Chest X-ray Abnormalities
Bone abnormalities

Key points

  • Bone abnormalities need to be searched for carefully
  • Chest radiography is not indicated for a suspected simple rib fracture
  • Malignant bone disease may manifest as either single or multiple lesions

Bones are the densest normal structures seen on a chest X-ray. Despite this, the power of the X-ray beam used is usually not optimised to view the bones, but rather to give greater detail to the lungs and soft tissues. For this reason abnormalities of the bones may not be obvious and so must be searched for carefully.

Bones visible on a chest X-ray include the ribs, clavicles, scapulae, humeri, and the spine. The sternum cannot be seen clearly because it overlies the spine and mediastinum.

Rib fractures

Chest radiography is not indicated for demonstration of a suspected simple rib fracture. This is because many fractures are not visible, and because management is not altered even if it is seen. If there is clinical suspicion of complications such as a pneumothorax, a chest X-ray is indicated.

Multiple acute rib fractures

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Multiple acute rib fractures

  • Blunt trauma to chest wall
  • Mobile supine chest X-ray
  • Multiple fractures of the 4th right rib (highlighted)
  • Other visible fractures of 3rd, 5th, 6th and 7th right ribs (arrowheads)
  • Raised right hemidiaphragm due to reduced ventilation secondary to pain
  • Increased density of the right lower zone due to lung contusion
  • Generalised increased density on the right likely due to a haemothorax
  • Note: A pneumothorax cannot be excluded on a supine X-ray

Old rib fractures

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Old rib fractures

  • There is angulation of the ribs at multiple fracture sites (arrows)
  • At the site of injuries there is increased density (whiter areas) due to callus formation

Malignant bone disease

There may be evidence of metastatic bone disease on a chest X-ray. This may manifest as a single bone metastasis, or as a diffuse abnormality representing widespread metastases. Bones may become denser (whiter) due to a sclerotic process (often seen in prostate cancer), or less dense (blacker) due to a lytic process (as is often the case in renal cell cancer).

Bone metastases may present with pathological fractures which may appear as acute or old fractures, depending on the stage of healing.

Primary bone tumours, both benign and malignant, are relatively uncommon.

Multiple bone metastases

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Multiple bone metastases

  • Pacemaker
  • Dense/sclerotic ribs (arrowheads)
  • Patchy dense/sclerotic clavicles and humeri (asterisk)
  • Bilateral lower zone consolidation with a pleural effusion on the right
  • No pathological fractures are seen

Clinical information

  • Known prostate cancer
  • Cough and fever

Diagnosis

  • Pneumonia with associated effusion
  • Metastatic bone disease

Note

  • This patient is susceptible to infections because of bone marrow suppression