Can an orthopedic surgeon evaluate a child with a painful bony swelling at the xiphoid process?

Orthopedic Evaluation of Pediatric Xiphoid Swelling

A pediatric orthopedic surgeon can appropriately evaluate a child with painful bony swelling at the xiphoid process, as the American Academy of Pediatrics explicitly recommends pediatric orthopedic surgeons for infants with limb malformations and bone-related conditions. 1

Primary Specialist Recommendations

Pediatric orthopedic surgery is an appropriate referral for this case based on the following considerations:

• The AAP guidelines state that pediatric orthopedic surgeons should evaluate infants, children, and adolescents with bone or joint infections, significant spinal deformity, and malformations of skeletal structures 1
• Pediatric orthopedic surgeons have completed orthopedic residency plus an additional ACGME-approved 1-year fellowship in pediatric orthopedics, providing specialized training for pediatric bone pathology 1

Alternative Specialist Considerations

Pediatric plastic surgeons are also guideline-recommended specialists for chest wall abnormalities in children:

• The AAP explicitly recommends pediatric plastic surgeons for hand trauma and malformations in children, including bone, tendon, and skin abnormalities, and this expertise extends to other skeletal malformations 2
• For children requiring surgical care, particularly those 5 years or younger, pediatric surgical specialists are strongly preferred 2

Clinical Context for Xiphoid Lesions

Most palpable anterior chest wall lesions in asymptomatic children are benign anatomical variants:

• In a series of 27 children with palpable anterior chest wall lesions and normal radiographs, all cases were benign, including prominent ribs, tilted sternum, asymmetric costal cartilage, or small subcutaneous nodules 3
• However, 36% of pediatric patients studied for thoracic abnormalities had anatomical variations of the thoracic cage such as sternal tilting and costal cartilage convexities 4

Painful lesions warrant more aggressive evaluation:

• Children with life-threatening chest wall lesions are more likely to present with chest pain and dyspneic respirations 4
• In endemic tuberculosis areas, costal tuberculosis should be considered in undiagnosed bony lesions 4
• Osteochondromas, though rare, can present as painful chest wall masses and may require surgical excision 5

Diagnostic Approach

Initial imaging should begin with plain radiographs in two planes:

• Conventional radiographs should always be the first investigation for suspected bone lesions 1
• If malignancy cannot be excluded with certainty on radiographs, MRI of the whole compartment is the best modality for local staging 1

Cross-sectional imaging has limited yield for asymptomatic lesions:

• The low yield of CT or MRI for asymptomatic anterior chest wall "bumps" should be considered when making imaging decisions 3
• However, chest CT can be diagnostically useful for undiagnosed bony lesions, particularly in tuberculosis-endemic areas 4

Critical Pitfalls to Avoid

Do not delay referral to a specialized center if malignancy is suspected:

• All patients with suspected primary malignant bone tumors should be referred to a bone sarcoma reference center before biopsy 1
• Bone sarcomas are frequently difficult to recognize as malignant by clinicians, radiologists, and pathologists 1

Avoid attempting biopsy outside a specialized center:

• The biopsy of a suspected primary malignant bone tumor should be carried out at the reference center by the surgeon who will perform definitive treatment 1

Consider age-appropriate differential diagnosis:

• Before 5 years of age, a destructive bone lesion is most commonly metastatic neuroblastoma or eosinophilic granuloma; above 5 years, it is often a primary bone sarcoma 1