Pediatric Surgeon Consultation for Painful Sternal Swelling
A child with a painful bony swelling at the lower end of the sternum should be referred to a pediatric surgeon, as this specialist is explicitly recommended by the American Academy of Pediatrics for chest wall abnormalities in children, and all patients 5 years or younger requiring surgical evaluation must be managed by pediatric surgical specialists. 1
Primary Specialist Recommendation
Pediatric surgeon is the appropriate specialist for chest wall lesions and sternal abnormalities in children, as the American Academy of Pediatrics guidelines specify that pediatric surgeons manage chest wall reconstruction and thoracic wall conditions in the pediatric population. 1
For children 5 years or younger, pediatric surgeon consultation is mandatory according to AAP guidelines, regardless of the suspected diagnosis. 1
For children older than 5 years, pediatric surgeon referral remains strongly preferred given the complexity of differentiating benign from pathologic chest wall lesions. 1
Clinical Context and Differential Diagnosis
Painful sternal swellings in children represent a wide spectrum from benign anatomical variations to serious pathology, including anatomical variants (36% of cases), infectious processes (tuberculosis of sternum/ribs), and malignant tumors (osteochondroma, Ewing's sarcoma, primitive neuroectodermal tumor). 2
Transient benign swelling of the sternocostal region can occur in infants aged 9 months to 1 year 4 months, resolving spontaneously within weeks, though this diagnosis requires specialist evaluation to exclude serious pathology. 3
In tuberculosis-endemic areas, costal and sternal tuberculosis must be considered in undiagnosed bony lesions, making specialist evaluation particularly important. 2
Alternative Specialist Options
If a pediatric surgeon is not locally available, contact a pediatric surgeon at a regional pediatric surgical center to discuss whether transfer is necessary, as outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients. 1
Pediatric orthopedic surgeons who manage limb and skeletal malformations may be considered as an alternative, though pediatric surgeons remain the primary recommendation for chest wall pathology. 4
Diagnostic Approach
Plain chest radiograph is the initial imaging modality of choice for evaluating chest wall lesions in children. 2, 5
Chest CT scan is diagnostically useful when plain radiographs show bony involvement, pleural abnormalities, or thoracic deformities, or when tuberculosis or malignancy is suspected. 2
Life-threatening lesions are more likely to present with chest pain and dyspneic respirations, and plain radiographs typically show bony or pleural involvement in these cases. 2
Critical Pitfalls to Avoid
Avoid attempting treatment by a general surgeon without pediatric training, as mortality outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients. 1
Do not assume all sternal swellings are benign without specialist evaluation, as malignant tumors and infectious processes require prompt diagnosis and treatment. 2
Arbitrary age cutoffs should not be used without considering individual patient factors such as severity of symptoms, presence of systemic signs, and radiographic findings. 1