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Keep Your Eyes on the Ribs: The Spectrum of Normal Variants and Diseases That Involve the Ribs¹

¹ From the Department of Radiology, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received October 5, 1998; revision requested October 15 and received January 14, 1999; accepted January 14. Address reprint requests to A.R.G.

View larger version (116K): [in a new window]   Figure 1a.   Normal findings at chest radiography. (a) Frontal view shows the inferior margins of portions of the posterior ribs as indistinct (arrows). This finding should not be confused with a destructive process. (b) Lateral view shows the posterior ribs as circular areas of increased opacity (solid arrows) or parallel lines (open arrows), depending on whether the rib is parallel or oblique to the x-ray beam. Loss of this normal appearance on the lateral view may be an important indicator of rib disease (cf Figs 11, 13, 24, 25). The inferior flange of the rib is also seen (arrowhead).

View larger version (102K): [in a new window]   Figure 1b.   Normal findings at chest radiography. (a) Frontal view shows the inferior margins of portions of the posterior ribs as indistinct (arrows). This finding should not be confused with a destructive process. (b) Lateral view shows the posterior ribs as circular areas of increased opacity (solid arrows) or parallel lines (open arrows), depending on whether the rib is parallel or oblique to the x-ray beam. Loss of this normal appearance on the lateral view may be an important indicator of rib disease (cf Figs 11, 13, 24, 25). The inferior flange of the rib is also seen (arrowhead).

View larger version (136K): [in a new window]   Figure 2.   Cervical ribs in an asymptomatic patient. Frontal chest radiograph shows bilateral cervical ribs (arrowheads); the left one fuses anteriorly to the first rib (arrow).

View larger version (144K): [in a new window]   Figure 3.   Forked rib in a 47-year-old man. Frontal chest radiograph demonstrates the inferior and superior ends of a duplicated right anterior fifth rib (arrowheads).

View larger version (121K): [in a new window]   Figure 4a.   Forked rib with isolated cartilaginous segment in an asymptomatic 21-year-old man. (a) Frontal chest radiograph shows a widened interspace between the right anterior fourth and fifth ribs with linear intercostal calcifications (arrow). (b) Oblique view shows the calcifications lying within the chest wall in the same plane as the ribs (arrows). This finding represents an unusual form of forking or duplication of the ribs. The calcifications resemble the typical costal cartilage calcifications seen in adults.

View larger version (144K): [in a new window]   Figure 4b.   Forked rib with isolated cartilaginous segment in an asymptomatic 21-year-old man. (a) Frontal chest radiograph shows a widened interspace between the right anterior fourth and fifth ribs with linear intercostal calcifications (arrow). (b) Oblique view shows the calcifications lying within the chest wall in the same plane as the ribs (arrows). This finding represents an unusual form of forking or duplication of the ribs. The calcifications resemble the typical costal cartilage calcifications seen in adults.

View larger version (136K): [in a new window]   Figure 5.   Fusion of the left third and fourth ribs in a 45-year-old man. Frontal chest radiograph shows close apposition of the posterior ribs (white arrow) and broad fusion of the anterior segments (black arrows). These findings represent a failure of normal segmentation. Vertebral anomalies may be found at the same level in some cases.

View larger version (141K): [in a new window]   Figure 6.   Bone bridging in a 34-year-old woman with no history of fracture or trauma. Frontal chest radiograph shows a bone bridge joining the right anterior first and second ribs. Pseudoarticulation is also present (arrows).

View larger version (119K): [in a new window]   Figure 7.   Pseudarthrosis of the right first rib in a 20-year-old man. Frontal chest radiograph shows dense, wavy margins along a rib defect (arrow). This finding is typical in pseudarthrosis and should not be mistaken for a fracture.

View larger version (149K): [in a new window]   Figure 8.   Ruptured hemidiaphragm in a 62-year-old man who sustained the injury in a motor vehicle accident. Frontal chest radiograph shows a rounded mass in the left lower thorax (white arrowheads). Fractures of the left sixth and seventh ribs (black arrowheads) indicate an area of substantial trauma and are a clue that the mass represents abdominal viscera herniated through a tear in the hemidiaphragm. Pneumopericardium is also present (arrows).

View larger version (103K): [in a new window]   Figure 9.   Flail chest in a 70-year-old man. Frontal chest radiograph shows fractures of the left third through sixth ribs (posterior fractures, arrows; anterior fractures, white arrowheads). An apical pneumothorax is also visible (black arrowheads).

View larger version (135K): [in a new window]   Figures 10, 11.   (10) Multiple myeloma in a 52-year-old man. Frontal chest radiograph shows vague areas of increased opacity over the left side of the chest. Smooth medial margins (arrowheads) indicate a pleural or chest wall origin. Interruption of the cortex of the left anterior fifth rib (straight arrow) and a pathologic fracture of the left eighth rib (curved arrow) are suggestive of a malignancy. (11) Metastatic breast cancer in a 69-year-old woman who presented with hypercalcemia. (a) Lateral chest radiograph shows absence of the ring shadow of the right posterior sixth rib with a mass smoothly indenting the lung (arrowheads). (b) Frontal view reveals destruction of the right sixth rib (arrowheads) as well as a subtler lesion of the left sixth rib (arrow).

View larger version (133K): [in a new window]   Figures 10, 11.   (10) Multiple myeloma in a 52-year-old man. Frontal chest radiograph shows vague areas of increased opacity over the left side of the chest. Smooth medial margins (arrowheads) indicate a pleural or chest wall origin. Interruption of the cortex of the left anterior fifth rib (straight arrow) and a pathologic fracture of the left eighth rib (curved arrow) are suggestive of a malignancy. (11) Metastatic breast cancer in a 69-year-old woman who presented with hypercalcemia. (a) Lateral chest radiograph shows absence of the ring shadow of the right posterior sixth rib with a mass smoothly indenting the lung (arrowheads). (b) Frontal view reveals destruction of the right sixth rib (arrowheads) as well as a subtler lesion of the left sixth rib (arrow).

View larger version (105K): [in a new window]   Figures 10, 11.   (10) Multiple myeloma in a 52-year-old man. Frontal chest radiograph shows vague areas of increased opacity over the left side of the chest. Smooth medial margins (arrowheads) indicate a pleural or chest wall origin. Interruption of the cortex of the left anterior fifth rib (straight arrow) and a pathologic fracture of the left eighth rib (curved arrow) are suggestive of a malignancy. (11) Metastatic breast cancer in a 69-year-old woman who presented with hypercalcemia. (a) Lateral chest radiograph shows absence of the ring shadow of the right posterior sixth rib with a mass smoothly indenting the lung (arrowheads). (b) Frontal view reveals destruction of the right sixth rib (arrowheads) as well as a subtler lesion of the left sixth rib (arrow).

View larger version (125K): [in a new window]   Figures 12, 13.   (12) Metastatic breast cancer in a 34-year-old woman. Frontal chest radiograph shows scattered sclerotic foci that are best appreciated inferolaterally where there are no overlying lung markings (arrows). Diffuse bone metastasis was indicated at concurrent radioisotope bone scintigraphy. (13) Metastatic prostate cancer in a 63-year-old man. (a, b) Frontal (a) and lateral (b) chest radiographs show a diffuse increase in bone density. The loss of distinct cortical lines is especially noticeable in some of the right ribs on the lateral view (arrows in b); the frontal view shows loss of corticomedullary distinction, which is particularly well seen in the fifth rib (arrow in a). (c) On a frontal chest radiograph obtained 5 months later, the change in the appearance of the ribs is striking (arrow). Sclerosis of the vertebral bodies may also be seen, but the lack of overlying lung markings makes evaluation of the ribs easier.

View larger version (150K): [in a new window]   Figures 12, 13.   (12) Metastatic breast cancer in a 34-year-old woman. Frontal chest radiograph shows scattered sclerotic foci that are best appreciated inferolaterally where there are no overlying lung markings (arrows). Diffuse bone metastasis was indicated at concurrent radioisotope bone scintigraphy. (13) Metastatic prostate cancer in a 63-year-old man. (a, b) Frontal (a) and lateral (b) chest radiographs show a diffuse increase in bone density. The loss of distinct cortical lines is especially noticeable in some of the right ribs on the lateral view (arrows in b); the frontal view shows loss of corticomedullary distinction, which is particularly well seen in the fifth rib (arrow in a). (c) On a frontal chest radiograph obtained 5 months later, the change in the appearance of the ribs is striking (arrow). Sclerosis of the vertebral bodies may also be seen, but the lack of overlying lung markings makes evaluation of the ribs easier.

View larger version (143K): [in a new window]   Figures 12, 13.   (12) Metastatic breast cancer in a 34-year-old woman. Frontal chest radiograph shows scattered sclerotic foci that are best appreciated inferolaterally where there are no overlying lung markings (arrows). Diffuse bone metastasis was indicated at concurrent radioisotope bone scintigraphy. (13) Metastatic prostate cancer in a 63-year-old man. (a, b) Frontal (a) and lateral (b) chest radiographs show a diffuse increase in bone density. The loss of distinct cortical lines is especially noticeable in some of the right ribs on the lateral view (arrows in b); the frontal view shows loss of corticomedullary distinction, which is particularly well seen in the fifth rib (arrow in a). (c) On a frontal chest radiograph obtained 5 months later, the change in the appearance of the ribs is striking (arrow). Sclerosis of the vertebral bodies may also be seen, but the lack of overlying lung markings makes evaluation of the ribs easier.

View larger version (144K): [in a new window]   Figures 12, 13.   (12) Metastatic breast cancer in a 34-year-old woman. Frontal chest radiograph shows scattered sclerotic foci that are best appreciated inferolaterally where there are no overlying lung markings (arrows). Diffuse bone metastasis was indicated at concurrent radioisotope bone scintigraphy. (13) Metastatic prostate cancer in a 63-year-old man. (a, b) Frontal (a) and lateral (b) chest radiographs show a diffuse increase in bone density. The loss of distinct cortical lines is especially noticeable in some of the right ribs on the lateral view (arrows in b); the frontal view shows loss of corticomedullary distinction, which is particularly well seen in the fifth rib (arrow in a). (c) On a frontal chest radiograph obtained 5 months later, the change in the appearance of the ribs is striking (arrow). Sclerosis of the vertebral bodies may also be seen, but the lack of overlying lung markings makes evaluation of the ribs easier.

View larger version (125K): [in a new window]   Figure 14a.   Metastatic prostate cancer in a 76-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity over the lower area of the left lung (arrows). (b) Lateral view shows a similar area of increased opacity with a smooth inferior margin (arrowheads). This finding, as well as the orientation of the area of increased opacity parallel to the anterior ribs, provide clues to the origin of the lesion. (c) Computed tomographic (CT) scan demonstrates a mass arising from the anterior fourth rib with underlying sclerosis of the rib (arrowhead).

View larger version (136K): [in a new window]   Figure 14b.   Metastatic prostate cancer in a 76-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity over the lower area of the left lung (arrows). (b) Lateral view shows a similar area of increased opacity with a smooth inferior margin (arrowheads). This finding, as well as the orientation of the area of increased opacity parallel to the anterior ribs, provide clues to the origin of the lesion. (c) Computed tomographic (CT) scan demonstrates a mass arising from the anterior fourth rib with underlying sclerosis of the rib (arrowhead).

View larger version (110K): [in a new window]   Figure 14c.   Metastatic prostate cancer in a 76-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity over the lower area of the left lung (arrows). (b) Lateral view shows a similar area of increased opacity with a smooth inferior margin (arrowheads). This finding, as well as the orientation of the area of increased opacity parallel to the anterior ribs, provide clues to the origin of the lesion. (c) Computed tomographic (CT) scan demonstrates a mass arising from the anterior fourth rib with underlying sclerosis of the rib (arrowhead).

View larger version (113K): [in a new window]   Figure 15a.   Pancoast tumor in a 56-year-old man who presented with right shoulder pain. (a) Initial frontal chest radiograph, which was part of a shoulder series, was interpreted as showing apical pleural thickening related to previous granulomatous disease. The right first rib cortex is intact (arrowheads). (b) On a frontal chest radiograph obtained 8 weeks later, there is early destruction of the medial margin of the first rib (arrowheads). (c) Frontal chest radiograph obtained 3 weeks after b shows nearly complete destruction of the first rib (arrowheads). The irregular interface of the mass with the lung indicates a pulmonary origin. (d) CT scan obtained at the same time as c shows a mass at the thoracic apex that also invades the adjacent T2 vertebral body (arrowheads).

View larger version (127K): [in a new window]   Figure 15b.   Pancoast tumor in a 56-year-old man who presented with right shoulder pain. (a) Initial frontal chest radiograph, which was part of a shoulder series, was interpreted as showing apical pleural thickening related to previous granulomatous disease. The right first rib cortex is intact (arrowheads). (b) On a frontal chest radiograph obtained 8 weeks later, there is early destruction of the medial margin of the first rib (arrowheads). (c) Frontal chest radiograph obtained 3 weeks after b shows nearly complete destruction of the first rib (arrowheads). The irregular interface of the mass with the lung indicates a pulmonary origin. (d) CT scan obtained at the same time as c shows a mass at the thoracic apex that also invades the adjacent T2 vertebral body (arrowheads).

View larger version (102K): [in a new window]   Figure 15c.   Pancoast tumor in a 56-year-old man who presented with right shoulder pain. (a) Initial frontal chest radiograph, which was part of a shoulder series, was interpreted as showing apical pleural thickening related to previous granulomatous disease. The right first rib cortex is intact (arrowheads). (b) On a frontal chest radiograph obtained 8 weeks later, there is early destruction of the medial margin of the first rib (arrowheads). (c) Frontal chest radiograph obtained 3 weeks after b shows nearly complete destruction of the first rib (arrowheads). The irregular interface of the mass with the lung indicates a pulmonary origin. (d) CT scan obtained at the same time as c shows a mass at the thoracic apex that also invades the adjacent T2 vertebral body (arrowheads).

View larger version (131K): [in a new window]   Figure 15d.   Pancoast tumor in a 56-year-old man who presented with right shoulder pain. (a) Initial frontal chest radiograph, which was part of a shoulder series, was interpreted as showing apical pleural thickening related to previous granulomatous disease. The right first rib cortex is intact (arrowheads). (b) On a frontal chest radiograph obtained 8 weeks later, there is early destruction of the medial margin of the first rib (arrowheads). (c) Frontal chest radiograph obtained 3 weeks after b shows nearly complete destruction of the first rib (arrowheads). The irregular interface of the mass with the lung indicates a pulmonary origin. (d) CT scan obtained at the same time as c shows a mass at the thoracic apex that also invades the adjacent T2 vertebral body (arrowheads).

View larger version (155K): [in a new window]   Figure 16a.   Osteochondroma in a 29-year-old man who presented with fever. (a) Frontal chest radiograph shows an area of increased opacity overlying the right anterior fifth rib. This finding could be mistaken for focal pneumonia. Closer inspection reveals expansion of the rib cortex (arrowheads) and calcification (arrow). (b) Lateral view shows the area of increased opacity oriented along the course of the rib (arrowheads; cf Fig 14b). (c) CT scan shows a sessile mass with cortical and medullary continuity projecting into the lung. Calcification is present in the cartilaginous cap of the mass (arrow).

View larger version (133K): [in a new window]   Figure 16b.   Osteochondroma in a 29-year-old man who presented with fever. (a) Frontal chest radiograph shows an area of increased opacity overlying the right anterior fifth rib. This finding could be mistaken for focal pneumonia. Closer inspection reveals expansion of the rib cortex (arrowheads) and calcification (arrow). (b) Lateral view shows the area of increased opacity oriented along the course of the rib (arrowheads; cf Fig 14b). (c) CT scan shows a sessile mass with cortical and medullary continuity projecting into the lung. Calcification is present in the cartilaginous cap of the mass (arrow).

View larger version (125K): [in a new window]   Figure 16c.   Osteochondroma in a 29-year-old man who presented with fever. (a) Frontal chest radiograph shows an area of increased opacity overlying the right anterior fifth rib. This finding could be mistaken for focal pneumonia. Closer inspection reveals expansion of the rib cortex (arrowheads) and calcification (arrow). (b) Lateral view shows the area of increased opacity oriented along the course of the rib (arrowheads; cf Fig 14b). (c) CT scan shows a sessile mass with cortical and medullary continuity projecting into the lung. Calcification is present in the cartilaginous cap of the mass (arrow).

View larger version (131K): [in a new window]   Figure 17a.   (a-c) Chondrosarcoma in a 45-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity overlying the middle of the right lung. (b) Lateral view shows a mass in the chest wall smoothly bulging into the lung (arrows). Rounded calcifications may be seen in the anterior portion of the mass (arrowheads). (c) CT scan shows the large mass in the chest wall. The mass contains nodular and ring calcifications typical of chondroid matrix (arrow). (d) CT scan obtained in a 30-year-old man shows a smaller chondrosarcoma arising at the costochondral junction. This tumor also contains nodular and ring calcifications (arrow).

View larger version (124K): [in a new window]   Figure 17b.   (a-c) Chondrosarcoma in a 45-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity overlying the middle of the right lung. (b) Lateral view shows a mass in the chest wall smoothly bulging into the lung (arrows). Rounded calcifications may be seen in the anterior portion of the mass (arrowheads). (c) CT scan shows the large mass in the chest wall. The mass contains nodular and ring calcifications typical of chondroid matrix (arrow). (d) CT scan obtained in a 30-year-old man shows a smaller chondrosarcoma arising at the costochondral junction. This tumor also contains nodular and ring calcifications (arrow).

View larger version (154K): [in a new window]   Figure 17c.   (a-c) Chondrosarcoma in a 45-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity overlying the middle of the right lung. (b) Lateral view shows a mass in the chest wall smoothly bulging into the lung (arrows). Rounded calcifications may be seen in the anterior portion of the mass (arrowheads). (c) CT scan shows the large mass in the chest wall. The mass contains nodular and ring calcifications typical of chondroid matrix (arrow). (d) CT scan obtained in a 30-year-old man shows a smaller chondrosarcoma arising at the costochondral junction. This tumor also contains nodular and ring calcifications (arrow).

View larger version (83K): [in a new window]   Figure 17d.   (a-c) Chondrosarcoma in a 45-year-old man. (a) Frontal chest radiograph shows a vague area of increased opacity overlying the middle of the right lung. (b) Lateral view shows a mass in the chest wall smoothly bulging into the lung (arrows). Rounded calcifications may be seen in the anterior portion of the mass (arrowheads). (c) CT scan shows the large mass in the chest wall. The mass contains nodular and ring calcifications typical of chondroid matrix (arrow). (d) CT scan obtained in a 30-year-old man shows a smaller chondrosarcoma arising at the costochondral junction. This tumor also contains nodular and ring calcifications (arrow).

View larger version (139K): [in a new window]   Figure 18a.   Osteosarcoma in a 24-year-old woman. (a) Frontal chest radiograph shows an ill-defined area of increased opacity over the lower portion of the right lung. The underlying right anterior sixth rib cannot be discerned. (b) Lateral view shows only a vague area of increased opacity with a smooth inner margin projected over the lower sternum (arrowheads). (c) Unenhanced CT scan reveals a densely calcified mass destroying the rib. Although the location of the mass is typical for the more common chondroid tumors, cloudlike osteoid matrix calcification is present.

View larger version (145K): [in a new window]   Figure 18b.   Osteosarcoma in a 24-year-old woman. (a) Frontal chest radiograph shows an ill-defined area of increased opacity over the lower portion of the right lung. The underlying right anterior sixth rib cannot be discerned. (b) Lateral view shows only a vague area of increased opacity with a smooth inner margin projected over the lower sternum (arrowheads). (c) Unenhanced CT scan reveals a densely calcified mass destroying the rib. Although the location of the mass is typical for the more common chondroid tumors, cloudlike osteoid matrix calcification is present.

View larger version (121K): [in a new window]   Figure 18c.   Osteosarcoma in a 24-year-old woman. (a) Frontal chest radiograph shows an ill-defined area of increased opacity over the lower portion of the right lung. The underlying right anterior sixth rib cannot be discerned. (b) Lateral view shows only a vague area of increased opacity with a smooth inner margin projected over the lower sternum (arrowheads). (c) Unenhanced CT scan reveals a densely calcified mass destroying the rib. Although the location of the mass is typical for the more common chondroid tumors, cloudlike osteoid matrix calcification is present.

View larger version (126K): [in a new window]   Figure 19a.   Tuberculosis in a 24-year-old man who presented with fever. (a) Frontal chest radiograph shows a loculate pleural effusion and periosteal reaction along the right 9th and 10th ribs (arrowheads). (b) CT scan shows the empyema being forced into the chest wall (arrow).

View larger version (157K): [in a new window]   Figure 19b.   Tuberculosis in a 24-year-old man who presented with fever. (a) Frontal chest radiograph shows a loculate pleural effusion and periosteal reaction along the right 9th and 10th ribs (arrowheads). (b) CT scan shows the empyema being forced into the chest wall (arrow).

View larger version (118K): [in a new window]   Figure 20.   Actinomycosis in a young woman with chest pain and a draining sinus in the chest wall on the left side. Frontal chest radiograph shows periosteal reaction along the left 10th and 11th ribs (arrowheads) as well as soft-tissue swelling in the chest wall (arrows). Patchy pneumonia is seen in the left lower lobe.

View larger version (118K): [in a new window]   Figure 21.   Coarctation of the aorta in a 36-year-old man. Frontal chest radiograph shows bilateral rib notching related to enlarged, tortuous collateral intercostal arteries (arrowheads). The descending aorta contour is indented at the site of coarctation (arrow).

View larger version (129K): [in a new window]   Figure 22.   Neurofibromatosis type 1 in a 38-year-old woman. Frontal chest radiograph shows extensive notching and broad scalloping of multiple ribs. Large plexiform neurofibromas indent the lung at multiple levels (arrows).

View larger version (109K): [in a new window]   Figure 23a.   Fibrous dysplasia. (a) Abdominal radiograph obtained in a 45-year-old man with McCune-Albright syndrome shows expansion of long segments of the right 11th rib and the left 9th, 10th, and 11th ribs (arrowheads). (b) Anteroposterior rib radiograph obtained in a 33-year-old woman with polyostotic fibrous dysplasia demonstrates involvement of both long (arrows) and short (arrowheads) segments of the lower left ribs.

View larger version (102K): [in a new window]   Figure 23b.   Fibrous dysplasia. (a) Abdominal radiograph obtained in a 45-year-old man with McCune-Albright syndrome shows expansion of long segments of the right 11th rib and the left 9th, 10th, and 11th ribs (arrowheads). (b) Anteroposterior rib radiograph obtained in a 33-year-old woman with polyostotic fibrous dysplasia demonstrates involvement of both long (arrows) and short (arrowheads) segments of the lower left ribs.

View larger version (126K): [in a new window]   Figure 24a.   Paget disease in an asymptomatic 51-year-old man. (a) Lateral chest radiograph shows enlargement and marked thickening of the cortical ring shadow of the right posterior eighth rib (arrow). (b) Frontal view demonstrates thickened cortex over a long segment (arrows). (c) CT scan shows bone enlargement with cortical thickening (arrow), thereby helping confirm the radiographic findings.

View larger version (128K): [in a new window]   Figure 24b.   Paget disease in an asymptomatic 51-year-old man. (a) Lateral chest radiograph shows enlargement and marked thickening of the cortical ring shadow of the right posterior eighth rib (arrow). (b) Frontal view demonstrates thickened cortex over a long segment (arrows). (c) CT scan shows bone enlargement with cortical thickening (arrow), thereby helping confirm the radiographic findings.

View larger version (117K): [in a new window]   Figure 24c.   Paget disease in an asymptomatic 51-year-old man. (a) Lateral chest radiograph shows enlargement and marked thickening of the cortical ring shadow of the right posterior eighth rib (arrow). (b) Frontal view demonstrates thickened cortex over a long segment (arrows). (c) CT scan shows bone enlargement with cortical thickening (arrow), thereby helping confirm the radiographic findings.

View larger version (126K): [in a new window]   Figure 25a.   Sickle cell-hemoglobin C disease in a 54-year-old woman. (a) Frontal chest radiograph shows diffusely increased bone density as evidenced by the absence of the normal cortical stripes along the superior ribs (arrows). (b) Lateral view demonstrates bone sclerosis by loss of the cortical ring shadows posteriorly (arrowheads). Typical central end plate depressions (arrows) provide a clue to the underlying disease. Identical findings may be seen in patients with chronic pure sickle cell anemia.

View larger version (132K): [in a new window]   Figure 25b.   Sickle cell-hemoglobin C disease in a 54-year-old woman. (a) Frontal chest radiograph shows diffusely increased bone density as evidenced by the absence of the normal cortical stripes along the superior ribs (arrows). (b) Lateral view demonstrates bone sclerosis by loss of the cortical ring shadows posteriorly (arrowheads). Typical central end plate depressions (arrows) provide a clue to the underlying disease. Identical findings may be seen in patients with chronic pure sickle cell anemia.