The medullary canal of the clavicle is large enough to accommodate commonly used intramedullary devices in the majority of cases. The medullary canal extends far enough medially and laterally for an intramedullary device to adequately bridge most middle third clavicle fractures. An alternative surgical option should be available in theatre when treating females as the medullary canal is too small to pass an intramedullary device past the fracture site on rare occasions.

Diagnosis of pulmonary tuberculosis (PTB) in children is challenging and radiographs are often normal or non-specific. Access to the chest using ultrasound is difficult, but access to the abdomen is simple and carries no radiation burden. Diagnosis of PTB using abdominal lymphadenopathy as a surrogate for mediastinal lymphadenopathy may present a simple and accurate additional diagnostic technique that is of value in developing countries. We determined the prevalence of abdominal lymphadenopathy in paediatric patients with confirmed TB presenting with respiratory symptoms. Chest radiographs and abdominal ultrasounds of 47 children with confirmed TB and respiratory symptoms were reviewed. The prevalence of abdominal TB was determined and comparisons made between thoracic and abdominal lymphadenopathy to determine the relative value of ultrasound. On ultrasound, the prevalence of abdominal lymphadenopathy was 19% and solid organ involvement was found in 23% of patients. Some 70% of children had thoracic lymphadenopathy on chest radiography, with 89% of patients having evidence of PTB. If chest radiography were to be considered the radiological reference standard, abdominal ultrasonography had a sensitivity of 18% (95% CI 7.0–35.5%) with a specificity of 79% (95% CI 49.2–95.1%) for thoracic lymphadenopathy. Ultrasound and chest radiography in combination detected a total of 36 patients with lymphadenopathy, with a 6% improvement in the rate of lymphadenopathy detection; however, this was not statistically significant. The prevalence of abdominal TB of 23% is noteworthy. We suggest that abdominal ultrasound has a definitive adjunctive role in investigating children with suspected TB.

The MRI criteria for diagnosis of TBM apply to HIV-infected children. The presence of nodular meningeal disease in all HIV-infected children has not previously been reported and requires further investigation.

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A 4-year-old girl was referred to Tygerberg Academic Hospital with a long-standing history of an asymptomatic anterior chest wall 'lump' . On physical examination, a bony mass was palpated in relation to the anterior aspect of the left 4th rib. Plain radiography demonstrated anterior widening of the left 4th rib (Fig. 1). Fearing a sinister cause, a multidetector computed tomography (MDCT) examination of the chest, with 3D reconstruction and volume rendering, was performed (Fig. 2). A congenital bifid left 4th rib was demonstrated. DiscussionA bifid rib, or sternum bifidum, is a congenital abnormality of the anterior chest wall, with the sternal end of the rib cleft into two. It occurs in approximately 1.2% of the population and is usually unilateral. Bifid ribs are frequently asymptomatic. A single bifid rib is most commonly a normal incidental finding discovered on chest radiography.1 It may be associated with Gorlin-Goltz basal cell nevus syndrome, a rare autosomal dominant condition characterised by multiple nevoid basal cell carcinomas, jaw cysts and bifid ribs. Further features include other rib anomalies, deficiency of the lateral clavicle, mandibular hypoplasia, macrocephaly and mental retardation.1 A large number of disease processes frequently affect the chest wall in children, including congenital anomalies, inflammatory and infectious processes and neoplasms, both benign and malignant.Congenital anomalies of the anterior chest wall are common. Apart from congenital anomalies, other benign primary bony lesions include fibrous dysplasia, aneurysmal bone cyst and osteochondromata. 4 Infectious causes such as osteomyelitis, tuberculosis and fungal infection could also be considered, although these lesions are often more aggressive and rarely asymptomatic. The literature highlights the fact that malignant lesions of the chest wall are commonly aggressive and are often associated with symptoms such as pain, dyspnoea and local tenderness. Plain radiography often reveals bony and pleural involvement in addition to chest deformities. It can be concluded for small, non-tender lesions isolated to the anterior chest wall that demonstrate no history of interval growth, that clinical examination and chest radiography may suffice, with ultrasound as backup.