Chronic pain associated with costal margin rupture

A 60-year-old man presented to our clinic with a 5-year history of severe, chronic chest pain. His symptoms began in September 2013 when he had a prolonged upper respiratory illness and persistent cough. After 2 weeks of coughing, he awoke one morning with severe left-sided chest pain and a large bruise over his left chest wall. He presented to his local hospital, where he was found to have a displaced left sixth rib fracture and a large left hemothorax, eventually requiring video-assisted thoracoscopic surgical (VATS) evacuation. After recovering from his acute illness, he developed chronic left chest wall pain and persistent clicking and popping of his costal margin. Along with the pain, he developed symptoms of depression and post-traumatic stress to a point at which he lost his business and had considered suicide. On physical examination, he had normal vital signs and a body mass index of 28.3 kg/m2. He had two scars on his left chest from his VATS. His left chest wall was severely tender to palpation from the midaxillary line to the sternum. He had marked, palpable instability of his costal margin on deep inspiration. He had no pain or tenderness on the …