 3 and 4). In four fractures involving the chondrosternal or chondrocostal junction, ne linear lucencies with a gas density were present in the cartilaginous cleft (Fig. 5A).

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Fig. 1.Drawing shows location of costal cartilage fractures. Two main sites are chondrosternal and chondrocostal junctions of rst rib and middle part of cartilages of second to eighth ribs.

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).
Discussion

Costal cartilage fractures are not radiographically recognizable unless the fracture involves a strongly calcied cartilage. Generally, costal cartilages are not visible on radiographs, with the exception of irregular ossication foci that appear during adulthood [4]. However, costal carti-

lages are easily recognizable with CT or sonography. On CT, cartilage density is relatively uniform (70120 H) and of higher density than that of the overlying muscles and fat, but less dense than calcium [5]. On sonography, the cartilage is less echogenic than the adjacent muscle and is delineated by a thin echogenic anterior margin. Cartilages are oriented along a horizontal or oblique axis. They appear as a round, ovoid, or ribbonlike pattern depending on the perpendicular or parallel orientation of the imaging plane with respect to the cartilage axis. Sonography, usually available in every emergency department, offers the advantage of easy multiplanar scanning capability, which is also obtained with multiplanar reformatted images from thin CT slices (Fig. 3).

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 signicant 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, calcications surrounding the fracture sites were seen in three lesions examined several weeks after the presumed causal trauma. Milgram [7] also observed focal calcications 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 identied radiographically [1]. In a sonographic study of patients with suspected rib fracture, Grifth et al. [3] found that 11% of all fractures were located in the costal cartilage or at the chondrocostal junction.

Fig. 2.26-year-old man with multiple rib fractures after motor vehicle collision. A, CT scan reveals interruption (arrows) with break in continuity of third costal cartilage. Patient also had multiple other bony rib and costal cartilage fractures (not shown). B, Sonogram of third rib shows interruption and displacement of hyperechogenic line, corresponding to ventral aspect of costal cartilage (arrows).

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CT and Sonography of Costal Cartilage Fractures

Fig. 3.28-year-old man with painful left parasternal lump for 6 months. Patient reported no traumatic history but was drug addict and engaged in contact sports. A, Bone scan shows discrete area of increased uptake in left parasternal area (arrow ) at level of lump, and several other intense foci in extremities of subjacent ribs corresponding to fractures. B and C, Transverse CT (B) and sagittal oblique multiplanar reformatted CT (C) scans perpendicular to costal cartilage of left sixth rib show heterogeneous focal swelling, with peripheral calcications. D and E, Curved frontal multiplanar reformatted (D) and maximum-intensity-projection (E) images from sets of CT slices of anterior chest wall show that focal hypodensity and peripheral calcications correspond to transverse area perpendicular to costal cartilage.

Fig. 4.46-year-old man with history of overlooked thoracic trauma that occurred 3 months earlier during stay in intensive care unit. A and B, CT scans show swelling of soft tissue surrounding irregular costal cartilage with focal interruptions (thick arrow, A) and typical fracture angulations (thick arrow, B). Note peripheral calcications (thin arrows).

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
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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. 4).

Cartilage fractures in our series were located at the chondrocostal or chondrosternal junction for the rst 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 reects the true prevalence of these fractures that could result
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Fig. 5.19-year-old man who experienced sudden onset of left parasternal pain during gymnastic training on parallel bars. S = sternum. A, CT scan shows thin band of gas density (thick arrow ) within gap between cartilage of rst left rib (thin arrow ) and sternum. B, Sonogram (dual image) of same region as A shows small hyperechogenic area (thick arrow ) corresponding to gas accumulation between hypoechogenic cartilage (thin arrow ) and hyperechogenic line delineating anterior aspect of sternum.

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 Tietzes and Cyriaxs syndromes. Costochondritis and Tietzes syndromes are ill-dened disorders characterized by pain originating from the chondrocostal articulations of the second to fth ribs, with local swelling in Tietzes syndrome. Pathogenesis is unclear and could be of traumatic origin. Diagnosis of Tietzes syndrome is generally based on clinical ndings, although cartilage swelling may be visible on CT [5] or sonography [10]. However, no abnormal ndings were found either on CT or sonography in another series [11]. Cyriaxs 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 costocostal articulations. The diagnosis is also based on clinical ndings [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 difcult 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. Nol for the histologic analysis of the biopsied specimens; and Franoise Martin, Martine Millecan, Jocelyne Burion, and Anne Smith for editorial assistance.

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