Case

A 13 year old patient is brought into the emergency room complaining of intermittent pain immediately lateral to the left edge of their sternum. There is pain when taking a deep breath or when coughing. They heard a “popping/click” sound earlier in the day and have had pain ever since. Physical exam confirms the point of maximum discomfort is just lateral to the left sternum.

Question 1/2 - What is your differential diagnosis?

Click on your selected option(s) below  (correct = 1, over-thinking = 2+)

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Incorrect. The described location of the pain is not consistent with the angle of the rib, which is located posterolateral on the chest wall.

Incorrect. The head/neck of a rib is located immediately lateral to the vertebral column (where the ribs articulate) and not immediately lateral to the sternum.  

Correct! The location immediately lateral to the sternum is most consistent with the location of the costal cartilage. This may have fractured or dislocated (costochondral separation, where a rib is pulled out of the costal cartilage connecting it to the sternum). Either mechanism would cause pain immediately lateral to the sternum.

Unlikely. While hemorrhage could cause pain, the spread of blood through the mediastinum and pleural surfaces is likely to irritate those membranes and cause more generalized discomfort.

Incorrect. Flail chest has multiple fracture points detaching a panel of the thoracic cage. The break points are usually anterior and at the angle of the rib (posterolateral thorax), a location not consistent with described patient discomfort.