Rib notching

Rib notching refers to deformation of the superior or inferior surface of the rib. It can affect a single rib (from trauma or solitary masses e.g. schwannoma) or can affect multiple ribs.

Differential diagnosis

The differentials differ according to whether it is the superior or inferior surface that is notched.

Superior rib notching

• abnormal osteoblastic activity
  • osteogenesis imperfecta
  • connective tissue diseases
    • rheumatoid arthritis
    • systemic lupus erythematosus (SLE)
    • Marfan syndrome
    • Sjogren syndrome
    • scleroderma ³
  • local pressure
• abnormal osteoclastic activity
  • hyperparathyroidism
• miscellaneous
  • neurofibromatosis type 1
  • restrictive lung disease
  • poliomyelitis
  • progeria
  • abnormal muscle pull

Inferior rib notching

• enlarged collateral vessels
  • coarctation of the aorta (Roesler sign)
  • interrupted aortic arch
  • subclavian artery obstruction
    • Takayasu disease
    • Blalock-Taussig shunt: involves only upper two rib spaces
  • arteriovenous malformation (AVM) of the chest wall
  • superior vena cava obstruction with enlarged venous collaterals
  • pulmonary AVM
  • tetralogy of Fallot ⁴
• neurogenic tumors
  • schwannoma (usually single)
  • neurofibromatosis type 1 (rarely can be superior if neurofibroma is very large)

Superior and inferior rib notching

• hyperparathyroidism
• neurofibromatosis type 1

History and etymology

Hugo Roesler (1899-1961) ⁸, an Austrian-American radiologist, was the first to describe the characteristic inferior rib notching of coarctation of the aorta, in 1928, hence Roesler sign ^5,6. Just over a century earlier, the German anatomist Johann Friedrich Meckel (the younger), (1781-1833) ⁷ recorded the presence of rib notching in coarctation on cadaveric studies in 1827 ⁵.