Absent posterior rib from heart surgery as an infant

Case contributed by Dr Matt Skalski

Presentation

Left shoulder pain.

Patient Data

Age: 25 years
Gender: Male

Borderline cardiomegaly and an azygos fissure.

Did you see the absent posterior T4 rib on the left? The first time this film was read it wasn't mentioned. 

Again noted is the absent posterior 4th rib on the left. Note how the rib appears to gradually taper and disappear as you move around posteriorly from the intact lateral and anterior aspect of the rib, which itself is hypoplastic. 

Although the absent rib wasn't first identified on the initial chest read, it was picked up on the shoulder study. Just one more example of why a good MSK shoulder read begins with the ribs. 

Case Discussion

A quote I will always remember from Dr. Deborah Forrester goes something like this: "The difference between a consultant and a resident is that when the resident is looking at the shoulder, the consultant is looking at the ribs." 

After recognising the absent posterior 4th rib on the shoulder x-ray, the patient's clinical notes were examined and there was documentation of a previous heart surgery when the patient was an infant. In this case, they removed the posterior 4th rib to gain access through the chest wall for the procedure, but left the periosteum intact. This is why there are wispy osseous elements trailing from the remnants of this rib.

This finding should not be mistaken for an aggressive pathology in the context of previous thoracic surgery in the region, which should be sought out in the patient's history to clarify the finding before hunting for a nonexistent pathology.  

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Case Information

rID: 29275
Case created: 14th May 2014
Last edited: 14th Mar 2016
Tag: rib
Inclusion in quiz mode: Included

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