Uncommon findings on ultrasound.

Technical Query is a troubleshooting column that covers image acquisition and processing. This issue's column is edited by Krys Geissler, M.Ed., R.T.(R)(M). Ms. Geissler is a former radiography instructor at the University of Alabama at Birmingham.

Problem

A woman in her early 40s visited a breast center in January 2006 with a palpable lump in her right breast. The patient had a history of infiltrating ductal carcinoma in her right breast that was treated with a lumpectomy followed by radiation treatment. The new lump was tender to the touch and caused the patient considerable pain when she sneezed or coughed. She could not remember any injury to her chest and had not noticed any bruising or redness to the breast area.

Solution

A mammogram was ordered and was negative. Therefore, a breast ultrasound was recommended to rule out cystic structures or indications of other pathology. The ultrasound revealed nothing abnormal in the breast tissue, but an irregular contour was noticed on the underlying rib. (See Fig. 1.) Rib detail radiographs and a bone scan were recommended to rule out a focal bone lesion.

The bone scan demonstrated 3 areas of increased radioisotope uptake in the right lateral ribs, which is indicative of rib fracture. The plain films revealed nondisplaced fractures of the right third, fourth and fifth ribs.

The most common cause of rib fracture is blunt trauma to the chest. In special circumstances, rib fractures may occur without acute injury. Stress fractures of the ribs have been associated with repetitive motion of the upper extremities, as seen with rowing and golf. In elderly or chronically ill patients, rib fractures may occur with severe coughing or hard straining, resulting in stress fractures. Spontaneous pathologic rib fractures also may occur with severe metabolic disease, osteogenesis imperfecta and progressive metatstatic disease.

Thanks to Paula Gill, R.T.(R)(M), RDMS, at the Women's Comprehensive Breast Center at Charleston Area Medical Center, Charleston, WVa, for submitting this query.