Beyond the chest wall: anterior rib malformation causing hepatic compression in an adolescent

Anterior chest wall deformities are rare in paediatric patients and may occasionally present with atypical clinical and radiological findings. We report the case of an adolescent presenting with intermittent chest pain, in whom imaging revealed an unusual anterior costal malformation associated with focal compression of the hepatic dome, initially raising suspicion of a hepatic lesion. Comprehensive cardiological and radiological evaluation excluded primary cardiac or hepatic disease. Cross-sectional imaging demonstrated a deformity of the anterior costal arch causing a well-defined indentation of the liver surface, consistent with extrinsic compression rather than true parenchymal pathology. Because of persistent symptoms and the anatomical abnormality, the patient underwent surgical correction. Intraoperative findings confirmed a costal deformity with direct mechanical compression of the liver. Surgical remodelling of the chest wall was successfully performed, with an uneventful postoperative course. This case emphasises the importance of considering chest wall anomalies in the differential diagnosis of apparent hepatic lesions and unexplained chest pain in children. Careful imaging interpretation is essential to avoid misdiagnosis, while a tailored surgical approach can provide effective symptom relief in selected patients.