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The CT characteristics of three cases of sternoclavicular pyarthrosis are reported. These cases demonstrate the value of CT in the early detection of the septic sternoclavicular joint and the associated osteomyelitis. The role of CT in the follow-up evaluation and guided needle aspirations of these infectious processes is also discussed.
We describe a 68-year-old woman who had suffered pain, swelling, heat, and redness in the region of both clavicles for the last 2 years. Her erythrocyte sedimentation rate was markedly elevated; tests for rheumatoid factor were negative. At surgical exploration, ankylosis of the sternoclavicular joints, especially on the left side, was found. Biopsy revealed chronic nonspecific inflammation with new bone formation, consistent with the diagnosis of sternocostoclavicular hyperostosis or pustulotic arthroosteitis.
A 46-year-old man who had been suffering from palmoplantar pustulosis (PPP) for 3 years had anterior chest pain and left temporal pain from six months after the onset of his disease. A bone scan revealed abnormal uptake at the sternoclavicular joint and left temporal region. The head CT and MRI gave the diagnosis of temporal osteomyelitis with meningitis and myositis. His headache continued even after tonsillectomy and was effectively treated with cyclosporine A (3 mg/kg/day). Oral cyclosporine A was beneficial for the osteomyelitis and skin lesions. Sterile lytic bone lesions occurring most often at the sternocostoclavicular joint have been associated with PPP. However, there have been no reports of a PPP patient with temporal osteomyelytic involvement.
Three patients are reported with Friedrich's disease, a rare deformity of the sternoclavicular joint. This clinical entity is a symptomatic expression of osteonecrotic changes of the medial inferior border of the clavicle, with a still unknown pathogenesis. In our own experience and according to that of others, conservative treatment for this rare condition may be advisable.
PURPOSE: Relapsing polychondritis is a generalized recurring disease of cartilage that involves joints, trachea, bronchi, laryngeal cartilages, costal cartilages, and cartilages of the ear and nose. It is associated with autoimmune diseases, including Hashimoto disease in some cases. METHODS: The authors evaluated a 29-year-old man with relapsing polychondritis who had symptoms and signs of a common cold for 2 months and anterior chest pain near the sternum for 1 month. RESULTS: After the diagnosis, the authors found that the patient had a history of thyroid therapy for hyperthyroidism 15 years before. Tc-99m MDP bone scintigraphy performed to evaluate anterior chest pain showed diffusely increased accumulation of radioactivity in all costocartilages and sternoclavicular joints. Based on that information, relapsing polychondritis was diagnosed. Ga-67 citrate scintigraphy was preformed to determine the optimum biopsy site of the cartilage. The diagnosis was histologically supported by the results of the open biopsy. CONCLUSIONS: In this case, Tc-99m MDP bone scintigraphy was useful for diagnosing relapsing polychondritis, and Ga-67 citrate scintigraphy was helpful in determining the biopsy site.
Hemodialysis patients are known to develop the complication of extrapulmonary tuberculosis more frequently than the general population. Tuberculous arthritis is a rare form of extrapulmonary tuberculosis and is reported to occur in approximately 1% of cases in nonuremic patients. Only 3 cases in dialysis patients, who were not proven by a bacterial culture or had died before treatment, have been reported. We report herein a culture-proven case of tuberculous arthritis developing at the sternoclavicular joint, which initially mimicked an apparent neoplasm in a hemodialysis patient. A favorable outcome was obtained after antituberculous therapy. Tuberculosis must be considered one of the most significant diagnoses in hemodialysis patients who present with a tumor-like lesion.
Bacterial infection of the sternoclavicular joint is an unusual event, with cases being reported in those with diabetes mellitus, in intravenous drug abusers, and in patients afflicted with rheumatoid arthritis. A case of this unique infection occurred in a person not known to be at risk for septic arthritis. Our report shows the difficulty in diagnosing this disorder.
The cases of 14 adult females with swelling, tenderness, and sclerosis of the inferomedial part of the clavicle are presented. They were seen during a 16-year period, suggesting that the condition is rare. In ten patients strain at the sternoclavicular joint seemed to be an etiological factor. Eleven patients were followed for periods of 1-13 years (mean 5 years). The clavicular sclerosis regressed and they all developed signs of osteoarthrosis. Based upon available biopsy results and review of reported cases, it is hypothesized that the radiographic changes are due to osteonecrosis of the medial end of the clavicle with subsequent development of osteoarthrosis.
OBJECTIVE: The purpose of this retrospective study was to examine the value of whole-body nuclear medicine imaging and to evaluate the typical scintigraphic pattern of sternocostoclavicular hyperostosis (SCCH) and/or pustulotic arthroosteitis (PAO). In this entity the correct diagnosis is frequently missed because of uncharacteristic changes in other imaging modalities. MATERIALS AND METHODS: Forty-nine patients (age range 15-65 years old, mean age 36 years) with sternocostoclavicular hyperostosis (SCCH) and/or pustulotic arthroosteitis (PAO) were examined with whole-body scintigraphy and conventional radiography. RESULTS: Forty-three of 49 patients with SCCH/PAO showed a characteristic "bullhead"-like high tracer uptake of the sternocostoclavicular region with the manubrium sterni representing the upper skull and the inflamed sternoclavicular joints corresponding to the horns (= bullhead sign). Scintigraphy revealed additional skeletal manifestations (spondylitis, sacroiliitis, osteitis) in 33 of 49 patients with SCCH and/or PAO. CONCLUSIONS: Bone scintigraphy is the imaging modality of choice for the diagnosis of skeletal involvement in PAO. Nuclear medicine reveals unexpected locations and shows the typical pattern of focal hot spots of the spine, sacroiliac joints and/or appendicular skeleton in the large majority of cases in combination with a bullhead-like tracer uptake of the sternocostoclavicular region. The bullhead sign is the typical and highly specific scintigraphic manifestation of SCCH and PAO in radionuclide bone scans and helps to avoid unnecessary biopsies.
OBJECTIVES: Severe sternum necrosis requiring extended resection necessitates plastic reconstruction of the resulting defect and stabilization of the chest. We analyzed the outcome of patients undergoing bilateral pectoralis major flap repair on functional and cosmetic results, chest stabilization and pulmonary function. METHODS: Twelve patients undergoing cardiac surgery between 1997 and 2001 suffered from a deep mediastinal wound infection and sternum necrosis. After a mean of two attempts of extensive wound debridement, all 12 patients underwent complete sternal resection with plastic reconstruction by bilateral pectoralis major flaps. Risk factors were obesity (n=10) and diabetes (n=11). Six months postoperatively patients underwent physical examination, pulmonary function testing and functional CT scan. RESULTS: Three patients died in hospital (two septic multiorgan failure, one heart failure) and nine were discharged with complete wound closure. One patient suffered a lethal stroke during follow-up. At 6-month follow-up no recurrent sternum infection had occurred. Chest stability was satisfactory without impairment of pulmonary function (VC 77.5+/-12.1% at follow-up vs 77.8+/-12.5% preoperatively). Mobility and force of arms and shoulder were adequate; at CT scan the maximum distance change between the former sternoclavicular joint in inspiration versus expiration was minimal. Quality of life questionnaires showed no significant limitations except a disturbed sleep and mild restriction of executing hobbies and social activities. CONCLUSIONS: Bilateral pectoralis major flap repair is a safe technique to cure severe mediastinitis necessitating complete sternal resection. Wounds close without extensive reconstructive surgery. Cosmetic results as well as stabilization of the chest were good. Patients reported an almost uncompromised quality of life without respiratory impairment.
Persistent pulling pain in the sternum, clavicles and both first ribs, especially during cold and wet weather, necessitated medical investigations and treatment in 3 patients. Externally a cylindrical or spindle-shaped swelling of the clavicles was noticeable and two patients had signs of superior caval obstruction in addition. X-rays showed hyperostosis of the sternal and middle part of the clavicle, synostosis of the sternoclavicular joints with involvement of the two first ribs as well as a thickening and increase in breadth of the sternum. In one patient there were additional swellings of the first to fourth ribs bilaterally. During the period of observation there was no radiological progression of the bone disease. Apart from a consistently raised erythrocyte sedimentation rate blood chemistry was normal. The sterno-costo-clavicular hyperostosis led to bilateral occlusion of the subclavian veins with resulting upper venous congestion in two patients. Histology of the biopsy samples showed a characteristic hyperostotic spongiosclerosis in all three cases. The cause of this sterno-costo-clavicular hyperostosis is unknown. Clinical, radiological and histological findings indicate that it is a uniform disease which has not previously been described.
BACKGROUND: Approximately 120 cases of posterior sternoclavicular joint (SCJ) dislocation have been documented in the medical literature since it was first described in 1824 by Sir Astley Cooper, a statistic which underlies its relative rarity. It is associated with high energy trauma, and although it may present innocently enough, it is a potentially life threatening injury. CASE AND RESULTS: We describe a case in which there was no clinical evidence of complication, although CT imaging revealed complete obstruction of the brachiocephalic vein and impingement of the aorta. This required open reduction and a novel fixation technique was employed. The reduction was stable at 8 month follow up appointment as evidenced by CT scan. CONCLUSIONS: We acknowledge that this type of complication is well recognised but emphasise that it should not be managed complacently. A high index of suspicion is required to determine the presence of serious complications in this type of injury, which may manifest insidiously.
BACKGROUND: Ectopic hamartomatous thymoma is a rare benign neoplasm occurring in the deep soft tissues adjacent to the sternoclavicular joint. Although clinical presentation and diagnostic imaging can be consistent with a malignant lesion such as a sarcoma, recognition of pathologic features can readily exclude such a diagnosis. However, this remains a challenge caused by their unusual histologic features and diverse composition. Recognition of this tumor is, however, important, because it follows a benign clinical course, and conservative surgical excision is the therapy of choice. METHODS: A literature review of all reports of ectopic hamartomatous thymoma was undertaken and compared with our indexed case. RESULTS: From this review, we identified 26 previous reports. Most patients were men, with a 4.5:1 predominance. There was a wide range of ages at presentation, from 26 to 79 years. All tumors were located in the lower neck, with the exception of one arising presternally. Treatment predominantly consisted of tumor resection, with no reported recurrences on follow-up. CONCLUSIONS: We conclude that ectopic hamartomatous thymoma is an extremely rare neoplasm usually presenting in the lower neck. Correct identification of this tumor is important, because it follows a benign course, and surgical excision is adequate therapy.
Variability in growth response of the mandible after replacement of the mandibular condyle with the costochondral junction of a rib (CCJ) is common. Other donor graft sites that are more similar to the mandibular condyle might be more suitable for mandibular condylar replacement. Previous studies have shown the histomorphologic and developmental similarities between the sternoclavicular joint (SCJ) and temporomandibular joint (TMJ). The purpose of this study was to evaluate histologically short-term adaptations within the TMJ after replacement of the mandibular condyle with the autogenous sternal head of the clavicle, and to compare these adaptations with autogenous CCJ and mandibular condyle (surgical control) transplants. Bilateral vertical ramus osteotomies were performed in 12 juvenile Macaca mulatta with the left condyle being immediately replaced and the right condyle removed and replaced with either the sternal head of the clavicle or costochondral junction of a rib. All grafts were stabilized with maxillomandibular fixation for five weeks. Two animals in each group were killed at five, 11, and 17 weeks postsurgery and prepared for histologic analysis. The results indicate that: 1) incorporation of all grafts into the recipient site occurred and all animals had good mandibular function and occlusion throughout the follow-up period; 2) the clavicular and mandibular condylar grafts were incorporated sooner than the CCJ grafts; 3) clavicular graft changes resembled those of the condylar grafts histologically while the costal grafts remained inert and unchanged; and 4) a new condylar process with cartilage similar to that of a normal mandibular condyle regenerated in the costal graft animals from cells presumably contributed by the periosteum of the mandibular ramus and TMJ capsule.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVES: To report the features of malignancies responsible for a chest wall mass and involving the sternum, the sternocostal and/or sternoclavicular joints, the chondrocostal junction and/or the adjacent soft tissues. METHODS: The medical records of patients with a chest wall mass due to malignant disease were reviewed retrospectively. The following data were abstracted from each record: characteristics of the pain and mass, constitutional symptoms, physical findings, laboratory test results, findings from imaging studies (plain radiographs, computed tomography and magnetic resonance imaging of the chest, radionuclide bone scan), histologic features of the biopsy specimen from the chest wall mass and origin of the mass. RESULTS: Seven men and three women with a mean age of 53.1 years were included in the study. A single patient had a history of malignant disease (lymphoma); in the remaining nine patients the chest wall mass was the first manifestation of the malignancy. All ten patients had pain with a mixed time pattern. The mass was located on the sternum in half the patients and in a parasternal location in the other half. Erythrocyte sedimentation rate elevation was found in seven patients, an increased serum level of lactate dehydrogenase in one and a monoclonal immunoglobulin in three. Sternal lesions were visible on plain radiographs in four patients. Computed tomography of the chest consistently disclosed sternal or sternocostal lytic lesions with spread to the adjacent soft tissues; in five cases, enlarged lymph nodes were visible in the anterior part of the mediastinum. Magnetic resonance imaging of the chest did not add to the information provided by computed tomography. Radionuclide uptake on the bone scan was increased, decreased, or normal at the site of the lesion. The cause was Hodgkin's disease in two cases, non-Hodgkin's lymphoma in three, metastatic bone disease in two (from an adenocarcinoma of the lung and a hepatocarcinoma, respectively), multiple myeloma in one, and solitary plasmacytoma in two. CONCLUSION: A chest wall mass can be caused by a known or as yet undiagnosed malignancy. Chest wall involvement due to malignant disease in rare, however. The specific features of sternal metastases, lymphomas involving the sternum, and sternal plasmacytomas are discussed. Nonmalignant chest wall lesions that can manifest as a bulging or swelling of the chest wall are reviewed.
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Pasteurella multocida is frequently responsible for infections in man due to wounds inflicted by animals (generally cats or dogs). However, the development of septic arthritis is a rare complication. We report 4 cases of Pasteurella multocida septic arthritis with demonstration of the organism in the joint in each case. Two cases presented with monoarthritis (sternoclavicular joint and wrist) and 2 cases had polyarticular involvement from the outset.
Besides the skeletal elements, i.e., the clavicle, scapula and humerus, several muscles and soft tissues also participate in the construction of the human shoulder. These elements from and surround the shoulder girdle joints, which are the acromioclavicular and glenohumeral joint. Towards the trunk a connection is achieved by the sternoclavicular joint. Ossification of the clavicle, scapula and humerus begins within the 5th to 7th embryonic week. Around the age of 20 years ossification is completed. Parallel to this development and during adulthood, age-dependent changes take place in the composition and mixture of the bone marrow from red to yellow marrow. The shoulder girdle joints are constructed to permit a wide range of motion of the arm against the trunk. At the glenohumeral joint the spherical humeral head glides within the concave groove of the glenoid cavity. Stability is attained by the fibrocartilaginous glenoid labrum, which enlarges the articulating areas and the joint capsule with its strengthening ligaments. Variation of the joint capsule insertion, the glenoid labrum or the bony surfaces may predispose to luxation. Additional support to prevent luxation is obtained by the glenohumeral ligaments and the long biceps tendon. Active movement is provided by the superficial muscles and the rotator cuff muscles. Several bursae support free movement and decrease friction of the musculotendineous systems near the joint. Despite this complex construction several degenerative diseases can impair free movement of the human shoulder.