Acta Radiologica

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Examination of the Soft Tissues of the Chest

J. Frimann-Dahl

To cite this article: J. Frimann-Dahl (1952) Examination of the Soft Tissues of the Chest, Acta
Radiologica, 37:3-4, 246-252, DOI: 10.3109/00016925209139875

To link to this article: https://doi.org/10.3109/00016925209139875

Published online: 14 Dec 2010.

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1'HOlI THE ROEKTGEN DEPARTMEXT (DIRECIOR: J. FRIAl.4SX-DAHL), ULLEVAL HOSPITAL.
OSLO, NORWAY

Pathological changes in the soft tissues of the extremities and tlic

flanks have been thoroughly studied by various authors. LAURELL,in
1928 described the abnormal structures visible in the subcutaneous tissues
in early stages of osteomyelitis: similar changes were observed in the
flanks in peritonitis. SKARBY, in 1946 stressed the importance of a care-
ful investigation of the soft tissues of the flanks in cases of perirensl in-
flammations. CARTY and FRAR'ZELL investigated the soft tissues in a
variety of lesions of the lower extremities, and FRIMANN-DAHL used the
method in 1949 for the diagnosis of acute thrombosis.
However, in lesions of the chest, such investigations have been of
secondary importance and only occasionally used. SKARBY and LINDBLOM
examined the inner wall of the chest in extrapleural inflammations and
demonstrated that a local swelling, corresponding to the abscess, existed.
The examinations now described were performed mainly t o look for
possible changes in the soft tissue of the chest in pleuritis and empyema
and to search for evidence for a differential diagnosis in inflammatory
lesions. One would expect changes in the soft tissues t o be more evident
and pronounced in acute inflammatory processes and empyema than in
ordinary pleuritis and in pure collections of fluid in the pleural cavity.
I n other lesions such as tumors, osteochondritis and fistulas the value
of the examination has been estimated.

Technic
The teclinic is worked out as siniply as possible. The patient rnay be
examined in any posture - standing, sitting or supine. We have preferred
Submitted for publication Oct. 3 . 1951.
 EXAMINATION OF TUE SOFT TISSUXS OF THE CHEST 247
to make the exposures in the sitting position in the chest-stand sub-
sequent to the conventional examination of the lungs. The supine position
has been used only for patients who are confined to bed. For comparison
the two sides are examined on the same film divided into two (size 24 x
30 cm.). The patient should be placed in a semi-oblique position with the
back against the casette and rotated 45" forward. The two sides must be
turned. a t the same angle, otherwise the structure will be unequally pro-
jected and the one may seem broader and thicker than the other. It may
be necessary t o make two exposures in different degrees of obliquity in
order to visualize the soft tissue a t the most suitable angle. I n general,
the soft tissue corresponding to the dorsal axillary line should be exam-
ined. In women care must be taken to turn the breast away to avoid over-
lapping of the shadows. The arm must be kept aside and, in the prone
position, rotated inwards. They should remain a t the same level on each
side and not be placed above the head as the scapulae then move laterally
and may cover the axillary soft tissue. We have used 60 kv. 200 ma, dis-
tance m. Exposures with a moving grid seem to give about the same
results as those made without any secondary screening. A convenient
exposure is soon obtained, and we have found a reliable criterion for an
adequate quality of the films to be a clear outlining of the structures by
the skin. Attention should be given to the processing so that the films
are not overdeveloped.

Anstoiuicd Considerations
d dense narrow band, the serratus muscle, stretches close to the thora-
cic wall from the axilla down towards the flank. The lateral contour of
this muscle often has a wave-like appearance. Parallel to this and more
laterally, a long, band-like, more regular density is observed correspond-
ing to the latissimus dorsi. Between these two muscles a clear zone, due
to a fat layer, is formed. More laterally the subcutaneous fat and the skin-
line bound the field. (Fig. 1 .) All these structures are nourished by branches
of the intercostal arteries, which may be definitely shown in cadaver
specimens after the injection of a contrast medium into the aorta. On the
original films the smallest vessels are observed running outwards t o the
subcutaneous fat and the skin.

Material
A great number of patients with fluid in the pleural cavity and inflam-
matory processes in the lung parenchyma have been examined by this
method. The material comprises 35 cases of pleurisy, mainly of tubercu-
lous origin. Clinical experience teaches that in some cases of pleurisy
17 --320088. drltr Rudiologirct. VoZ. 37.
248 J . FRIMANN-DAHL

Fig. 1. Soft tissue film of the chest. Contrast
injected in the aorta. Inter-costal arteries
penetrating the chest wall and running out
to the skin. (Specimen).
Fig. 2. Soft tissues of the chest in a
case of empyema, showing edema.
Space between muscles obliterated.
Network-like designs in subcutaneous
tissue, Similar findings have not heen
observed in pleurisy.

percussion may give a more decreased resonance than would be expected

from the amount of fluid present. Changes in the soft tissue could thus
be anticipated, but positive findings have so far been scanty. In some
 ESAMINATION O F THE SOFT TISSUES OF TLIE ('IIEST 249

F1g. 3 a. Fig. 3 11.

Fig. 3 x . Changes in the .oft tissues in a case of a costal metaitasis. Edema and
Iiyl)(~eniiacaubecl by the tumor infiltration.
1). Left side for compa1ison.

instance.; a slight edeina has been observed and in one case; a thickenin2
of tlic ))skin-lineo could be demonstrated.
I n rmpyernas tlie positive findings have also generally been few. How-
ever, in some instances iiiarked changes Tirere foixnd in tlie soft tissues
right out as far as the skin. (Fig. 2.) The findings are very similar t o
those in acute inflanzinatory processes followed by etlenia. The clear
zone between the serratus and the latissimixs muscles is obliterated and
reticulated structures ilia? be observed in the subcutaneous fat layer.
The most pronouiiced changes were visible in a case of costal destruc-
tion. d coiiventional film showed a medium-sized collection of fIuid in
2.iO J. FRI,\IAIUI\'-DAIIL

Fig. 4 a. Fig. 1 b. Fig. 5.

Fig. 4. a. Abscess in the subcutaneous tissues after thoracoplasty.
1). Sound side for comparison.
Fig. 5. Thoracic tumor showing extrapleural and subcostal swelling.

t h e pleural cavity and the diagnosis was pleurisy. However, re-exaniina-

tion revealed a thickening and broadening of the soft tissues and blurring
o €the muscular borders. On one of the films, a little more exposed, a local
defect was observed in the 5th rib corresponding to the axillnry line.
(Fig. 3.) Biopsv revealed a metastasis probably from a hypernephroma.
Thus the diagnosis of tumor infiltration was made indirectly from the
soft tissue examination.
I n a case in which thoracoplastp l i d been performed, a localized
 ESAMIINATIOX OF THE SOFT TISSUES OF TTIE CHEST 251

Fig. 6. Thickening of
the soft tissue in a case
of coarctation. Tortuous
vessels present on the
original film.

thickening of the soft tissues with a corresponding coniplete blurring

of the intermuscular spaces was observed. This opacity proved t o be a n
abscess which subsided after surgical treatment. (Fig. 4.)
X s pointed out by SKARBYand LISDBLOM, extrapleural thickening
and subcostal sweIlings in cases of thoracic tumors and abscesses may
be very well shown on soft tissue films. (Fig. 5 . )
The possibility of showing the tortuous vessels in the soft tissue of t h e
chest in cases of coarctatio aortae is also of interest. PEREIRAS and
CASTELLANOS have demonstrated such changes by means of a contrast
medium injected retrogradely into the aorta. Only one case of coarcta-
tion was available for soft tissue investigation in this material and the
films did not show the changes satisfactorily enough for detailed re-
production. (Fig. 6.) Further experience in this field may provide a new
diagnostic aid in this lesion.
252 J. FRIMANN-DABL

Notching of the ribs is certainIy pathognomonic evidence of this le-

sion, but changes in the ribs are lacking in at least 20 yo of the cases;
in such instances soft tissue films may give decisive support for the
diagnosis.
SUMMARY
Examinations of the soft tissues of the chest are described. Films are made with
the patient supine on a Bucky table or sitting in an ordinary chest-stand, The method
may bc raluable in differentiating various lesions of the chest, such as abscesses. tumors
and empyemas. Soft tissue changes in a case of coarctation are described.

Z U SA 1131E N F A S SU N G
Untersuchungen der Weichteile der Thorax siiid beschrieben. Die Bufnahnien wir-
den in liegender Stellung am Trochoskop, oder in sitzender Stellung gemacht. Die Metode
kann fiir die Entdeckung von Tumoren, Abscessen und Empyemen wertvoll sein. Weich-
teilbefunde in einem Fall von Coarctatio sind beschrieben.

RESUME
1)cscription Jes parties molles d u thorax. Les cliches sont pris avm Ic nialatle couch4
sur une vtahle de Bucky)) ou assis d a m une position thoracique ordinairc. Le proc6d4
pent aroir de l'importance pour distingner les diverses affections du thorax. telles que
abciq tumeurs et empyhmes. Les altkrations survenues dans les parties inollts au cours
d'un cas rle coarctation aortique sont dhcrites.

REFERENCES
1. CARTY,J.: Soft tissue roentgenography. Am. J. Roentgenol. 35 (1936), 474.
2. FRANTZELL. 8.:Rontgenologische Weichteilsleiden r o n Cutis und Subcutis. d c t a
radiol. 25 (1945), 460.
3 . FRIMAKS-DAHL, J.: Roentgen Examination in acute Thrombosis. Radiolog?. 34 (1950),
408.
4. LAURELL, H.: c b e r die Roiitgensymptorne bei einem Fail von intra- und retropetitone-
aler Entziindung und iiber friihe rontgenologische Zeichen der akuten Osteomyelitis.
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5 . LINvuBLou, K.: Subcostal swelling of the soft tissue in osteochondritis. -4cta radiol. 25
(1944), 610.
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