In a 54-year-old diabetic male with remote chest trauma presenting with persistent intermittent unilateral chest pain, what imaging and diagnostic studies are indicated and what is the most likely diagnosis?

Probable Diagnosis: Post-Traumatic Musculoskeletal Pain vs. Delayed Cardiac Contusion Sequelae

In a 54-year-old diabetic male with remote chest trauma and persistent intermittent unilateral chest pain, the most likely diagnosis is chronic musculoskeletal chest wall pain (costochondritis or rib/sternal injury sequelae), but given his diabetes and cardiac risk factors, you must first exclude delayed cardiac complications and acute coronary syndrome before attributing symptoms to benign causes.

Immediate Diagnostic Workup Required

First-Line Testing (Perform Immediately)

• 12-lead ECG to assess for ST-segment changes, T-wave inversions, Q waves indicating prior or ongoing ischemia, or low-voltage/electrical alternans that could suggest pericardial effusion 1
• Cardiac troponin levels to detect any myocardial injury, as elevated troponins may indicate cardiac contusion sequelae or unrecognized myocardial damage from the prior trauma 2, 3
• Chest radiograph to evaluate for:
  • Sternal fractures (best seen on lateral and sagittal reconstructions) 2
  • Rib fractures or callus formation at old fracture sites
  • Cardiomegaly or pulmonary edema 1
  • Pericardial effusion (though sensitivity is limited) 4

Critical Decision Point: ECG and Troponin Results

If ECG shows ischemic changes OR troponins are elevated:

• Immediate cardiology consultation and hospital admission 1
• Initiate aspirin therapy and consider sublingual nitroglycerin 1
• Proceed to transthoracic echocardiography (TTE) to assess:
  • Wall motion abnormalities suggesting cardiac contusion or ischemia 2, 3
  • Pericardial effusion or signs of tamponade physiology 2, 5
  • Valvular function and ejection fraction 2

If ECG and initial troponins are normal but symptoms persist:

• Proceed to stress testing within 72 hours to evaluate for inducible ischemia 1
• Consider CT chest with IV contrast as the imaging modality of choice for comprehensive evaluation of:
  • Sternal or rib fractures with associated soft tissue injury 2
  • Hemopericardium or pericardial thickening 2
  • Coronary artery calcification and anatomy 2
  • Chest wall hematoma or chronic inflammatory changes

Why Cardiac Evaluation Cannot Be Deferred

High-Risk Features Present

• Diabetes mellitus is a major cardiac risk factor that increases likelihood of atypical presentations of coronary disease 1, 6
• Remote chest trauma can cause delayed cardiac complications including:
  • Myocardial contusion with persistent dysfunction 3, 7
  • Pericardial inflammation or constrictive changes 2
  • Coronary artery dissection or thrombosis (rare but possible) 7
• Intermittent chest pain in a diabetic patient may represent anginal equivalents with atypical presentation 6

Cardiac Contusion Sequelae

• Blunt cardiac trauma can manifest with delayed arrhythmias, wall motion abnormalities, and persistent troponin elevation weeks to months after injury 7
• Echocardiography is the primary tool to identify myocardial dysfunction following trauma, showing regional wall motion abnormalities or reduced ejection fraction 3
• However, do not perform echocardiography for isolated sternal fractures if ECG and troponins are normal, as this represents low-risk injury 2, 3

Advanced Imaging: CT Chest Protocol

CT chest with IV contrast is the gold standard for evaluating remote chest trauma complications 2:

• Superior to plain radiography for detecting:

  • Sternal fractures with displacement or nonunion 2
  • Pericardial thickening (>3mm) suggesting chronic pericarditis 2
  • Hemopericardium or organized pericardial fluid collections 2
  • Coronary artery calcification and stenosis 2

• 3D reconstructions allow accurate assessment of chest wall deformities and fracture healing 2

• Contrast enhancement displays cardiovascular anatomy and can identify:

  • Active bleeding sources (unlikely in remote trauma but possible with pseudoaneurysm) 2
  • Pericardial enhancement suggesting inflammation 2

When to Use CT Without Contrast

• If patient has prior chest surgery or retained metal fragments, CT without contrast is preferred for accurate diagnosis 2
• Can identify hemopericardium by measuring attenuation (blood measures 40-60 Hounsfield units) 2

Musculoskeletal Diagnosis of Exclusion

Only after cardiac causes are excluded, consider:

• Costochondritis or Tietze syndrome (localized tenderness at costochondral junctions)
• Chronic rib or sternal fracture pain with callus formation
• Intercostal neuralgia from nerve injury during trauma
• Chest wall myofascial pain from muscle injury

Confirmatory Findings for Musculoskeletal Pain

• Pain reproduced by palpation of specific chest wall locations
• Pain worsens with movement, deep breathing, or coughing
• No radiation to arm, jaw, or back (unlike cardiac pain)
• Normal cardiac workup including ECG, troponins, and imaging 6

Critical Pitfalls to Avoid

• Do not attribute chest pain to anxiety or musculoskeletal causes without first excluding cardiac disease in a diabetic patient with trauma history 1, 6
• Do not rely on single troponin measurement; serial troponins may be needed if initial value is borderline 2
• Do not assume remote trauma is irrelevant; cardiac contusion can have delayed presentations with persistent dysfunction 7
• Do not perform bedside ultrasound alone if you lack competency in detecting subtle pericardial effusions or wall motion abnormalities; formal echocardiography is required 5

Disposition and Follow-Up

• If high-risk features present (abnormal ECG, elevated troponin, hemodynamic instability): Emergency department referral for immediate evaluation 1, 6
• If intermediate risk (normal initial workup but persistent symptoms): Urgent outpatient cardiac evaluation within 24-72 hours with stress testing 1, 6
• If low risk (normal cardiac workup, reproducible chest wall tenderness): Trial of NSAIDs for musculoskeletal pain with close follow-up 6