A 57-Year-OId Man with Rib Pain with Deep Breathing

The Resolution

 

Differential Diagnosis

• Pneumothorax
• Skin fold
• Rib fracture
• Sternal fracture

Diagnosis

The initial x-ray demonstrates vertical lucency in the right lateral chest—possibly indicative of pneumothorax or skin fold. Skin fold is favored as air does not extend to the apex. The second image, with the arms pulled away, shows resolution of a finding consistent with skin fold.

 

Learnings/What to Look for

• The radiographic appearance of pneumothorax depends primarily on the positioning of the body
• Pneumothorax shows conformity of linear shadows with visceral pleural anatomy; skin folds do not
• Typically, skin folds do not demonstrate lateral lucency, but there is a pitfall—perception of relative lucency lateral to the added density of the skin fold due to Mach effect

 

Pearls for Urgent Care Management and Considerations for Transfer

• Short-term use of a topical steroid will reduce inflammation in the area
• If the area is infected, an antifungal agent may be necessary
• Patient education should focus on preventing future incidence and include recommendations to avoid tight-fitting clothing; keeping skin as dry and cool as possible; and drying thoroughly after bathing or swimming before getting dressed
  • Female patients should be advised to ensure brassieres have adequate support

 

Acknowledgment: Images and case provided by Experity Teleradiology.