Should I order a chest MRI with or without contrast for a patient with cartilage pain in the chest after a negative X-ray for rib fractures?

MRI for Costochondral Pain: Contrast Not Indicated

You should not order an MRI for this patient—neither with nor without contrast—as it is not the appropriate imaging modality for evaluating isolated costochondral or chest wall pain after negative radiography. 1

Why MRI Is Not Appropriate

The American College of Radiology (ACR) Appropriateness Criteria explicitly state there is no relevant literature to support the use of chest MRI in the primary evaluation of nontraumatic chest wall pain beyond specific post-surgical or oncologic contexts. 1 MRI chest is valuable only for:

• Post-treatment evaluation of chest wall neoplasms (where T1-weighted fat-suppressed sequences with gadolinium contrast are superior to CT for detecting residual/recurrent tumor) 1
• Determining etiology of rib fractures in patients with known malignancy 1
• Early detection of sternal wound infections (limited by susceptibility artifacts from sternotomy wires) 1

Your patient has none of these indications—she has isolated costochondral pain after trauma with negative X-ray.

What You Should Do Instead

First-Line Approach: Ultrasound

Point-of-care ultrasound is the appropriate next imaging step for this clinical scenario. 2, 3, 4, 5, 6

• Ultrasound detects costal cartilage fractures that are invisible on radiography and CT 5, 6
• Standard chest radiographs miss up to 50% of rib fractures and are particularly poor at detecting cartilage injuries 2
• In one study, 68.8% of patients with normal radiographs and CT had chondral rib fractures detected by ultrasound 5
• Ultrasound using a 7.5 MHz linear transducer can identify fractures by showing disruption of the anterior echogenic margin of the costal cartilage 6
• Dynamic ultrasound has 89% sensitivity and 100% specificity for detecting slipping rib syndrome 2

Clinical Pearls for Ultrasound Detection

• Costal cartilage appears relatively hypoechoic compared to osseous rib 6
• Fractures show clear disruption of the anterior echogenic margin 6
• Associated findings include subperiosteal hematoma (most common, 15% of cases) 5
• The technique is non-ionizing, readily available, and can be performed at point-of-care 3, 4

If Ultrasound Is Unavailable or Equivocal

CT chest without contrast would be the next consideration, but only if:

• There is concern for other pulmonary pathology 2
• High suspicion for occult fracture requiring definitive diagnosis 1
• Need to evaluate for complications like pneumothorax 2

CT is more sensitive than radiography for rib fractures (detecting anterior/posterior fractures better), but still has limitations for non-calcified cartilage. 1

Management Regardless of Imaging

While pursuing appropriate imaging:

• First-line analgesia: Regular acetaminophen 2
• Second-line: NSAIDs for severe pain (consider adverse events) 2
• Non-pharmacological measures: Immobilization, cold compresses 2
• Expected healing time: 6-8 weeks typically, though complete recovery may take up to 2 years for severe injuries 2

Critical Pitfall to Avoid

Do not order MRI with or without contrast for isolated chest wall/costochondral pain. This represents inappropriate resource utilization, unnecessary cost, and potential patient harm from gadolinium exposure without diagnostic benefit. 1 Gadolinium-based contrast agents carry risks including nephrogenic systemic fibrosis in patients with renal impairment and gadolinium retention in tissues even with normal renal function. 7