TOACS FCPS Station · Chest X‑ray: Coarctation of Aorta

📷 Chest X‑ray (PA view)

Chest X-ray showing rib notching and figure-3 sign in coarctation of aorta

Figure 1 · PA chest radiograph · Coarctation of Aorta

🔍 Key radiographic features:

✓ Rib notching – inferior rib erosions (collateral intercostal vessels)
✓ Figure‑3 sign – indentation of the aorta at the coarctation site
✓ Cardiomegaly – left ventricular enlargement
✓ Prominent ascending aorta – post-stenotic dilation
✓ Enlarged left subclavian artery (if pre-ductal coarctation)

📋 Clinical scenario (examiner prompt)

A 12‑year‑old girl is referred for evaluation of upper extremity hypertension (150/90 mmHg in right arm, 95/60 mmHg in leg) discovered during school screening. She is asymptomatic but has a continuous murmur over the left infrascapular area and diminished femoral pulses (radio-femoral delay). The chest X‑ray (PA view) is shown.

Upper extremity hypertension Rib notching Radio-femoral delay Continuous murmur

🧑‍⚕️ Examiner tasks · TOACS

1. Identify the diagnosis from the X‑ray and clinical context.

2. Describe the X‑ray findings (rib notching, figure‑3 sign, cardiomegaly).

3. Explain the pathophysiology (juxtaductal narrowing → collaterals → rib notching).

4. Discuss associated conditions and management options.

⚠️ Key concept: Rib notching on chest X‑ray is a classic sign of coarctation of the aorta in older children, caused by erosion of ribs by enlarged intercostal collateral vessels. The figure‑3 sign represents the indentation of the aorta at the coarctation site.

🎯 Expected answers (for examiners)

• Diagnosis: Coarctation of the aorta (juxtaductal)
• X‑ray findings: Rib notching (3rd-8th ribs), figure‑3 sign, LV enlargement
• Pathophysiology: Narrowing → elevated LV pressure → collaterals → rib erosion
• Associated conditions: Bicuspid aortic valve (70%), Turner syndrome (45,XO)
• Management: Balloon angioplasty with stent (first-line for older children)

⚡ Quick FCPS‑style MCQ

Rib notching on chest X‑ray in a child with hypertension is most suggestive of:

A. Coarctation of the aorta B. Neurofibromatosis C. Rickets D. Osteogenesis imperfecta

Finding	Significance
Rib notching	Collateral circulation (intercostal arteries)
Figure‑3 sign	Indentation at coarctation site
Cardiomegaly	LV pressure overload
Bicuspid AV	70% association
Turner syndrome	45,XO – screen for coarctation

🩻 TOACS FCPS Station · Chest X‑ray: Coarctation of Aorta

📷 Chest X‑ray (PA view)

🧑‍⚕️ Examiner tasks · TOACS

📌 Topic summary ·