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OBJECTIVES The Haller index (HI) is widely utilized as a quantitative indicator to assess the extent of the pectus excavatum (PE) deformity, which is the most common chest wall abnormality in children. Both preoperative correction planning and postoperative follow-up need to be based on the standard of normal thoracic growth and development. However, there is currently no established reference range for the HI in children. Consequently, the goal of this study was to conduct a preliminary investigation of normal HI values among children to understand thoracic developmental characteristics. METHODS Chest computed tomography images obtained from January 2012 to March 2022 were randomly selected from the imaging system of the Children's Hospital of Chongqing Medical University. We divided the images of children into a total of 19 groups: aged 0–3 months (1 group), 4–12 months (1 group) and 1 year to 17 years (17 groups), with 50 males and 50 females, totaling 100 children in each group. HI was measured in the plane where the lowest point of the anterior thoracic wall was located and statistically analysed using SPSS 26.0 software. RESULTS A total of 1900 patients were included in the study. Our results showed that HI, transverse diameter and anterior-posterior diameter were positively correlated with age (P  <   0.05). Using age as the independent variable and HI as the dependent variable, the best-fit regression equations were HI-male = 2.047 * Age0.054(R2 = 0.276, P<0.0001) and HI-female = 2.045 * Age0.067(R2 = 0.398, P<0.0001). Males had significantly larger thoracic diameters than females, and there was little difference in the HI between the 2 sexes. CONCLUSIONS The HI rapidly increases during the neonatal period, slowly increases during infancy and stops increasing during puberty, with no significant differences between the sexes. [ABSTRACT FROM AUTHOR]

Septic arthritis of the sternoclavicular joint is a rare joint infection, and it sometimes leads to a chest wall abscess or mediastinitis. We report a case of a 70-year-old man who was diagnosed with empyema caused by an anterior chest wall abscess extended from septic arthritis of the sternoclavicular joint. It is very rare that arthritis causes empyema combined with an anterior chest wall abscess, and this is the first report of such a case. The patient was successfully treated with surgical drainage. [ABSTRACT FROM AUTHOR]

Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest. [ABSTRACT FROM AUTHOR]

Objectives: The study was designed to evaluate entheseal sites and anterior chest wall (ACW) of patients with ankylosing spondylitis (AS) using ultrasound (US) and investigate the correlation between disease activity and US score. Methods: This prospective cross‐sectional study included 104 patients with AS and 50 control subjects. Each patient underwent US scanning of 23 entheses and 11 sites of the ACW. The US features, including hypoechogenicity, thickness, erosion, calcification, bursitis, and Doppler signal, were evaluated. Disease activity was assessed based on C reactive protein (CRP), erythrocyte sedimentation rate (ESR), disease activity score‐C reactive protein (ASDAS‐CRP), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Results: The most commonly involved entheses on US were the Achilles tendon (AT) and quadriceps tendon (QT). The most involved site of ACW was the sternoclavicular joint (SCJ). Compared with the control group, significant differences were observed in the AS group in the rates of US enthesitis and ACW in AT (P =.01), SCJ (P =.00), and costochondral joint (CCJ) (P =.01). Patients with high or very high disease activity had a higher erosion score (P =.02). The erosion score was weakly positively associated with CRP, ESR, BASDAI, ASDAS‐CRP, and ASDAS‐ESR (correlation coefficient: 0.22–0.45). Conclusions: The most commonly involved entheseal sites on US were AT and QT, while the site of ACW was SCJ. The US assessment of AS should take the ACW into account. High disease activity might indicate erosion in AS. [ABSTRACT FROM AUTHOR]

Purpose: To report a rare variant muscle. Methods: Aberrant muscle was observed in the anterior chest wall musculature during routine cadaver prosection. Results: Musculus sternalis consisting of two muscular bellies united at an angle by an intermediate tendon was observed anterior to the pectoral major of the left side. The muscle did not have any bony attachment. Conclusions: The present case represents a hybrid muscle with superior belly derived from the prepectoral mass and inferior belly from ventral longitudinal muscle column. Clinically, the musculus sternalis may be misinterpreted as a pathological mass or lesion thus its accurate knowledge is significant to radiologists, angiologists and surgeons for better interpretation of mammographic images, safer interventions and for reconstructive surgeries. [ABSTRACT FROM AUTHOR]

Abstract Background The anterior chest wall (ACW) involvement is characteristic of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome, yet little research has focused on its magnetic resonance imaging (MRI) findings. Purpose To characterize the MRI features of the ACW in patients with SAPHO syndrome. Methods Seventy-one patients with SAPHO syndrome and ACW involvement evidenced by bone scintigraphy were recruited in this cross-sectional study. The ACW region was scanned using sagittal, axial, and oblique coronal Dixon T2-weighted sequences and axial Dixon T1-weighted sequences. The characteristics of both active inflammatory and chronic structural lesions were evaluated. Results The ACW lesions exhibited an asymmetrical distribution and a predilection for the sternocostoclavicular region (93.0%). Notably, 91.5% of the patients had lesions in the area of the anterior first ribs. Bone marrow edema (BME) was observed in 63 (88.7%) patients, which mainly affected the sternocostal joints (87.3%) and the manubrium sterni (84.5%). All of the BMEs were distributed under the articular surface or the bone cortex, consistent with the distribution of the ligaments and joint capsules. Synovitis was detected in 64 (90.1%) patients, with a predilection for the sternoclavicular joints (76.1%). A soft tissue mass or infiltration was found in all the patients who had bone marrow edema. Thirteen (18.3%) patients showed venous stenosis. Structural changes included bone bridge formation (80.3%), hyperostosis (43.7%), and fat infiltration (39.4%). Four common patterns of involvement were observed: the first rib area, the sternoclavicular area, the sternal angle area, and the areas of the second to sixth sternocostal joints. Conclusion The ACW lesions of SAPHO syndrome demonstrated a triad of enthesitis, synovitis, and osteitis, suggesting complex interactions among the ligaments, synovium, and bones in the region. The inflammatory changes in the first rib area were highlighted in SAPHO syndrome.

Introduction: To evaluate, factors associated with new ultrasonographic lesions of the anterior chest wall in spondyloarthritis (SpA) after a follow up of 5 years.Methods: SpA Patients included in 2013 in a first study were evaluated five years later. Ultrasound B mode and power Doppler examination of the two sternoclavicular joints and the manubrio-sternal joint were performed by the same two examinators at baseline and five years later. The presence of erosion, synovitis, ankylosis, power Doppler signal, joint effusion and joint space narrowing were assessed blind of the first evaluation.Results: Among the 131 patients at baseline, 58 patients were evaluated 5 years later. The mean age was 48.2±11.9 years old, with 86% of male and mainly an axial disease (78%). Patient characteristics are comparable to the original cohort. The most frequent lesions were ankylosis of the manubriosternal joint (38%) and erosions of the sternoclavicular joint (29%). 31 patients (53%) developed a new lesion of the ACW. There is a statistically significant association between new lesions of the ACW and higher ASDAS CRP (1,86±1,07 VS 3,0±2,17 P<0,01) and with CRP (5,34±7,85 VS 16,2±35, P=0,035) in the moment of the examination. There was no baseline factor associated with the structural progression.Conclusion: The occurrence of new lesions of the anterior chest wall is associated with a higher disease activity and a higher CRP at 5 years. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to describe the distribution of Anterior Chest Wall (ACW) arthropathies in a tertiary care center and identify clinical, biological and imaging findings to differentiate osteoarthritis (OA) from non-osteoarthritis (N-OA) etiologies., Methods: Search from medical records from January 2009 to April 2022, including patients with manubriosternal and/or sternoclavicular and/or sternocostal joint changes confirmed by ultrasonography, computed tomography or magnetic resonance imaging. The final study group was divided into OA and N-OA subgroups., Results: A total of 108 patients (34 males and 74 females, mean age: 47.3 ± 13 years) were included. Twenty patients had findings of OA, while 88 were diagnosed with N-OA pathologies. SpA was the most common etiology in the N-OA group (n = 75). The other N-OA etiologies were less common: rheumatoid arthritis (n = 4), Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome (n = 3), infectious arthritis (n = 3) and microcrystalline arthropathies (n = 3). Regarding the distinctive features, ACW pain was the inaugural manifestation in 50% of patients in OA group and 18.2% of patients in N-OA group (p = 0.003); high inflammatory biomarkers were more common in N-OA group (p = 0.033). Imaging findings significantly associated with OA included subchondral bone cysts (p < 0.001) and intra-articular vacuum phenomenon (p < 0.001), while the presence of erosions was significantly associated with N-OA arthropathies (p = 0.019). OA was independently predicted by the presence of subchondral bone cysts (p = 0.026)., Conclusion: ACW pain is a common but often underestimated complaint. Knowledge of the different non-traumatic pathologies and differentiation between OA and N-OA etiologies is fundamental for appropriate therapeutic management., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

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Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Anterior chest wall (ACW) inflammation is not an uncommon finding in patients with axial spondyloarthritis (ax-SpA) and reportedly occurs in 26% of these patients. Radiologists may only be familiar with spinal and peripheral joint imaging, possibly due to the inherent challenges of ACW imaging on some cross-sectional imaging modalities. Knowledge of relevant joint anatomy and the location of sites of inflammation allows the interpreting radiologist to better plan appropriate imaging tests and imaging planes. Accurate assessment of disease burden, sometimes in the absence of clinical findings, may alert the treating rheumatologist, allowing a better estimation of disease burden, increased accuracy of potential imaging scoring systems, and optimize assessment and response to treatment. This article reviews salient anatomy and various imaging modalities to optimize diagnosis, important differential diagnoses, and the interpretation of ACW imaging findings in ax-SpA. [ABSTRACT FROM AUTHOR]

Paradoxical reactions like immune reconstitution inflammatory syndrome (IRIS) as seen with patients on retroviral treatment in HIV infection, have also been identified in HIV sero-negative patients with extra pulmonary tuberculosis especially lymph-node tuberculosis. Musculoskeletal tuberculosis presenting as a cold abscess of the anterior chest wall is a rare entity which poses diagnostic and therapeutic challenge. A 35-year-old immunocompetent male came with complains of painless lump on right side of his chest over 9th and 10th intercostal space which gradually increased and extended upto 11th rib area. Clinically, diagnosis of cold abscess was made and antitubercular therapy (ATT) was started. Despite of being on ATT for 3 weeks, patient developed pain and signs of inflammation. Fluid was aspirated and sent for biochemical and microbiological investigations. The aspirated fluid was positive for acid fast bacilli by ZN stain and grew Mycobacterium tuberculosis in culture, sensitive to first line ATT. Pyogenic and fungal culture was negative. This case presented as an anterior chest wall cold abscess which deteriorated on initiation of first line ATT, thus creating a suspicion of resistance to ATT which was cleared on ATT susceptibility testing. Hence, this case underlines the possibility of treatment paradoxes seen in immunocompetent musculo-skeletal tuberculosis.

A 17-year-old female college student presented with recurrent abscess over the anterior chest wall since one and half year. Morganella morganii was isolated from the aspirated pus. Patient was started on oral ciprofloxacin and the lesion resolved in two weeks.

Necrotizing fasciitis is a potentially fatal soft tissue infection characterized by generalized necrosis and gas formation in the subcutaneous tissues and fascia. It is rarely seen in the head and neck area. This report presents the case of a 62-year-old diabetic female patient with generalized cervicofacial necrotizing fasciitis extending to the front chest wall. The cause of the disease was the extraction of the infected second molar tooth. Debridement was performed on the generalized necrotic fascia, subcutaneous tissue, and the skin extending from the preauricular area to the front chest wall and nipples. A series of debridement procedures were necessary because of generalized necrosis. The patient received intensive medical supportive treatment. Following the debridement procedures, the defective area from the neck to the front chest wall was closed up with split-thickness skin graft. Abscessed tooth extraction can lead to cervicofacial necrotizing fasciitis. Necrotizing fasciitis still remains as a potentially fatal disease. Early diagnosis, early radical surgical debridement, and a multidisciplinary approach constitute the significant factors in preventing mortality in such patients. Level of Evidence: Level V, therapeutic study [ABSTRACT FROM AUTHOR]

Résumé Les articulations sterno-claviculaires (SCC) sont probablement trop rarement examinées par les rhumatologues, alors qu’elles peuvent être d’une grande aide dans le raisonnement diagnostique. Leur situation anatomique, à l’interface entre le thorax et l’épaule, peut égarer l’analyse sémiologique. Toute douleur de l’épaule ou de la paroi thoracique antérieure doit faire rechercher une pathologie de l’articulation SCC, par la recherche d’une tuméfaction ou rougeur locale, et la pression sur l’articulation. L’imagerie (radiographie, scanner, IRM, scintigraphie, échographie) est parfois rendue difficile d’interprétation du fait des structures adjacentes et de la fréquence des anomalies non spécifiques de cette articulation. La richesse en enthèses de cette région en fait le lit des atteintes des spondyloarthrites, bien connues et démontrées. L’atteinte dans le SAPHO, impressionnante par l’hyperostose et l’ostéite caractéristique, ne doit pas faire négliger les atteintes plus discrètes rencontrées dans les spondylarthrites ankylosantes ou les rhumatismes psoriasiques. Cependant, d’autres atteintes inflammatoires sont possibles : les atteintes infectieuses, à pyogènes ou à germes atypiques ou à croissance lente, mais aussi, de manière plus rare, les atteintes dans le cadre de la polyarthrite rhumatoïde ou des arthrites microcristallines. Enfin, les atteintes arthrosiques sont fréquentes après 50 ans, mais rarement symptomatiques. Sternoclavicular joints (SCC) are probably too rarely considered by the rheumatologists. However, they can be of great help in the diagnostic reflection. Their anatomical location, between the chest and the shoulder joint, can mislead the semiology analysis. Every patient presenting with shoulder pain must have an examination of the SCC, by looking for local swelling or redness, and pressuring the joint. Imaging (X-rays, CT-scan, MRI, scintigraphy, ultrasonography) can be hard to interpret because of the adjacent structures and the frequency of non-specific abnormalities of this joint. There are lots of entheses in this region, which explains the frequent and demonstrated correlation of SCC pathology with spondyloarthritis. In SAPHO syndrome, hyperostosis and osteitis are very impressive. However, one must not neglect the more discreet SCC symptoms encountered in ankylosing spondylitis and psoriatic arthritis. Other inflammatory conditions are possible in the SCC: septic arthritis (by pyogenic or atypical germs), and more rarely, rheumatoid arthritis or microcrystalline arthritis. Finally, osteoarthritis of the SCC is common over the age of 50, but rarely symptomatic. [ABSTRACT FROM AUTHOR]

Résumé L’échographie ostéo-articulaire est un outil maintenant utilisé de manière courante en rhumatologie pour l’exploration des articulations périphériques. Les sondes hautes fréquences permettent d’étudier de manière fine tous les tissus du système musculo-squelettique ainsi que les structures neurologiques ou vasculaires adjacentes. De nombreuses pathologies pariétales sont sources de douleurs thoraciques et sont souvent mal connues des médecins. Le rhumatologue est en première ligne dans l’exploration de ces douleurs au vu de son expertise clinique. Cependant, il dispose de peu d’examens complémentaires permettant d’explorer de manière adéquate cette région soumise à beaucoup d’artefacts notamment liés aux mouvements. Dans cette mise au point, nous verrons dans un premier temps l’échoanatomie normale de la région thoracique antérieure. Nous verrons ensuite les principales applications actuelles de cette technique dans des domaines aussi divers que les pathologies inflammatoires, mécaniques, traumatiques ou tumorales. Cependant, au vu de la pauvreté de la littérature dans ce domaine, il sera nécessaire d’initier de nouvelles études afin de mieux cerner l’intérêt et la place que peut avoir l’échographie dans l’exploration des douleurs de la paroi thoracique antérieure. Ultrasonography is now widely used in rheumatology to explore pathological changes of peripheral joints. High frequency probes allow a precise study of the different structures of the musculoskeletal systems (tendons, muscles, ligaments) but also the surrounding nerves and vascular structures. Anterior thoracic pain can arise from pathological changes of the muscular, articular or bony part of the chest wall. These diseases are poorly known and frequently underdiagnosed. Few imaging modalities are currently available to explore this region. X-ray, CT scan and MRI have all shortcomings due to the superposition of the intra-thoracic organs (heart, lungs) and to the numerous artefacts induced by the chest movements. Ultrasound has several advantages that can be used to assess thoracic wall diseases. In this review, we will first describe the normal echoanatomy of the anterior thoracic chest wall. We will then discuss the current indications and strengths of this imaging modality in pathological conditions such as spondyloarthropathies, bone metastasis, traumatic or mechanical diseases. In view of the paucity of the literature on this subject, new studies will be needed to further confirm the usefulness of thoracic wall ultrasonography in the management of thoracic pain. [ABSTRACT FROM AUTHOR]

We here report the case of a 64-year old woman followed up for cirrhosis due to hepatitis C virus who didn't respond favorably to antiviral treatment. During her last follow-up visit, she reported the occurrence of painful anterior chest hump. Physical examination showed hard immobile mass at the level of the manubriosternal joint. The patient underwent sternoclavicular CT scan, which objectified expansive osteolytic lesion centered upon the sternal manubrium invading the soft tissues (A, B). The biopsy revealed malignant papillary epithelial tumor expressing pancytokeratin and CK7. Patient's profile suggested the presence of a metastasis from cholangiocarcinoma or osteophilic tumor. Gynecological examination, associated with mammogram and breast ultrasound, excluded a gynecological origin. The diagnosis of thyroid tumor was excluded on ultrasound. Chest CT scan showed multiple secondary pulmonary nodules. Abdominal angioscanner revealed the presence of a tissutal hepatic mass measuring 6 cm invading the portal bifurcation with portal vein thrombosis, suggesting hepatocellular carcinoma (HCC) (C). Given the discrepancy between anatomopathological data and morphological data, immunohistochemical study of the anti-Hep-Par-1 was performed, showing antibody expression on tumor cells. The diagnosis of manubriosternal metastasis from poorly differentiated hepatocellular carcinoma was retained. The patient was recommended to undergo chemotherapy. Bone metastases revealing HCC are exceptional. However, HCC should be suspected in patients with lytic bone lesion, especially in patients with chronic liver disease. Given its poor prognosis, treatment is based on palliative therapy with the aim of improving mainly the quality of life of patients. [ABSTRACT FROM AUTHOR]

Background The thoracoacromial artery perforator (TAAP) flap used in its pedicle or in the free microvascular variant is an emerging flap for use as a reconstructive option for the head and neck region. Patients and Methods Between 2006 and 2013, 17 patients with a mean age of 34 years (range, 17-59 years) underwent a TAAP flap procedure for reconstruction of postoncologic and posttraumatic head and neck defects. Results The pedicle TAAP flap was used to reconstruct neck (n = 5) and hypopharyngeal defects (n = 5); the free TAAP flap was used to resurface lower hemiface (n = 4), tongue (n = 1), and intraoral (n = 2) defects. The flap size ranged from 4.5 x 7 cm to 12 x 17 cm, with a mean thickness of 0.5 cm. The pectoralis major muscle was preserved in all of the cases. All of the patients healed uneventfully. The donor site was closed directly in four cases; a skin graft was used in four patients, and the donor site was covered by a local flap in one case. Conclusions Our experience proved the consistent feasibility of the successful use of the TAAP flap for head and neck reconstructions resulting in adequate color matching, texture, and pliability in combination with limited anterior chest wall donor site morbidity. Its hairless nature ensures that this flap is a suitable primary option for inner lining reconstruction of oropharyngeal defects. [ABSTRACT FROM AUTHOR]

Pectus excavatum (PE) is a relatively common deformity involving the anterior chest wall. It is represented clinically as a conical depression of the sternum and costal cartilages with the apex at the xiphoid process. Associated features and symptoms vary but generally involve respiratory and cardiac abnormalities. Since it's initial description, numerous surgical techniques have been developed to correct PE, with the Ravtich (open) and Nuss (minimally invasive) procedures being the most commonly employed. Although the etiology remains unclear, the pathogenesis of PE is currently thought to involve the overgrowth of the costochondral region of the ribs. In addition, documented case reports of familial pectus excavatum exist, suggesting a heritable form of the defect. Numerous genetic markers have also been discovered, linking PE to various genetic syndromes. [ABSTRACT FROM AUTHOR]

Sternocostoclavicular hyperostosis (SCCH) is a chronic inflammatory disorder which presents with erythema, swelling, and pain of the sternoclavicular joint. Approximately one half of patients have acne or pustular lesions with the best described association being with palmoplantar pustulosis (PPP). Extrasternal articular disease occurs in about a quarter of patients. The inflammatory process spans several years and has periods of exacerbation followed by remission. The histologic picture demonstrates a sterile osteomyelitis of the sternum and medial end of the clavicle. The diagnosis of SCCH is confirmed radiographically by hyperostosis and sclerosis of the sternum with involvement of the first rib on computed tomography (CT). The focal uptake of radiopharmaceutical on bone scintigraphy called the ‘bullhead’ sign is highly sensitive of SCCH. Treatment is aimed at easing pain and modifying the inflammatory process. Evidence over the last two decades suggests a role for intravenous bisphosphonates and tumor necrosis factor alpha inhibitors. A low level of awareness of SCCH often leads to a delay in diagnosis. This translates into significant morbidity and brings a psychological burden. Untreated chronic inflammation of the sternoclavicular joint leads to restricted mobility and secondary degenerative joint changes. In the search for a diagnosis, patients often undergo multiple serologic and imaging studies and in the experience of the author are referred to multiple specialists before a correct diagnosis is made. Greater awareness of SCCH is needed to prevent the irreversible physical and psychological impairments associated with the disease. [ABSTRACT FROM PUBLISHER]

Necrotizing soft tissue infections are uncommon, seen most frequently in immune-compromised patients. The infections occur most frequently along the lower aspects of the body, such as the legs, perineum, and lower abdomen. It is extremely uncommon for necrotizing fasciitis to occur along the chest wall, with only a few of such cases have been reported. We discuss a case of anterior chest wall necrotizing fasciitis that involves the areola and infra axillary region with their successful management. [ABSTRACT FROM AUTHOR]

Résumé La paroi thoracique antérieure est fréquemment touchée au cours de la spondyloarthrite (de 25 à 44 % des cas selon les séries) et de façon encore plus nette au cours du syndrome SAPHO (plus de 2/3 des cas). La symptomatologie clinique est faite de douleurs spontanées ou à la pression, et peu corrélée aux constatations d’imagerie. Dans la polyarthrite rhumatoïde, l’atteinte est plus rare. L’atteinte de la symphyse pubienne est rarement au premier plan dans les rhumatismes inflammatoires et se manifeste alors par des douleurs abdominales basses ou une gêne à la marche. Involvement of the anterior chest wall is frequent in spondyloarthritis (25 to 44% of the cases in the series of the literature), and even more frequent in SAPHO syndrome (over 2/3 of the patients). Clinical expression is made by spontaneous or pressure related pain, and poorly correlated with imaging findings. This involvement is less frequent in rheumatoid arthritis. Involvement of the symphysis pubis is rarely the main symptom during chronic arthritis, and is then revealed by abdomino-pelvic pain or walking impairment. [ABSTRACT FROM AUTHOR]

The objective of this report is to provide a description of diagnostically significant scintigraphically recognizable sites and patterns of acquired hyperostosis syndrome (AHYS) on the anterior chest wall (ACW), which is involved in 82% of AHYS patients. In 49/90 of our own AHYS patients, planar bone scans of the ACW were performed with the gamma camera, applying an average of 650 MBq of 99mTc-phosphate complexes. In addition, 53 atraumatic patients with extrathoracic cancer were available for routine whole-body scintigraphy. None of these patients had increased uptake identifiable as metastasis clinically or by imaging modalities in either the ACW or the rest of the skeleton. The scintigraphic involvement of the various morphological ACW structures is described in AHYS. Moreover, attention is called to the diagnostic significance of focal hyperactivities at the anterior end of the 2nd – 8th rib of adults, which are in the 5th place with respect to their frequency in AHYS. The diagnostic significance of sternocostal-joint involvement in AHYS can likewise be recognized by bonescan scintigraphy and will be discussed. Bone scintigraphy is more sensitive than radiomorphological imaging in AHYS. This, however, only applies under three conditions. 1. The increased radiotracer uptake in the upper sternocostoclavicular region must be assessed on both the anterior and the posterior view of the ACW scan. 2. In addition to the anterior view of the routine scintiscan, further anterior scans with reduced scan time of the gamma camera are usually necessary. This ensures better visibility of the involvement of certain morphological structures that are important for AHYS diagnosis. Moreover, a statement can be made about the inflammatory ossifying activity/inactivity of the AHYS on ACW. 3. Increased radionuclide uptake in the manubrium sterni and corpus sterni on the anterior scan should be verified by additional lateral or oblique scans of the thorax (sternum). [ABSTRACT FROM AUTHOR]

Lipoma is one of the most common mesenchymal tumors, usually seen over the trunk and proximal portions of the extremities. However, giant lipoma are very rarely seen over the chest wall and axilla in children. In rural areas, patients usually do not bother to be treated, which leads to complications, as seen in our case. Here, we report a rare case of a three-year-old child who presented with a large swelling on the right side of the anterior chest wall and in the axillary region. On histopathology, the diagnosis was lipoma. At the six-month follow-up, the child was normal without any complications. The clinical features, radiological and pathological findings and management of the lesion are discussed. If such a large tumor is not treated in a timely manner, it can cause respiratory discomfort or lead to malignancy. [ABSTRACT FROM AUTHOR]

Introduction: A majority of odontogenic infections can be successfully managed with routine incision and drainage and empirical antibiotics. Sometimes an odontogenic infection may spread to contiguous spaces and descend along the neck causing significant morbidity and rarely even mortality. Case report: We report a case of an odontogenic infection which had an unusual spread to the anterior chest wall. [ABSTRACT FROM AUTHOR]

Musculoskeletal tuberculosis (MT) occurs in 1-3% of patients with tuberculosis, while MT of the chest wall constitutes 1% to 5% of all cases of musculoskeletal MT. They are most frequently found at the margins of the sternum and along the rib shafts. Computed tomography is a useful tool for investigation in the diagnosis of abscess and in determining the extent of an abscess. Antituberculous chemotherapy and surgical excision should be started immediately after the appropriate microbiological and histological samples have been obtained if the clinical suspicion is high. We presented our experience with a 49-year-old woman who had musculoskeletal tuberculosis at the anterior chest wall together with a review of the literature on this subject. [ABSTRACT FROM AUTHOR]

Paradoxical reactions like immune reconstitution inflammatory syndrome (IRIS) as seen with patients on retroviral treatment in HIV infection, have also been identified in HIV sero-negative patients with extra pulmonary tuberculosis especially lymph-node tuberculosis. Musculoskeletal tuberculosis presenting as a cold abscess of the anterior chest wall is a rare entity which poses diagnostic and therapeutic challenge. A 35-year-old immunocompetent male came with complains of painless lump on right side of his chest over 9th and 10th intercostal space which gradually increased and extended upto 11th rib area. Clinically, diagnosis of cold abscess was made and anti-tubercular therapy (ATT) was started. Despite of being on ATT for 3 weeks, patient developed pain and signs of inflammation. Fluid was aspirated and sent for biochemical and microbiological investigations. The aspirated fluid was positive for acid fast bacilli by ZN stain and grew Mycobacterium tuberculosis in culture, sensitive to first line ATT. Pyogenic and fungal culture was negative. This case presented as an anterior chest wall cold abscess which deteriorated on initiation of first line ATT, thus creating a suspicion of resistance to ATT which was cleared on ATT susceptibility testing. Hence, this case underlines the possibility of treatment paradoxes seen in immunocompetent musculo-skeletal tuberculosis. [ABSTRACT FROM AUTHOR]

Background: Combinations of sternal and spinal fractures often occur due to high velocity accidents and are associated with a high incidence of concomitant injuries. The anterior thoracic wall is described as the fourth column of torso stability, which is why sternovertebral injuries (SVI) present a high risk of sagittal deformation of the trunk, in particular injuries of the thoracic spine. To date, no studies have been published on the frequency distribution of the involved vertebral bodies in large patient groups., Objectives: This study was intended to elaborate a frequency distribution of vertebral fractures accompanying sternal fractures (SF) and examine the risk of a vertebral fracture accompanying a SF., Material and Methods: A total of 48,193 cases with the main or secondary diagnosis of a SF and 897,963 cases with vertebral fractures based on routine data of German hospitals from the years 2005-2012 were evaluated. A concomitant injury to the spinal column was examined for each vertebral body and then evaluated statistically., Results and Conclusions: Of all patients with a SF 30.96% also suffered from a vertebral fracture. Of these 3.11% were SF as the main diagnosis and 60.89% the secondary diagnosis. While vertebral fractures generally occurred most frequently in the region of the thoracolumbar transition and the second cervical vertebral body, the SVI showed a further frequency peak in the range from the lower cervical spine to the middle thoracic spine. The present study was able to show a frequency distribution of accompanying vertebral body injuries in a large and representative collective in the case of SF for the first time.

Background: Sternum fractures are mostly located on the sternal corpus, seldom on the manubrium. Fractures of the sternal manubrium are, however, more frequently associated with severe concomitant injuries of thoracic organs, and therefore deserve special attention. In addition, in its function as a capstone in between the anterior chest wall and the shoulder girdle, it is exposed to a multiplicity of forces. Therefore the questions arise what types of fractures are observed in today's clinical practice, how to classify them and which treatment options are available. This study reports on different types of fractures which involve the manubrium sterni., Methods: Between January 2012 and October 2014, data was collected from all severely injured patients (ISS ≥16), which received a CT scan of the thorax in our Level-I-Trauma Center and retrospectively analyzed concerning sternal fractures. Fracture type, collateral injuries, age, and information about the circumstances of the accident were noted., Results: Of 890 evaluable patients, 154 (17.3%) had a fracture of the sternum and 23 (2.6%) of the manubrium. Fractures of the manubrium appeared in following types: A-type-transverse fracture (n=11) in 1st intercostal space by direct blunt trauma or flexion of the torso with sagittal instability; B-type-oblique fracture (n=9) by seat belt injury with rotatory instability; C-type-combined, more fragmentary fracture (n=3) by direct blunt trauma with simultaneous flexion of the torso and multi directional instability. Fractures only little dislocation were treated conservatively, and unstable fractures were surgically stabilized (n=10)., Conclusions: In summary, three main types of fractures could be found. A-type fractures were stabilized with a longitudinal plate osteosynthesis and B-type fractures with transverse positioned plates. To treat complex C-type fractures, plates with a T- or H-form could be a good solution. Level of evidence: Level III retrospective prognostic cohort study., Competing Interests: Conflicts of Interest: S Schulz-Drost is a member of the AO Thoracic Expert Group (THEG) and has a consultant agreement with DePuySynthes. The other authors have no conflicts of interest to declare.

We here report the case of a 64-year old woman followed up for cirrhosis due to hepatitis C virus who didn't respond favorably to antiviral treatment. During her last follow-up visit, she reported the occurrence of painful anterior chest hump. Physical examination showed hard immobile mass at the level of the manubriosternal joint. The patient underwent sternoclavicular CT scan, which objectified expansive osteolytic lesion centered upon the sternal manubrium invading the soft tissues (A, B). The biopsy revealed malignant papillary epithelial tumor expressing pancytokeratin and CK7. Patient's profile suggested the presence of a metastasis from cholangiocarcinoma or osteophilic tumor. Gynecological examination, associated with mammogram and breast ultrasound, excluded a gynecological origin. The diagnosis of thyroid tumor was excluded on ultrasound. Chest CT scan showed multiple secondary pulmonary nodules. Abdominal angioscanner revealed the presence of a tissutal hepatic mass measuring 6 cm invading the portal bifurcation with portal vein thrombosis, suggesting hepatocellular carcinoma (HCC) (C). Given the discrepancy between anatomopathological data and morphological data, immunohistochemical study of the anti-Hep-Par-1 was performed, showing antibody expression on tumor cells. The diagnosis of manubriosternal metastasis from poorly differentiated hepatocellular carcinoma was retained. The patient was recommended to undergo chemotherapy. Bone metastases revealing HCC are exceptional. However, HCC should be suspected in patients with lytic bone lesion, especially in patients with chronic liver disease. Given its poor prognosis, treatment is based on palliative therapy with the aim of improving mainly the quality of life of patients.

We herein report a rare case of a 66-year-old woman who had synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome with marked sternal osteitis and bilateral pleural effusions. SAPHO syndrome was diagnosed based on the characteristic features of a hyperostotic sternum and thoracic spine. The inflammatory changes of sternal osteitis and involvement of the adjacent soft tissue were assumed to be the cause of the pleural effusions. The effusions decreased during the natural course of the disease and resolved after methotrexate therapy. The pain dramatically decreased with oral tramadol. Physicians should consider the possibility of SAPHO syndrome in patients with anterior chest pain and pleural effusions.

Tuberculous ulcer of the anterior chest wall as a result of direct extension from underlying pleural and pulmonary tuberculosis is a very rare entity. Its clinical presentation may resemble a tumor or abscess. Isolated chest wall tuberculous ulcer without bone involvement is even rarer. An illustrated case report is presented., (Copyright © 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Objective: To determine the prevalence and type of ultrasonographic (US) lesions of the anterior chest wall (ACW) in cases of spondyloarthritis (SpA)., Methods: This monocentric, prospective, and controlled study included patients consulting for SpA (Assessment of Spondyloarthritis International Society criteria) and control subjects. Clinical (pain and swelling) and US assessments (synovitis, joint effusion, erosion, ankylosis, margin narrowing, or Doppler signal) were performed on the sternoclavicular (SCJ) and the manubriosternal (MSJ) joints. The main characteristics of SpA were recorded [disease duration, biologic features, Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), radiographic and extraarticular involvement]., Results: The study included 131 patients with SpA and 49 control subjects (same age and sex ratio). Clinical and US involvement of ACW were found in, respectively, 39% and 35.5% of SpA and in 12% and 14.3% of controls (p < 0.01). US highlighted erosions (34 vs 0), margin narrowing (12 vs 0), power Doppler activity (18 vs 2; p < 0.05), and ankylosis of the MSJ (24 vs 3). US involvement was associated with disease duration (14.9 vs 11.1 years; p = 0.04), age (45 vs 41 years; p = 0.004), radiographic change of sacroiliac joint (p = 0.05), and presence of inflammatory bowel disease (IBD; p = 0.03). No associations were found with HLA-B27, psoriasis, enthesitis, uveitis, or clinical involvement of ACW. Clinical involvement is associated with a higher BASDAI (47 vs 32; p = 0.0009) and ASDAS (2.9 vs 2.2; p = 0.006)., Conclusion: US involvement of ACW is frequent in SpA (36.5%), mainly with erosion of SCJ and ankylosis of MSJ. It is associated with disease duration, radiographic sacroiliitis, and IBD.

Objective: To determine the prevalence of anterior chest wall (ACW) pain in patients with recent inflammatory back pain (IBP) suggestive of spondyloarthritis (SpA), and to investigate the influence of ACW pain on the overall features of these patients., Methods: The DESIR cohort is a prospective, multicenter French cohort of patients with early IBP suggestive of SpA, including 708 patients (mean age 33.8 yrs, 53.8% females, 57.3% HLA-B27-positive). ACW pain was defined by at least 1 episode of chest wall pain attributed to SpA by the rheumatologist, after ruling out other causes of chest pain. Data on the baseline demographic characteristics, functional status and quality of life, imaging features, bone mineral density, and blood tests were compared in patients with and those without ACW pain. Factors associated with ACW pain were identified by univariate and multivariate analysis (logistic regression)., Results: The prevalence of ACW pain in the DESIR cohort (n = 316/708 patients) was 44.6% (95% CI 40.9-48.3). ACW pain occurred after the first symptoms of IBP in 62%. Localization was diffuse in 41% of the positive cases. A stepwise multivariate analysis found an association between ACW pain and the enthesitis score, involvement of thoracic spine, diagnosis of ankylosing spondylitis (AS), and radiographic abnormalities of sacroiliac joints., Conclusion: In recent IBP suggestive of SpA, presence of ACW pain is associated with enthesitis, thoracic spine involvement, radiographic sacroiliitis, diagnosis of AS, and with a more severe disease. ACW pain could be interpreted as a diagnostic feature for AS.

Background: Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap., Methods: A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels., Results: THE PERFORATORS THROUGH THE PM MUSCLE TO THE OVERLYING SKIN INCLUDED THREE REGIONAL GROUPS: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery., Discussion: The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.