Discussion Author(s): Kerry Ann Hudson, ENS MC USNR
While this patient has evidence of a rib fracture on plain film radiographs of the ribs, it is imperative to rule out a pathologic fracture due to metastatic breast cancer considering her past medical history of invasive ductal carcinoma. She presented with right sided anterior chest pain and due to her past medical history, a bone scan was done prior to the rib series. Normally, in a patient presenting with anterior chest pain/rib pain, the plain radiographs should be done first, followed by bone scan which has increased sensitivity in finding bone metastasis that are not evident on plain films. In her case, the bone scan showed an area of increased radiotracer uptake in the right anterior ribs. This finding was confirmed as a rib fracture via the rib series plain radiographs. In this patient, the history matches the radiographic presentation of fracture secondary to trauma/fall. With her past medical history, it is important to rule out the pathological fracture, though. Evidence of such a fracture involves the presence of underlying abnormal bone. Breast cancer bone metastasis can present as blastic or lytic lesions. Blastic lesions are not associated with pathological fractures and do not cause bone pain. On the other hand, lytic lesions are associated with pathologic fractures and intense bone pain. There are no blastic or lytic regions identified in her rib series, thus precluding a diagnosis of bone metastasis associated with a pathological fracture.
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