Thomas Wang: A 28-Year-Old Stockbroker With Severe Anterior Chest Pain





Learning Objectives





  • Learn the common causes of chest wall pain.



  • Develop an understanding of the unique anatomy of the chest wall.



  • Develop an understanding of the causes of costosternal joint pain.



  • Develop an understanding of joint injury.



  • Learn the clinical presentation of costosternal syndrome.



  • Learn how to use physical examination to identify pathology of the costosternal joint.



  • Develop an understanding of the treatment options for costosternal joint pain.



Thomas Wang







Thomas Wang is a 28-year-old stockbroker with the chief complaint of, “My chest is killing me.” Thomas stated that about 1 week ago, he was involved in a motor vehicle accident when driving home from a party. “A dog ran out of nowhere and startled me, and the next thing I remember is waking up after crashing into a tree. The good news is I didn’t hit the dog; the bad news is I got a DUI. I had a couple of glasses of wine with my friends, but thought I was okay to drive home.” I asked if he was wearing his seatbelt and he gave me an “are you kidding me?” look as he answered that he always wears his seatbelt. “Doctor, I don’t know whether it was the seatbelt or the airbag that got my chest, but it hurts whenever I take a deep breath or reach for anything. I had to buy some go-cups because I can’t get my coffee mugs out of the cabinet! I thought it would get better, but it really hasn’t.” I responded, “I’m happy to hear you were wearing your seatbelt. So, did you hit your head?” He said he didn’t think so, that he thought he just fell asleep after he hit the tree. They took him to the emergency room, and the scan of his head didn’t show anything. “Doctor, I really screwed up here. I hope I don’t lose my license for this little stunt. My blood alcohol was off the charts! I can’t figure it out; it was only a couple of glasses of wine. I really bunged up my chest. They said nothing was broken, so why does it hurt so much?”


I asked Thomas if he had anything like this happen before. He shook his head and responded, “Never. I never drink and drive. I usually take an Uber, but they were on price surge, and that is just a rip-off. I was sure I was good to drive.” “What I meant, Thomas, was have you ever passed out or lost consciousness?” “No,” he responded. “That has never happened. I am very careful with the distracted driving and all—you know what I mean? What worries me is that my chest just isn’t getting better, and it is making it really hard to sit at a computer monitor all day. It feels like something is broken in the front of my chest. I am even having a hard time reaching up to wash my hair and to shave.”


I asked Thomas about any previous problems with alcohol, passing out, DUIs, or forgetting where he was, and he shook his head no. “Doc, I was never much of a drinker, just a couple glasses of wine with dinner. I really enjoy the California reds.” I asked Thomas what he tried to relieve his chest pain, and he said that he had tried some Advil and Tylenol, but they didn’t do much. He went on to say that a heating pad seemed to help a little bit. I asked Thomas what made his pain worse, and he said, “Any time I use my arms to reach for anything or take a deep breath. I hate it when I have to cough or sneeze because that really hurts.” Thomas went on to say that when he reached up, he felt pain in the front of his chest around his breast bone. I asked how he was sleeping, and he shook his head and said, “Doc, I’ll bet this pain wakes me up 100 times a night. I usually sleep on my left side, but since I had the wreck I can’t do that, so I try to sleep on my right side. Every time I roll over to my left side, the pain wakes me up.”


I asked Thomas to point with one finger to show me where it hurt the most. He pointed to each side of his sternum and said, “Doc, it’s right here where something is wrong. It feels like something is broken. I keep thinking there should be a bruise or something, but it’s down deep.” I asked if he had any fever or chills, and he shook his head no.


On physical examination, Thomas was afebrile. His respirations were 16 and his pulse was 68 and regular. His blood pressure was 112/70. His head, eyes, ears, nose, throat (HEENT) exam was normal, with no scleral icterus. His cardiopulmonary examination was unremarkable. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly; specifically, I was unable to detect any hepatomegaly. There was no costovertebral angle (CVA) tenderness or peripheral edema. His low back examination was unremarkable. Visual inspection of the chest wall was unremarkable; specifically, there was no obvious bony deformity or infection. I noted that Thomas was splinting his shoulders a little forward to avoid moving his chest wall. Palpation of the costosternal joints exacerbated Thomas’s pain ( Fig. 1.1 ). I did not appreciate any obvious separation of the costosternal joint. I performed the shoulder retraction test for costosternal syndrome, which was positive bilaterally ( Fig. 1.2 ). Examination of the joints of the hands and other major joints revealed no evidence of inflammatory arthritis. A careful neurologic examination of the upper extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. Thomas’s mental status examination was normal.




Fig. 1.1


Palpation of the costosternal joint.



Fig. 1.2


To elicit a shoulder retraction test in patients who are suspected of suffering from costosternal syndrome, the patient is placed in the standing position with the shoulders in neutral position, facing the examiner. The patient is then asked to retract the shoulder vigorously. The shoulder retraction test is considered positive if the retraction maneuver reproduces the patient’s anterior chest wall pain.

From Waldman S. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . ed. 4. Philadelphia: Elsevier; 2021 [Fig. 143-1].


Key Clinical Points—What’s Important and What’s Not


The History





  • A history of acute trauma to the chest wall from an airbag and seatbelt



  • A history of motor vehicle accident



  • History of driving while intoxicated



  • History of daily alcohol intake



  • No history of previous significant chest wall pain



  • No fever or chills



  • Exacerbation of pain with deep inspiration and elevation of the upper extremities



  • Sleep disturbance



The Physical Examination





  • Patient is afebrile



  • Palpation of costosternal joints reveals tenderness bilaterally (see Fig. 1.1 )



  • No evidence of infection



  • Shoulder retraction test for costosternal syndrome positive bilaterally (see Fig. 1.2 )



Other Findings of Note





  • Normal HEENT examination



  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination



  • No peripheral edema



  • Normal upper extremity neurologic examination, motor and sensory examination



  • Examination of other joints normal



What Tests Would You Like to Order?


The following tests were ordered:




  • Plain radiographs of the chest wall



  • Complete blood count



  • Comprehensive chemistry panel, including liver enzymes



Test Results


The plain radiographs of the sternum and costosternal joints revealed no fractures or dislocations.


The complete blood count revealed no megaloblastic anemia.


The comprehensive chemistry panel was within normal limits with no elevation of liver enzymes.


Clinical Correlation—Putting it all Together


What is the diagnosis?




  • Costosternal syndrome secondary to acute traumatic injury



The Science Behind the Diagnosis


Anatomy of the Costosternal Joints


The cartilage of the true ribs articulates with the sternum via the costosternal joints ( Fig. 1.3 ). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding movement. The cartilage of the second through sixth ribs articulates with the body of the sternum via true arthrodial joints. These joints are surrounded by a thin articular capsule. The costosternal joints are strengthened by ligaments but can be subluxed or dislocated by blunt trauma to the anterior chest. Posterior to the costosternal joint are the structures of the mediastinum. These structures are susceptible to needle-induced trauma if the needle is placed too deeply. The pleural space may be entered if the needle is placed too deeply and laterally, and pneumothorax may result.


Jun 18, 2022 | Posted by in PAIN MEDICINE | Comments Off on Thomas Wang: A 28-Year-Old Stockbroker With Severe Anterior Chest Pain
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