Infant who had been abused

Gross pathological image of posterior rib fractures in child abuse — CXR (above) and complete skeletal survey showed no evidence of rib fractures. Gross pathological image (below) shows callus formation along the posterior aspect of the left 4th-8th ribs.

The diagnosis was left 4th-8th chronic posterior rib fractures which were not detected on the skeletal survey in a child abuse patient.

Infant with swollen right leg

Radiograph of femur fracture in child abuse — AP radiograph of the right femur shows a lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the right 7th and 9th ribs laterally, the right 7th-9th ribs posteriorly, the left 3rd-7th ribs laterally and the left 8th rib posteriorly.

The diagnosis was an acute displaced fracture of the right femur and chronic rib fractures of the right 7th and 9th ribs laterally, the right 7th-9th ribs posteriorly, the left 3rd-7th ribs laterally and the left 8th rib posteriorly in a child abuse patient.

Infant with right hip pain

Radiograph of femur fracture in child abuse — AP and lateral radiographs of the right femur (above) show a linear lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the lateral aspect of the right 5th-6th ribs.

The diagnosis was an acute nondisplaced fracture of the right femur and chronic right 5th-6th lateral rib fractures in a child abuse patient.

Infant who has been shaken

Radiograph of metaphyseal spur — AP and lateral radiographs of the right knee shows a spur along the lateral aspect of the metaphysis which was proven at autopsy to be a spur and not a fracture.

The diagnosis was a metaphyseal spur proven at autopsy in a child abuse patient.

Infant who has been shaken

Radiograph of classic metaphyseal lesion / bucket handle fracture / corner fracture of the tibia in child abuse — AP radiograph of the right tibia and fibula (left) shows a faint bucket handle irregularity of the distal tibial metaphysis. Lateral radiograph of the right tibia and fibula (right) shows anterior and posterior corner irregularities of the distal tibia metaphysis.

The diagnosis was a classic metaphyseal lesion (bucket handle fracture / corner fracture) of the distal right tibia in a child abuse patient.

Infant with leg pain

Radiograph of classic metaphyseal lesion / bucket handle fracture of the femur and tibia in child abuse — AP radiograph of the lower extremities shows bucket handle irregularities of the metaphyses of the bilateral distal femurs and bilateral proximal tibiae. There is also periosteal reaction of the distal left femur and bilateral tibiae.

The diagnosis was classic metaphyseal lesions (bucket handle fractures) of the bilateral distal femurs and bilateral proximal tibiae in a child abuse patient.

Infant with cough who had experienced a traumatic delivery 4 months ago

CXR of posterior rib fracture due to birth trauma — CXR AP shows clear lungs and an area of callus surrounding the right 7th rib posteriorly.

The diagnosis was chronic right 7th posterior rib fracture caused by a traumatic birth.

Febrile newborn who had a traumatic delivery due to shoulder dystocia 3 days ago

CXR of posterior rib fractures due to birth trauma — CXR AP shows lucent lines without surrounding periosteal reaction through the left 5th-7th ribs posteriorly.

The diagnosis was acute left 5th-7th posterior rib fractures caused by birth trauma.

Infant who fell out of bed

CXR of posterior rib fractures which were initially missed in child abuse — CXR AP (above) from initial skeletal survey was unremarkable. Repeat CXR AP (below) from follow-up skeletal survey 2 weeks later shows interval development of periosteal reaction around the left 8th-9th ribs posteriorly.

The diagnosis was healing left 8th-9th posterior rib fractures in a child abuse patient.

Infant with a large burn on the scalp

3D CT construction of anterior rib fractures in child abuse — 3D CT reconstruction with contrast of the chest shows callus formation around the right 4th-8th ribs and left 4th-9th ribs anteriorly.

The diagnosis was chronic right 4th-8th and chronic left 4-9th anterior rib fractures in a child abuse patient.

Infant with bruising

CXR of posterior rib fractures in child abuse — CXR AP shows lucent lines without surrounding periosteal reaction through the right 6th-8th and left 6th-11th ribs posteriorly.

The diagnosis was acute right 6th-8th and acute left 6th-11th posterior rib fractures in a child abuse patient.

Infant with respiratory distress

CXR of posterior rib fractures in child abuse — CXR AP shows poorly expanded but grossly clear lungs bilaterally. There is dense periosteal reaction / callus formation around the posterior aspect of the left 8th and 9th ribs.

The diagnosis was chronic left 8th-9th posterior rib fractures in a child abuse patient.

School ager with a rapidly enlarging soft tissue mass of the right chest and arm

CXR and CT of malignant peripheral nerve sheath tumor in neurofibromatosis type 1 — CXR PA and lateral shows a right apical thoracic mass with associated rib thinning that had rapidly increased in size in a short interval. Axial CT without contrast of the chest better defined the right apical mass and demonstrated multiple serpiginous nodules in the soft tissues of the right anterior chest wall.

The diagnosis was degeneration of a plexiform neurofibroma into a malignant peripheral nerve sheath tumor in a patient with neurofibromatosis type 1.

School ager with cafe-au-lait spots

CXR and CT of plexiform neurofibroma in neurofibromatois type 1 — CXR PA shows a large soft tissue mass in the apex of the right lung which causes thinning of the right 1st-5th ribs posteriorly. CT without contrast of the chest shows multiple small nodules throughout the soft tissues of the chest wall.

The diagnosis was multiple plexiform neurofibromas in a patient with neurofibromatosis type 1.

Newborn with a posterior left chest wall mass on prenatal ultrasound

MRI of lymphatic malformation of the chest wall — Axial T1 without contrast (top), T2 (middle) and T1 with contrast (bottom) MRI of the chest shows a mass composed of multiple large fluid-filled structures separated by thin septations which faintly enhance.

The diagnosis was lymphatic malformation.

Newborn with a large left chest wall deformity

CXR and CT of mesenchymal hamartoma of chest wall — CXR AP shows a large mass arising from the left 4th-6th ribs. Axial CT without contrast of the chest with soft tissue windows (right upper and middle) show the mass to have a fluid-fluid level within it superiorly while bone windows (right lower) show the mass to be calcified.

The diagnosis was mesenchymal hamartoma of the chest wall.

Young adult treated for leukemia as a preschooler, now with new palpable sternal mass

CT of epithelioid sarcoma with pulmonary metastases — Axial CT without contrast of the chest with soft tissue (above) and lung (below) windows shows a heterogeneous mass contiguous with the rectus muscles and anterior to the lower sternum which appears to be eroding into the sternum along with multiple peripheral pulmonary soft tissue nodules.

The diagnosis was epithelioid sarcoma with pulmonary metastases.

Teenager with right posterior chest wall pain and swelling for 2 years

CT of Ewing sarcoma of the rib — Axial CT with contrast of the chest shows a large heterogenous non-enhancing soft tissue mass centered around the posterior aspect of the right 11th rib. 3D CT reconstruction better demonstrates the lesion’s origin from the right 11th rib.

The diagnosis was Ewing sarcoma.

Young adult status post radiation therapy for sarcoma with an incidental finding on CXR

CXR and CT of osteochondroma of the rib — CXR PA shows a calcific density in the head of the left third rib. Contiguous images from an axial CT without contrast of the chest shows a bony outgrowth at the proximal aspect of the left third rib posteriorly.

The diagnosis was osteochondroma of the left third rib.

School ager with cystic fibrosis and a right chest wall mass

CXR of osteomyelitis of the rib — CXR PA and magnified view of the ribs (below) shows dense opacity in the right upper lobe and marked periosteal reaction of the right 4th rib posteriorly.

The diagnosis was botryomycosis (recurrent staphylococcus infection) resulting in osteomyelitis of the rib in a patient with cystic fibrosis.

School ager with a protuberant left chest wall

CXR and CT of pectus excavatum — CXR PA and lateral and axial CT without contrast of the chest shows marked depression of the sternum posteriorly leading to deformation of the chest wall.

The diagnosis was pectus excavatum.

Teen with a palpable anterior left chest wall mass

CXR and CT of rib fusion — CXR shows a contour irregularity of the left second rib anteriorly. 3D CT shows a pseudoarthrosis between the left first and second ribs.

The diagnosis was rib fusion / pseudoarthrosis of the left first and second ribs.

Teenager with left chest wall mass

CXR and CT of rhabdomyosarcoma of the chest wall — CXR PA and lateral (above) shows an ill defined left-sided pleural-based process. Axial CT without contrast of the chest (below) shows a mass arising from the muscles of the left chest wall which invades up into the pleural space and down into the abdomen, sparing the ribs.

The diagnosis was rhabdomyosarcoma.

Newborn with a large soft tissue mass on their back

US and CT of infantile fibrosarcoma — Sagittal US of the mass (above) revealed increased vascularity peripherally and central ulceration. Axial and sagittal CT with contrast of the chest (below) shows a mass arising near the right scapula of heterogenous density with variable enhancement.

The diagnosis was infantile fibrosarcoma.

Infant with torticollis and a right superior chest wall mass

CT and US of fibromatosis coli / torticollis tumor — Axial CT with contrast of the chest (above) shows asymmetry of the sternocleidomastoid muscles, right larger than left. Transverse US of the chest (middle) at the same level of the CT better shows the enlarged right sternocleidomastoid muscle. Sagittal US of the sternocleidomastoid muscles (bottom) shows the normal smooth contour of the left sternocleidomastoid muscle and the spindle shaped appearance of the right sternocleidomastoid muscle.

The diagnosis was fibromatosis colli.