Chest x-ray abnormalities
Bone abnormalities
Bones are the densest normal structures seen on a chest x-ray. Despite this, the power of the x-rays 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, humera, 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 fractures. This is because many fractures are not demonstrated, and because management is not altered. If there is clinical suspicion of complications such as a pneumothorax a chest x-ray is then indicated.
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
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Multiple rib fractures
- Mobile supine chest x-ray
- Multiple fractures of the 4th right rib (blue)
- Other visible fractures of 3rd, 5th, 6th and 7th right ribs (arrowheads)
- Raised right hemidiaphragm
- Increased density of the right lung base
Clinical information
- Fall from height - blunt trauma to right chest wall
Diagnosis
- Multiple rib fractures
- Underventilation of the right lung base (due to pain) with possible lung contusion in this area
- A pneumothorax cannot be seen
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Hover over image to show findings
Increased bone density
- PA chest x-ray
- Lucent areas of lung with distorted vascular markings due to emphesyma (red circle)
- Lung hyperinflation also due to emphesyma with flattening of the left hemidiaphragm - (red line)
- Multiple old partly healed rib fractures (arrowheads)
- Visible acute rib fracture (arrow)
Clinical information
- Known emphysema
- Long term steroid use resulting in osteoporosis
- Chest pain
Diagnosis
- Chronic cough resulting in multiple fractures of osteoporotic ribs
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).
Primary bone tumours, both benign and malignant, are relatively uncommon.
Hover over image to show findings
Multiple bone metastases
- Pacemaker
- Dense/sclerotic ribs (arrowheads)
- Patchy dense/sclerotic clavicles and humera(*)
- Bilateral lower zone consolidation with a pleural effusion on the right
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