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Costal Cartilage Injuries - Radsource. Clinical History: A 2. MRI of the sternum was performed.
A (1. A) fat- suppressed T2- weighted coronal image and (1. B,C) fat- suppressed proton density- weighted axial images are provided. What are the findings? What is your diagnosis? Figure 1. Findings: Figure 2: The (2.
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A) fat- suppressed T2- weighted coronal image reveals a vertical fracture (arrow) involving the sternochondral junction of the left 1st rib. Sequential axial images through the area of injury reveal chondral separation (arrow) at the sternal attachment on the more cephalad slice (2. B). On the more inferior slice (2. C), the chondral fracture is redemonstrated and a triangular chondral fragment (arrowhead) remains firmly attached to the sternum. Soft- tissue edema compatible with contusion injury is also present (asterisks). Diagnosis. Acute fracture of the left medial 1st costal cartilage. Introduction. A wide variety of pathology may be seen at the ribs, including traumatic, neoplastic, infectious, and metabolic lesions.
Following trauma, rib fractures are often suspected, and typically are readily identified on plain radiographs. The clinical presentation of costal cartilage injuries, however, may be identical to that of rib fractures, but cartilage injuries are not detectable with radiographs unless considerable costal calcification is present. Computed tomography and ultrasound have been reported as effective in revealing costal cartilage fractures. MRI, with its superior soft tissue contrast and proven ability to evaluate cartilage elsewhere in the musculoskeletal system, would be expected to be the best modality for the evaluation of costal cartilage. However, this approach has received little attention, with only a single published series by Subhas et al. Anatomy and function.
The anatomy of the anterior ribs and costal cartilages is not widely recognized by many physicians. Because this region is infrequently imaged, many radiologists and even orthopaedic surgeons are surprised when visualizing the size of the costal cartilages at the anterior ribs. The anatomy is consistent.
The costal cartilage of the 1st rib attaches to the manubrium, and the 2nd through 7th rib costal cartilages attach to the sternal body. The costal cartilages become increasingly wide from the 1st through 7th ribs. The 8th through 1. The last two ribs have no direct or indirect sternal attachment. The costal cartilages are a protective shock absorber for trauma to the anterior chest. Their flexibility also allows the ribcage to expand during respiration.
A 3. D representation of the thorax demonstrates the normal anatomy of the costal cartilages. Illustration by Michael E. Stadnick, M. D. MRI technique and normal appearance.
MR imaging of costal cartilage can be challenging, as the ribs of course move with normal respiration. An effective technique in patients who can tolerate it is to position the patients prone using a spine or torso coil, which results in relatively less motion at the anterior chest. Generally acceptable results can be obtained with supine imaging as well, keeping imaging times relatively short, and when available, utilizing fast imaging techniques including breath- hold sequences. Another factor to remember is that because the chest contains the heart and great vessels, considerable pulsation artifact exists, and care must be taken to control the phase encoding direction, since pulsation artifact propagates in the phase encoding direction. As a result, axial images should be obtained with phase encoding right- left, and sagittal images with phase encoding superior- inferior, such that pulsation artifacts do not extend through the anterior chest wall (3). Figure 3: 3. A. A STIR axial image was performed with the phase encoding direction mistakenly set up as anterior- posterior. Although costal cartilage is visible (asterisks), it is suboptimally visualized, particularly on the left, as cardiac pulsation artifact propagates through the anterior chest wall.
In general, costal cartilage injuries are best evaluated with a combination of T1- weighted and fat- suppressed T2- weighted or STIR image contrast (4). Proton density fat- suppressed views are also effective for costal cartilage pathology. T1- weighted images reveal normal anatomy and are useful for marrow evaluation in ossified regions. The coronal plane tends to be the most effective though pathology can be confirmed with sagittal or axial views. Figure 4: 4. A. B. Costal cartilages of the 2nd and 3rd ribs bilaterally demonstrate normal low signal intensity on T1 and fat- suppressed T2- weighted coronal images.
MR Imaging of Costochondral Injury. Costal cartilage injuries are most common in younger patients, as significant trauma, frequently sports- related, is a typical etiology., In our practice at Radsource, the most frequent cause we see is a direct blow to the chest in American football players.
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