今日の臨床サポート

肋軟骨炎

著者: 十倉知久 八戸市立市民病院 救命救急センター

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2022/09/28
患者向け説明資料

概要・推奨   

  1. 肋軟骨部(肋骨肋軟骨接合部、胸肋関節部を含む)の触診で腫脹・熱感・発疹を伴わない圧痛があり、かつ再現性があることが非常に重要である(推奨度1M)
  1. 本疾患は除外診断が非常に重要であり、特に心血管リスクや心肺症状がある場合、心電図、胸部X線、必要に応じて採血、胸部CTを行う(推奨度1)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
十倉知久 : 未申告[2022年]
監修:箕輪良行 : 未申告[2022年]

改訂のポイント:
  1. 定期レビューを行い、特に診断について追記した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 肋軟骨炎は、肋骨肋軟骨接合部や胸肋関節の非化膿性の炎症であり、通常は片側性の疼痛で複数箇所に起こる[1][2]
  1. 一般的に40~50歳の中年に発症して、やや女性に多い傾向がある[1][2]
  1. プライマリーケアセッティングでは、受診患者の約1~3%が胸痛を主訴としており、20~50%が胸壁由来と診断され、肋軟骨炎と診断されるのは6~13%である[1][2][3]
  1. 一方、救急部門では、受診患者の約9~10%が胸痛を主訴としており、非心原性胸痛の15~45%が筋骨格系由来と診断される[1][4]
  1. 特に虚血性心疾患との鑑別が重要である。高血圧、糖尿病、喫煙歴などのリスク因子がある場合は、心電図や胸部X線が必要となる。
  1. その他、後述する鑑別疾患を常に考慮すべきであり、場合により他の画像が必要となることがある。
  1. 治療に関するエビデンスはないが、非ステロイド抗炎症薬(NSAIDs)を使用することが多い。通常、約3週間で自然軽快して良好な経過をたどる。
 
肋骨肋軟骨接合部、胸肋関節

肋骨肋軟骨接合部、胸肋関節は肋軟骨炎の好発部位である。

出典

img1:  植西憲達先生ご提供
 
 
問診・診察のポイント  
  1. 肋軟骨部(肋骨肋軟骨接合部、胸肋関節部を含む)の触診で腫脹・熱感・発疹を伴わない圧痛があり、かつ再現性があることが非常に重要な診断ポイントとなる[1][2][3]
  1. 典型的な症状は、深呼吸、咳嗽、体幹の動きで増悪する胸骨周囲の胸痛である[1][2][3]
  1. 第2~5肋軟骨レベルで起こることが多い。

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文献 

Timothy Mott, Gregory Jones, Kimberly Roman
Costochondritis: Rapid Evidence Review.
Am Fam Physician. 2021 Jul 1;104(1):73-78.
Abstract/Text
PMID 34264599
Anne M Proulx, Teresa W Zryd
Costochondritis: diagnosis and treatment.
Am Fam Physician. 2009 Sep 15;80(6):617-20.
Abstract/Text Costochondritis, an inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall, is a common condition seen in patients presenting to the physician's office and emergency department. Palpation of the affected chondrosternal joints of the chest wall elicits tenderness. Although costochondritis is usually self-limited and benign, it should be distinguished from other, more serious causes of chest pain. Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation. History and physical examination of the chest that document reproducible pain by palpation over the costal cartilages are usually all that is needed to make the diagnosis in children, adolescents, and young adults. Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph. Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status. Clinical trials of treatment are lacking. Traditional practice is to treat with acetaminophen or anti-inflammatory medications where safe and appropriate, advise patients to avoid activities that produce chest muscle overuse, and provide reassurance.

PMID 19817327
Mark H Ebell
Evaluation of chest pain in primary care patients.
Am Fam Physician. 2011 Mar 1;83(5):603-5.
Abstract/Text
PMID 21391528
Maria M Wertli, Tenzin D Dangma, Sarah E Müller, Laura M Gort, Benjamin S Klauser, Lina Melzer, Ulrike Held, Johann Steurer, Susann Hasler, Jakob M Burgstaller
Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study.
PLoS One. 2019;14(2):e0211615. doi: 10.1371/journal.pone.0211615. Epub 2019 Feb 1.
Abstract/Text BACKGROUND: Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out.
OBJECTIVE: To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).
METHODS: Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing.
RESULTS: In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation.
CONCLUSION: In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.

PMID 30707725
S E Epstein, L H Gerber, J S Borer
Chest wall syndrome. A common cause of unexplained cardiac pain.
JAMA. 1979 Jun 29;241(26):2793-7. doi: 10.1001/jama.241.26.2793.
Abstract/Text Twelve patients with severe, often incapacitating chest pain initially believed to be cardiac in origin were shown on subsequent evaluation to have chest wall syndrome. Diagnosis was suspected by the atypical nature of pain in 11 of 12 patients and confirmed by chest wall tenderness simulating the spontaneously occurring pain in all. Seven patients had chest wall syndrome in conjunction with other associated cardiac conditions. Five patients had isolated chest wall syndrome. All five had normal ejection fractions and no regional wall abnormalities on radionuclide cineangiographic studies performed during symptom-limited supine exercise, findings observed in few patients with coronary artery disease. Chest wall syndrome should be considered in all patients with chest pain, as its recognition can greatly aid in patient care.

PMID 448839
G Rovetta, P Sessarego, P Monteforte
Stretching exercises for costochondritis pain.
G Ital Med Lav Ergon. 2009 Apr-Jun;31(2):169-71.
Abstract/Text The term costochondritis (ChC) indicates a painful and persistent inflammation at the costochondral or costosternal junction. The usual conservative treatment (NSAIDs), local splinting, local heat) and sometimes disappointing. The aim of this study is to evaluate the effect of stretching exercises in a group of patients affected with ChC. This retrospective open study involved 51 outpatients with diagnosis of ChC: thirty four consecutive patients were treated with stretching exercises, 34 patients matched for age, pain and disease duration constituted the control group. All the patients had spontaneous pain at least in the one of the costochondral junctions at the third to seventh rib. The intensity of spontaneous pain was measured by means of the visual analogic scale of Scott-Huskisson. The homogeneity of the two groups at the beginning of the study was checked for VAS, for disease duration and age by means of Mann-Whitney test for non-parametric measures. The statistical analysis of pain was done by Friedman analysis of variance and Student-Newman-Keuls multiple comparisons tests. The results showed a progressive significant amelioration in patients treated with stretching exercises as respect as the control group (p<0.001). The goal of therapy of costochondritis is to reduce inflammation and the pain. The NSAIDs, local injection of anaesthetic or steroid has insufficient effectiveness. The possibility to improve the pain by means of simple stretching exercises can supply a useful instrument in order to treat the condition of these patients.

PMID 19827277
M Kamel, H Kotob
Ultrasonographic assessment of local steroid injection in Tietze's syndrome.
Br J Rheumatol. 1997 May;36(5):547-50. doi: 10.1093/rheumatology/36.5.547.
Abstract/Text The purpose of this study was to investigate the value of ultrasonographic examination in the diagnosis of Tietze's syndrome and assessment of the changes in costal cartilage following local steroid injection. Nine patients with Tietze's syndrome and 20 normal subjects were studied consecutively. Ultrasound examination was performed using a Sonoline SL Siemens Machine with a linear 5 MHz small parts transducer and ATL Apogee 800 with a 10 MHz linear array transducer. The affected costochondral joint was injected with a combination of 15 mg of triamcinolone hexacetonide and 1 ml of 2% lidocaine. Ultrasound examination was performed following the clinical evaluation and repeated immediately after the injection, then 1 and 4 weeks later. Abnormal echo appearance was detected as an inhomogeneous increase in the echogenicity with intense broad posterior acoustic shadow. Hypoechogenicity and a decrease in the size of costal cartilage were observed 1 week after local steroid injection with absence of the posterior acoustic shadowing. Ultrasonographic examination of costal cartilage is easy and quick to perform. We believe that ultrasound should be the screening procedure of choice for Tietze's syndrome. Local steroid injection proved to be clinically safe and effective in the treatment of patients with Tietze's syndrome.

PMID 9189056

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