Basics
Description
Costochondritis is chest pain that emanates from a costal cartilage and is reproducible on compression of that cartilage.
Epidemiology
- Frequency of sternal wound infections following median sternotomy is 0.1-1.6%.
- Costochondritis accounts for 10-31% of all pediatric chest pain.
- Peak age for chest pain in children is 12-14 years.
Pathophysiology
- Inflammation of unknown etiology (histologic examination is usually normal)
- Infection
- Can present months to years after surgery (the costal cartilage is avascular, making it vulnerable to infection if it has been exposed, injured, or denuded of perichondrium)
- Complication of median sternotomy
- Occurs by spread from adjacent osteomyelitis or may arise de novo during surgery
Etiology
- Infectious
- Bacterial
- Staphylococcus aureus (especially after thoracic surgery)
- Salmonella (in sickle cell disease)
- Escherichia coli
- Pseudomonas sp.
- Klebsiella sp.
- Fungal
- Aspergillus flavus
- Candida albicans
- Posttraumatic injury
Diagnosis
History
- Inflammatory costochondritis
- Pain usually preceded by exercise or an upper respiratory tract infection
- Description of pain
- Usually sharp
- Affects the anterior chest wall
- Localized or radiates to the back or abdomen
- Usually unilateral (left side greater than right side)
- The 4th-6th costochondral junction is the usual site of pain.
- Motion of the arm and shoulder on the affected side elicits the pain.
- Girls are affected more often than are boys.
- Tietze syndrome
- Onset is usually abrupt but can be gradual.
- Believed to be caused by a minor trauma, although etiology is unknown
- Description of pain
- Radiates to arms or shoulder
- May last up to several weeks
- Swelling at the sternochondral junction may persist for several months to years.
- Usually affects the 2nd or 3rd costochondral joint
- Pain is aggravated by sneezing, coughing, deep inspiration, or twisting motions of the chest.
- No differences in frequency between sexes
- Infectious costochondritis
- Slow, insidious course
- Usually unimpressive clinical symptomatology
Physical Exam
- Usually normal
- Inspect for evidence of trauma, scars, bruising, and swelling.
- Palpation and percussion of the costochondral and costosternal junctions should reproduce and localize the pain.
- In Tietze syndrome, spindle-shaped swelling is visible at the sternochondral junction.
Diagnostic Tests & Interpretation
Lab
- WBC count not helpful (even when infection present)
- EKG (may be helpful if cardiac etiology is being considered)
Imaging
- Radiologic studies (chest x-ray, CT) usually not helpful
- Gallium scan
- May be useful in some cases of infectious origin
- Not highly specific
- May show increased radionuclide uptake
- No evidence of osteomyelitis of the sternum in most cases
- Technetium bone scan
Differential Diagnosis
- Cardiovascular
- Myocardial infarction
- Pericarditis
- Pericardial effusion
- Myocarditis
- Endocarditis
- Cardiomyopathy
- Premature ventricular contractions
- Supraventricular tachycardia
- Dissecting aneurysm
- Pulmonary
- Asthma
- Exercise-induced bronchospasm
- Pneumonia
- Pleural effusion
- Pneumothorax
- Pulmonary embolism
- GI
- Gastroesophageal reflux
- Esophagitis
- Gastritis
- Achalasia
- Mechanical
- Muscle strain
- Stress fractures
- Precordial catch syndrome
- Trauma
- Rheumatologic
- Rheumatoid arthritis
- Ankylosing spondylitis
- Oncologic
- Rhabdomyosarcoma
- Leukemia
- Ewing sarcoma
- Miscellaneous
- Tietze syndrome
- Psychogenic chest pain
- Breast tissue pain (both sexes)
Treatment
General Measures
- Inflammatory costochondritis
- Anti-inflammatory and analgesic agents
- Reassurance
- If pain disturbs normal activities and sports, infiltration with local anesthetic may prove useful.
- Infectious costochondritis
- Prolonged course of intravenous (IV) antibiotics
- Prompt surgical resection of all involved cartilage
- Reconstructive surgery with muscular flaps should be done.
Alert
- Infectious costochondritis
- Long-term IV antibiotics alone do not resolve the problem; surgical resection and repair also are required.
- There is a tendency for the infection to spread to adjacent costal cartilages and across the sternum to the contralateral chest wall.
- In general, avoid costochondral junctions when performing surgical procedures in the chest (i.e., chest tube placement).
Alert
- Inflammatory costochondritis
- Important cause of school absence
- Adolescents tend to limit physical activity unnecessarily for long periods.
- Restriction of activities is usually not required.
- Most adolescents still worry about cardiac problems, even after the diagnosis has been made.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Inflammatory costochondritis
- Long-lasting condition
- Follow-up once a year is recommended.
- Infectious costochondritis
- Long-term follow-up after surgery is mandatory.
Prognosis
- Inflammatory costochondritis: excellent
- Infectious costochondritis: prognosis relates to
- Underlying clinical condition of the patient (i.e., immunocompromised, postradiation therapy for cancer, postcardiac surgery)
- Extent of surgery required to reconstruct the area damaged by the infection
Additional Reading
- Brown RT, Jamil K. Costochondritis in adolescents. A follow-up study. Clin Pediatr. 1993;32(8):499-500. [View Abstract]
- Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46(2):189-203. [View Abstract]
- Mendelson G, Mendelson H, Horowitz SF, et al. Can (99m)technetium methylene diphosphate bone scans objectively document costochondritis? Chest. 1997;111(6):1600-1602. [View Abstract]
- Selbst DM. Consultation with the specialist. Chest pain in children. Pediatr Rev. 1997;18(5):169-173. [View Abstract]
- Son MB, Sundel RP. Musculoskeletal causes of pediatric chest pain. Pediatr Clin North Am. 2010;57(6):1385-1395. [View Abstract]
- Talner NS, Carboni MP. Chest pain in the adolescent and young adult. Cardiol Rev. 2000;8(1):49-56. [View Abstract]
Codes
ICD09
ICD10
- M94.0 Chondrocostal junction syndrome [Tietze]
SNOMED
- 64109004 Costalchondritis (disorder)
- 30128009 Tietze's disease
FAQ
- Q: Am I having or will I have a heart attack?
- A: Chest pain does not imply a heart problem. This pain arises from the chest wall; there is no risk of a myocardial infarction. A cardiac etiology to chest pain in an adolescent is usually uncommon.
- Q: Is costochondritis related to arthritis?
- A: There is no relation to any form of arthritis.
- Q: Where does the name Tietze syndrome come from?
- A: The syndrome is named after German surgeon Alexander Tietze (1864-1927), who first described the syndrome in 1921.