Rare case of Left fourth and sixth costovertebral dislocation abutting the aorta: a report

Regarding the thoracic cage injuries, on the right, there were fractures at the neck and at the costochondral junction of the first rib, and comminuted fractures of the second through seventh ribs posteriorly. On the left, there were fractures of the head and neck of the first rib; costal cartilages of the first, second, and fourth ribs; costochondral junctions of the fifth and sixth ribs; and body of the second through ninth ribs at more than one site except for the eight rib (flail chest). There was subluxation of the left fourth costotransverse joint and a fracture/dislocation of the left fourth costocentral joint; there was a tiny intra-articular chip fracture of the posterior aspect of the head of the rib. There was also a subluxation of the left sixth costocentral joint. The heads of both the left fourth and sixth ribs abutted the posterior aspect of the proximal descending aorta. These costovertebral joint injuries and their proximity to the aorta were not described on the initial CT report.

The patient underwent multiple subsequent chest CTs for ongoing fever. The last scan performed 54 days post trauma demonstrated persistent costovertebral joints malalignment and no aortic injury. A transverse fracture through the superior endplate of T4 with no significant loss of height or involvement of the posterior wall was occult on the initial CT and became apparent on subsequent CTs. Over the course of his hospitalization, the patient underwent surgical fixation of the pelvic fractures. His recovery was complicated by infarctions at the left posterior inferior cerebellar artery and right posterior cerebral artery territories. The patient was discharged to a rehabilitation center after a 75-day hospitalization.

The authors commented – “In conclusion, this case report presented dislocations of non-consecutive left fourth and sixth CVJs where the rib head abutted the aorta. It documents an unusual presentation of a rare entity and suggests that conservative management may be acceptable in some of these cases. It also raises awareness among radiologists about these injuries, which can be easily overlooked, but are important for the stability of the thoracic spine. Finally, this report emphasizes the association between CVJ dislocations and spine injuries, which can sometimes be occult on initial imaging. Future studies with larger sample sizes and long-term follow-up could help determine the optimal management of CVJ dislocations.” 

Further reading:

Left fourth and sixth costovertebral dislocation abutting the aorta

Natalia Gorelik, Dany Croteau et al

Skeletal Radiology (2024) 53:187–192

https://doi.org/10.1007/s00256-023-04415-3