Chest wall lumps should be divided into those of skeletal origin, by far the most common, and those of nonskeletal origin. Skeletal causes of lumps include trauma, accidental or nonaccidental, rickets, and, less commonly, malignancy, infection or congenital anomalies. Nonskeletal lumps represent abnormalities of other chest wall elements resulting in accessory nipples, precocious puberty, male gynecomastia, hemangiomas, or infection. Skeletal lumps, other than a prominent xyphoid process, should all be evaluated by medical imaging, and child physical abuse should be considered in the differential diagnosis of traumatic or unexplained injuries.

• In neonates, skeletal anomalies likely represent a clavicle callus from a missed clavicle fracture, or a congenital skeletal anomaly.

• Although dark-skinned infants and toddlers are most at risk, rickets should be considered in any infant, especially breast-fed infants, who have not had vitamin D supplementation, and older children with intake less than the equivalent quantity of vitamin D (400 IU) found in 1,000 ml of vitamin D fortified milk.

• The most common infant nonskeletal lump is an accessory nipple.

• Rib fractures in an infant or child, usually posterior, strongly suggest child physical abuse. Significant force is needed to fracture children’s ribs since the thoracic cage is compliant and elastic when young. Children with acquired skeletal lumps should be evaluated for nonaccidental trauma. In preadolescents, trauma represents the most likely cause of a skeletal anomaly, usually resulting from a motor vehicle accident or fall from a height.

• Preadolescents may have either precocious thelarche or, especially when obese, pseudoprecocious puberty. Precocious puberty is much less frequent.

• Adolescent males may complain of lumps that reflect gynecomastia.

• Bone malignancies rarely present in the first decade.

• Congenital and asymptomatic lumps are usually benign. Pectus carinatum is rare and is often not diagnosed at birth but can be associated with an underlying ventriculoseptal defect.

• Growth over time raises concern for infection, malignancy, or trauma.

• A hemangioma will grow over time and then involute.

• Pain, redness, or other associated symptoms raise the concern of infection, malignancy, or trauma.

• Tenderness or erythema at the location is concerning for trauma, infection, and malignancy.

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