A 10-year-old male presented, who referred to the orthopaedic clinic, with a symptomatic chest wall lesion.
A 10-year-old boy presented with a lump on the right chest wall. This had been noticeable for over three years and had been slowly enlarging. It was tender when felt. An examination when done revealed the presence of a 6 x 4 x 3 cm swelling over the right anterior chest wall. An AP chest radiograph investigation showed that he had a bifid right third rib (Fig. 1).
Bifid or forked ribs are known to occur in 3 to 6 per 1000 live births. In three cases of bifid ribs found at routine dissection, the third and fourth ribs were found to be involved. The distal parts of the osseous rib bifurcated at an angle of 60 degrees, and both of the branches had their own costal cartilages, and the arterial supply was from a small branch of the intercostal artery. The intercostal nerves did not bifurcate and continued along the lower margins of the lower branches of the bifid ribs. Bifid ribs may produce a noticeable chest wall swelling. If the patients are symptomatic, they are often referred for a specialist's opinion. Symptomatic chest wall swellings should be investigated further as in a histopathologcal study of samples aspirated from 227 chest wall lesions; 36% are malignant and 56% are benign lesions. Inflammatory lesions (54%) or lipomas (30%) are the commonest amongst benign lesions. Rare cases of tuberculosis involving the sternum, epithelioid leiomyosarcomas, and neuroendocrine tumors involving ribs, malignant nerve sheath tumors involving the chest wall, metastatic carcinomas of the stomach and the prostate, and papillary carcinoma thyroid have been reported in this series. Bifid ribs can be readily diagnosed on a plain chest radiograph (Fig.1) and this variant of the normal requires no intervention. Other normal rib variants include a discontinuity of the first rib, bridge formation anteriorly and forked rib anteriorly, small costal bridge, ridge shaped fusion anteriorly, fusion posteriorly, costal cartilage bridging or bifurcation and birurcated rib of Luschka. Asymptomatic chest wall swellings in children are usually related to normal variations in the bone or the cartilage of the chest wall. Bifid ribs are one of the skeletal abnormalities associated with the Gorlin–Goltz syndrome or the basal cell nevus syndrome. This condition, which has a prevalence of 1 in 60,000, is an autosomal dominant condition with incomplete penetrance. It comprises multiple nevoid basal cell carcinomatas, odontogenic keratocysts, palmar pits and ectopic calcification of the falx cerebri. Other skeletal abnormalities described are frontal and parietal bossing, hypertelorism and Sprengal’s deformity. The authors suggest that patients with a symptomatic chest wall swelling should be investigated initially with a plain chest radiography and if bifid ribs are noted, then the Gorlin–Goltz syndrome should be suspected and the condition be excluded by a further examination.
Bifid third rib.
Based on the provided frontal and zoomed X-ray images of the chest, the thoracic cage of the child appears largely symmetrical, the lung fields are clear, and the cardiac silhouette shows no obvious enlargement or abnormal shape. In a certain rib (noted where a bifurcation is visible on the images), the continuity of the rib structure appears normal, yet there is a bifurcated shape at the distal end, presenting as a “bifid” or “forked” structure, suggesting a possible congenital variant (Bifid rib). There is no apparent bony destruction, abnormal soft tissue mass, or evidence of rib fracture on the images.
According to the X-ray presentation, bifurcation at the end of the rib is a typical morphological feature. Although uncommon in the general population, it is a known congenital chest wall variation, which in some cases may be accompanied by localized chest wall protrusion or discomfort.
If a palpable mass or pain is present in the area, it could potentially be due to a lipoma, hemangioma, or inflammatory lesion. However, no abnormal soft tissue mass or signs of bony destruction are observed in this imaging study, making this possibility relatively less likely.
Bifid ribs can also appear in Gorlin–Goltz syndrome (Nevoid Basal Cell Carcinoma Syndrome). If the patient or family members have multiple basal cell carcinomas, odontogenic keratocysts, or intracranial calcifications, further investigation is warranted.
Considering the child’s age, clinical symptoms, and imaging findings, the most likely diagnosis is Congenital Bifid Rib. Currently, there is no indication of malignancy or inflammation on the images, nor is there evidence suggesting other chest wall tumors. It is recommended to closely monitor the child for any other related signs (e.g., skin, craniofacial, or oral symptoms) and, if present, conduct further examinations to rule out Gorlin–Goltz syndrome.
1. Conservative Observation
• For patients with bifid ribs who have no significant functional impairment or severe pain, conservative therapy is often employed.
• Periodic follow-up and repeat X-ray examinations are advised to monitor any structural changes in the chest wall.
• If symptoms are mild, nonsteroidal anti-inflammatory drugs (NSAIDs) or simple analgesics may be considered for symptom relief.
2. Surgical Treatment
• In rare cases where there is significant pain, a palpable protrusion, or a notable impact on appearance and quality of life, surgical correction may be considered.
• Preoperative evaluations including CT scans and other imaging are necessary to rule out other structural abnormalities or associated deformities.
3. Rehabilitation/Exercise Prescription
• Principle: Gradual progression, safety, effectiveness, and individualization.
• Initial Phase (first 2–4 weeks): Focus on low-intensity thoracic mobility exercises such as gentle stretching and breathing exercises (combining abdominal and chest breathing), ensuring exercise intensity does not cause significant chest pain.
• Intermediate Phase (4–8 weeks): Building on initial adaptation, introduce low-intensity aerobic exercises (e.g., walking, swimming) 3–4 times a week, 20–30 minutes each session, maintaining a moderate heart rate, and avoiding strenuous upper limb or chest loading.
• Later Phase (after 8 weeks): If symptoms improve significantly, gradually incorporate mild resistance exercises (dumbbells, resistance bands) 2–3 times a week, controlling the load to avoid excessive chest wall traction or pain, and pay attention to proper form and breathing rhythm.
• Monitoring: Throughout the rehabilitation process, closely monitor any chest wall pain or discomfort, and promptly communicate with professionals to adjust exercise volume and methods as needed.
Disclaimer: This report is a reference analysis based on current imaging findings and clinical data and cannot replace in-person consultation or professional medical advice. Please follow the recommendations of the attending physician or specialist for actual diagnosis and treatment.
Bifid third rib.
