P3.256: When Diagnosis is Deceptive: Thoracic Pathologic Fracture Mimicking Slipping Rib Syndrome

Introduction: Slipping rib syndrome is a condition in which hypermobility of the ribs, most commonly the 8th-10th ribs, causes painful impingement of the surrounding nerves and/or soft tissues. This condition mostly presents unilaterally, and bilateral anterior rib pain as a result of slipping rib syndrome is atypical.

Case Description: A 16-year-old male presented with intermittent bilateral lower rib pain for two years, with worsening symptoms over the previous two months. He was diagnosed by a pediatric general surgeon with slipping rib syndrome, and treatment via steroid injection or physical therapy was recommended. Rib x-rays at that visit were normal. 2.5 months later, the patient experienced an acute onset of severe bilateral rib pain after bending over and was unable to stand upright, prompting a visit to the ED and subsequently the general surgeon with ongoing disabling pain. He was referred to a sports medicine pediatrician for an ultrasound-guided intercostal nerve block, upon which he received immediate post-injection relief and improvement in posture and pain. Due to the severe, atypical symptoms, an MRI of the chest was recommended. This revealed lymph node enlargement and a pathologic compression fracture of the T7 vertebra with concern for malignancy. Further testing revealed findings of stage IVA Classical Hodgkin Lymphoma. He subsequently began chemotherapy in conjunction with treatment via a rigid thoracic lumbar sacral orthosis (TLSO) brace and physical therapy for his pathologic T7 compression fracture. Serial radiographs of the fracture demonstrated increasing angulation of the vertebra. After 2 months of bracing, he was instructed to wean from the brace and continue with core and upper back strengthening through sports physical therapy. The patient has since weaned from the brace with his healing T7 fracture but continues to have bilateral anterior rib discomfort. He is still undergoing chemotherapy treatment for his lymphoma and will continue with PT with an emphasis on stabilization and ambulation out of the brace without pain. He is continued to be monitored by orthopedics with repeat x-rays to evaluate the height/angulation of the T7 vertebra.

Discussion: This case describes an uncommon condition with a rare diagnosis, however, highlights a few key points, including the importance of evaluating why symptoms have suddenly changed when a condition is chronic, examining a patient thoroughly even when being referred for a specific reason, and considering referred thoracic pain as an etiology when a patient presents with bilateral atraumatic rib pain.

Conclusion: This case illustrates the unique presentation of bilateral anterior rib pain due to slipping rib syndrome exacerbated by a T7 pathologic compression fracture in the setting of stage IVA Classical Hodgkin Lymphoma. Atypical presentation accompanied by an acute severe progression of symptoms prompted advanced imaging to reveal malignancy and associated pathologic fracture, which otherwise would not have been identified.