What could be causing a recent change in the appearance of my chest bone, possibly due to a previous trauma or condition affecting the shoulder region?

Evaluation of Recent Change in Chest Bone Appearance

Start with a chest radiograph as your initial imaging study to evaluate for specific causes of chest wall changes including fractures, infection, neoplasm, or structural deformities. 1

Initial Clinical Assessment

Look specifically for:

• Tenderness to palpation at the costochondral or sternoclavicular joints, which suggests costochondritis (the most common cause of nontraumatic chest wall pain, accounting for 42% of cases) 2, 3
• Visible swelling at a costochondral junction, which would indicate Tietze syndrome rather than simple costochondritis 2
• History of recent trauma (even minor, such as coughing), previous shoulder injury, or prior chest surgery that could explain structural changes 1
• Pain characteristics: stinging or pressing quality, retrosternal or left-sided location, reproducible with palpation 3
• Associated symptoms: fever (infection), weight loss (malignancy), or symptoms of spondyloarthritis 1, 2

Imaging Algorithm

First-Line Imaging

Obtain chest radiography in two planes as the mandatory first investigation for any suspected musculoskeletal pathology with visible changes or swelling 4. This will identify:

• Rib or sternal fractures (though sensitivity is limited for ≤3 rib fractures at initial presentation) 5
• Bone destruction suggesting malignancy 6
• Sternoclavicular or manubriosternal joint abnormalities 1
• Chest wall soft tissue changes 1

If Radiographs Are Normal But Concern Persists

Proceed to CT chest (with or without IV contrast) as the next appropriate study 1. CT is superior for:

• Detecting subtle fractures, particularly of ribs and sternum 7
• Evaluating bone destruction or periosteal reaction 1
• Characterizing chest wall masses and differentiating primary tumors from inflammatory conditions 2
• Assessing costochondral junction abnormalities 1

Important caveat: CT has limited reliability for determining chest wall invasion by tumors unless definite bone destruction is present 6. Tumor extension into soft tissue or fat planes between ribs is unreliable on CT alone.

When to Consider Advanced Imaging

MRI chest without IV contrast is appropriate when 1, 4:

• Malignancy cannot be excluded and you need detailed soft tissue characterization
• Evaluating extent of osseous involvement in infection or tumor
• CT findings are equivocal

Bone scintigraphy (whole body bone scan) should be considered if 1, 2:

• Known or suspected malignancy is present (complementary to CT)
• Multiple sites of involvement are suspected
• Undifferentiated costochondral pain persists despite normal radiographs

Ultrasound can be useful for 2, 8:

• Detecting costochondral abnormalities not visible on radiographs (higher sensitivity than CT for costochondral involvement)
• Guiding aspiration if fluid collection or abscess is suspected
• Evaluating soft tissue changes in real-time

Specific Clinical Scenarios

If Previous Trauma or Shoulder Injury

• Radiographs may miss up to 50% of rib fractures initially 5
• Consider CT if clinical suspicion is high despite normal radiographs 7
• Look for sternoclavicular joint subluxation or dislocation on imaging 8

If Prior Chest Surgery

• CT chest (with or without IV contrast) is the appropriate next study after radiographs 1
• Evaluate for hardware complications, osteomyelitis, or chronic infection 1
• MRI is challenging in this setting due to altered bone signal from prior surgery but remains sensitive for soft tissue and marrow edema 1

If Suspected Infection

• CT or MRI are both appropriate after normal radiographs 1
• Look for periosteal reaction, cortical erosions, soft tissue abscesses, or draining sinuses 1
• Consider image-guided aspiration for culture if fluid collection is identified 4

If Suspected Malignancy

• Bone scan and CT chest are both usually appropriate as complementary studies 1
• Critical: If tumor is suspected, refer to a specialized sarcoma center before biopsy 4
• Definite bone destruction on CT confirms chest wall involvement by malignancy 6

Common Pitfalls to Avoid

• Do not rely solely on initial chest radiographs for rib fractures or lung contusions—diagnostic accuracy improves significantly at 24 hours post-injury 5
• Do not assume CT findings of tumor extending into chest wall fat or between ribs indicate invasion—this is unreliable unless bone destruction is present 6
• Do not order FDG-PET/CT as initial imaging in patients without known malignancy—there is no evidence supporting this approach 1
• Do not dismiss costochondritis based on imaging alone—it is primarily a clinical diagnosis with tenderness to palpation as the hallmark finding 2, 3