• Inflammation of unknown etiology (histologic examination is usually normal)
• Infection
  • Complication of median sternotomy
  • 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)
  • Occurs by spread from adjacent osteomyelitis or may arise de novo during surgery
    • Bacterial
      • Staphylococcus aureus (especially after thoracic surgery)
      • Salmonella (in sickle cell disease)
      • Escherichia coli
      • Pseudomonas species
      • Klebsiella species
    • Fungal
      • Aspergillus flavus
      • Candida albicans
    • Posttrauma

• Costochondritis accounts for 10% to 22% of all pediatric chest pain.
• Peak age for chest pain in children is 12 to 14 years old.
• Incidence of sternal wound infections following median sternotomy is 0.1% to 1.6%.

• 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

• Cardiovascular
  • Myocardial infarction
  • Pericardial effusion
  • Dissecting aneurysm
• Pulmonary
  • Pneumonia
  • Pulmonary embolism
  • Pneumothorax
• Mechanical
  • Muscle strain
  • Stress fractures
  • Trauma
• Rheumatologic
  • Rheumatoid arthritis
  • Ankylosing spondylitis
• Oncologic
  • Rhabdomyosarcomas
• Leukemia
  • Ewing sarcoma
• Miscellaneous
  • Tietze syndrome
  • Psychogenic chest pain
  • Breast tissue pain (both sexes)

• 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 fourth to sixth 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.

• Onset is usually abrupt, but can be gradual.
• Believed to be caused by a minor trauma, though 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 second or third costochondral joint
• Pain is aggravated by sneezing, coughing, deep inspiration, or twisting motions of the chest.
• No differences in frequency between sexes

• Slow, insidious course
• Usually unimpressive clinical symptomatology

• 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.

• WBC not helpful (even when infection present)

• Radiologic studies (chest radiography, CT) 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:
  • Not highly specific

• Antiinflammatory and analgesic agents
• Reassurance
• If pain disturbs normal activities and sports, infiltration with local anesthetic may prove useful.

• Prolonged course of IV antibiotics
• Prompt surgical resection of all involved cartilage
• Reconstructive surgery with muscular flaps should be done.

• Inflammatory costochondritis
  • Long-lasting condition
  • Follow-up once a year is recommended.
• Infectious costochondritis
  • Long-term follow-up after surgery is mandatory.

• 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.
• 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).

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.

Q: Is costochondritis related to arthritis?
A: There is no relation to any form of arthritis.

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Chicarilli ZN, Ariyan S, Stahl RS. Costochondritis: pathogenesis, diagnosis and management considerations. Plast Reconstr Surg 1986;77:50–59.

Culliford AT, Cunningham JN, Jeff RH. Sternal and costochondral infections following open heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:714–726.

Fraz M. Pediatric respiratory disease: diagnosis and treatment. Philadelphia: WB Saunders, 1993:162–172.

Mendelson G, Mendelson H, Horowitz SF, et al. Can ^99mtechnetium methylene diphosphate bone scans objectively document costochondritis?Chest 1997;111:1600–1602.

Miller JH. Accumulation of gallium-67 in costochondritis. Clin Nucl Med 1980;5:362–363.

Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: a prospective study. Pediatrics 1988;82:319–323.