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Atraumatic Disorders of the Sternoclavicular Joint Thomas O. Higginbotham, MD, and John E. Kuhn, MD Abstract The sternoclavicular joint is the diarthrodial articulation between the axial and ap-pendicular skeletons. It is subject to the same disease processes that occur in joints, including degenerative arthritis, rheumatoid arthritis, infection, and subluxation. Most of these conditions present with swelling of the joint, which may be associated with pain and/or tenderness. Plain radiographs can demonstrate changes on both sides of the joint. Because of variations in anatomy, computed tomography scans and magnetic resonance images are often necessary to clarify the pathology. With theexceptionofacuteinfection,mostconditionscanbemanagednonsurgically,with joint resection reserved for patients with persistent symptoms. J Am Acad Orthop Surg 2005;13:138-145 The sternoclavicular joint, a saddle- ament,whichconnectsthesuperome-shapedsynovialjoint,istheonlybony dial margins of each clavicle. The ex-articulationbetweentheaxialandap- tracapsularcostoclavicular(rhomboid) pendicular skeletons (Fig. 1, A). The ligament,extendingfromthefirstrib largemedialclaviclearticulatessome- and costal cartilage to the inferome-what incongruently with a shallow dialmarginoftheclavicle,furthersta-socket formed by the superomedial bilizes the sternoclavicular articula-manubrium and the first costal car- tion (Fig. 1,A).Articular branches of tilage, creating a joint with little in- theinternalthoracicandsuprascapu-herentbonystability.Betweenthetwo lar arteries provide the blood supply articular surfaces is a dense fibrocar- tothesternoclavicularjoint.Innerva-tilaginousarticulardiskseparatingthe tion is provided by branches of the joint into two distinct synovial cav- medial suprascapular nerve and the ities.Anintra-articulardiskligament nerve to the subclavius muscle. originatesfromthejunctionofthefirst The great vessels of the brachio-rib and sternum, passes through the cephalic trunk, the common carotid sternoclavicularjoint,andattacheson artery, and the internal jugular vein theposteriorandsuperiormedialclav- lie directly posterior to the sterno-icle.Thatligamentcontributestojoint clavicular joint (Fig. 1, B). The sur-stabilityandpreventsmedialdisplace- geon must be knowledgeable about ment of the clavicle. It is contiguous the relationship of these vascular with the anterior and posterior ster- structures to the sternoclavicular noclavicular ligaments, which are joint and plan the surgical approach thickenings of the fibrous joint cap- accordingly. sule that function as the primary re-straintstoanteriorandposteriortrans- lationofthemedialclavicle.1 Thejoint Patient Evaluation capsule extends laterally to include theepiphysisoftheclavicle.Thester- Because many of the conditions that noclavicular joint also is reinforced affect the sternoclavicular joint are superiorly by the interclavicular lig- systemic, a careful history, including systemic complaints, family history of arthritis, and drug use should be doneforallpatientswhopresentwith sternoclavicularjointcomplaints.The physician should pay careful atten-tion to warmth, fluctuance, bony en-largement, and sternoclavicular joint translation. Plainradiographsareindicatedin the initial evaluation of sternoclavic-ular joint disorders, but other imag-ing modalities typically are required. Computed tomography (CT) scans areindicatedfordiseaseprocessesin which bony destruction or ossifica-tion may occur. Magnetic resonance imaging (MRI) provides more de-tailed and useful information when evaluating suspected pathology in-volving inflammation, a soft-tissue mass, or osteonecrosis of the medial clavicle (ie, Friedrich’s disease). Bone scanscanhelpcorrelateactiveinflam-mation of the sternoclavicular joint Dr.HigginbothamisResident,DepartmentofOr-thopaedics, University of Michigan, Ann Arbor, MI. Dr. Kuhn is Chief of Shoulder Surgery, VanderbiltSportsMedicineandShoulderSurgery, Nashville, TN. None of the following authors or the departments withwhichtheyareaffiliatedhasreceivedanything of value from or owns stock in a commercial com-pany or institution related directly or indirectly to the subject of this article: Dr. Higginbotham and Dr. Kuhn. Reprint requests: Dr. Kuhn, Vanderbilt Sports Medicine and Shoulder Surgery, 2601 Jess Neely Drive, Nashville, TN 37212. Copyright 2005 by the American Academy of Orthopaedic Surgeons. 138 Journal of the American Academy of Orthopaedic Surgeons Thomas O. Higginbotham, MD, and John E. Kuhn, MD Figure 1 A, Bony and ligamentous anatomy of the sternoclavicular joint. The major supporting structures include the anterior capsule, the posterior capsule, the interclavicular ligament, the costoclavicular (rhomboid) ligament, and the intra-articular disk and ligament. B, Ret-rosternal anatomy. Note the proximity of the sternoclavicular joint to the trachea, aortic arch, and brachiocephalic vein. with symptoms of pain. Laboratory studies may help elucidate the diag-nosis when infectious or inflamma-tory conditions are suspected. Severalatraumaticpathologiccon-ditionsaffectthesternoclavicularjoint (Table 1). There may be subtle differ-ences in their presentation, findings on physical examination and radio-logicstudies,andlaboratoryprofiles. Osteoarthritis The most common condition affect-ingthesternoclavicularjointisosteoar-thritis (OA), which can manifest as partofasystemicprocessorasarthri-tis affecting the sternoclavicular joint only.Degenerativechangesinthester-noclavicularjointbecomeincreasing-ly common with advanced age. Kier et al2 radiographically examined 55 cadavericsternoclavicularjointspec-imens. Moderate to severe degener-ativechangeswereuncommoninpa-tients younger than age 40 years but werepresentin53%ofspecimensold-erthanage60years.Postmenopausal women are more susceptible than ei- ther men or premenopausal women toOAofthesternoclavicularjoint,but theetiologyisunknown.Ahistoryof manual labor or a radical neck dis-sectionarealsoriskfactorsforthede-velopment of OA of the sternocla-vicular joint. Patients with OAmay report pain and swelling at the sternoclavicular joint,whichmaybeaggravatedbypal-pation,ipsilateralshoulderabduction, or forward elevation of the shoulder beyond horizontal. Some patients, however,maylackpain,havenormal motion,andhavenodiscomfortwith stresstesting.Otherphysicalfindings includeprominenceatthemedialend oftheclavicle(causedbyosteophytes), a fixed subluxation, or crepitus on range of motion. The increase in size orappearanceofamassmayraisepa-tientconcernaboutneoplasiaormet-astaticdisease,buttheseprocessesare exceedinglyrareinthesternoclavicu-larjointandcanberuledoutwithap-propriate imaging. Patients present-ing with an increase in the size of the medialclavicleshouldbeimagedwith plainradiographs.CTisoftenrequired tofullyvisualizethejoint.Osteophytes indicativeofOAmaybeseenonplain radiographs, but sclerosis and joint space narrowing may be difficult to seethroughvariationsinanatomyand overlapofbonyshadows3 (Fig.2).CT scans are helpful in diagnosing sub-tle degenerative changes in the infe-rior medial aspect of the clavicle and aremoreeffectivethaneitherplainra-diographs or bone scans. Most patients with symptomatic OA of the sternoclavicular joint re-spond to nonsurgical treatment, such as rest, anti-inflammatory medica-tion,andlocalcorticosteroidinjection. Resection of the medial head of the clavicle is reserved for patients with severe symptoms who have been un-responsive to nonsurgical treatment for at least 6 months. With resection, the costoclavicular ligament must bepreservedandtheanteriorcapsule repaired to prevent residual joint instability.Intheirreviewofresection arthroplasty for the treatment of degenerative sternoclavicular arth-ritis, Pingsmann et al4 reported good to excellent results in seven of eight patients (mean follow-up, 31 months). Vol 13, No 2, March/April 2005 139 Atraumatic Disorders of the Sternoclavicular Joint Table 1 Features and Test Results of Atraumatic Disorders of the Sternoclavicular Joint Age Disorder (yrs) Sex Associated Conditions and Pain Side Risk Factors Erythema Radiographic Findings Laboratory Values Osteoarthritis Rheumatoid arthritis Septic arthritis Atraumatic subluxation Seronegative spondylo-arthropathies Crystal deposition disease Sternocosto-clavicular hyperostosis Condensing osteitis Friedrich’s disease (aseptic osteonecrosis) >40 M = F Any F > M Any M = F 10-30 F > M <40 M > F >40 M > F 30-60 M > F 25-40 F > M Any F > M + B + B +++ U Infrequent U Occasional B +++ U during flare + B + U + U Manual labor, radical neck dissection, postmenopausal women Symmetric polyarthritis HIV, intravenous drug abuse, diabetes Generalized ligamentous laxity Urethritis, uveitis, nail pitting Other joint involvement Synovitis, acne, pustulosis, hyperostosis, osteitis None None Rare Sclerosis, Normal osteophytes + Minimal May have change +RF, +ANA +++ Sclerotic, lytic, or ­WBC, mixed lesions ­ESR, ­CRP − Normal Normal − Marginal +HLA-B27 erosions, cysts ++ Calcification of +BRFC, soft tissue −BRFC − Hyperostosis, ­ESR, other ossification rheumatologic of intercostal markers ligaments normal − Medial clavicle Normal enlargement, preserved joint space, marrow obliteration − Irregular end of Normal medial clavicle ESR, normal WBC ANA = antinuclear antibodies, B = can present bilaterally, BRFC = birefringent crystals, CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, HIV = human immunodeficiency virus, RF = rheumatoid factor, U = typically presents unilaterally, WBC = white blood cell count. + = elevated levels or presence of, ++ = moderate elevation, +++ = marked elevation, − = not seen or absence of. Many individuals who develop changes in the sternoclavicular joint, such as enlargement, subchondral sclerosis, and osteophytes, are com-pletely asymptomatic. These patients may be referred for an evaluation of the asymmetry of the sternoclavicu-lar joint. This condition would be bet-tercalledosteoarthrosisbecausethere doesnotseemtobeaninflammatory componenttothecondition.Intheab-senceofsymptoms,notreatmentoth-er than counseling is required. Rheumatoid Arthritis Involvement of the sternoclavicular joint in rheumatoid arthritis (RA) is variable. One study indicated ster-noclavicularjointinvolvementin30% of 105 patients.5 Changes were gen-erally present within 1 year of diag-nosis of RA, but plain radiographs were frequently unremarkable. The pathologic process of RA involves synovial inflammation, pannus for-mation, bony erosions, and degener- ation of the intra-articular disk. Isolated involvement is rare, and ev-idenceofpolyarticulardiseaseandbi-laterality are common. Patients may report swelling, tenderness, crepitus, and painful limitation of movement. The underlying process is treated, usually in conjunction with a rheu-matologist.As with degenerative ar-thritis, patients with symptoms re-fractorytomedicalmanagementmay benefit from medial clavicle exci-sion. 140 Journal of the American Academy of Orthopaedic Surgeons Thomas O. Higginbotham, MD, and John E. Kuhn, MD Figure 2 Axial computed tomography scan demonstrating osteoarthritis of the sternocla-vicular joint. Note sclerosis on both sides of the joint with subchondral cysts in the clavicle, and anterior soft-tissue swelling. antibioticsensitivityofthepathologic organism and the extent of the infec-tion(ie,abscess).Inmostcases,prompt irrigation and drainage are done in the operating room, along with ad-ministrationofappropriateparenteral antibiotics.Aggressiveorganismsmay requireresectionofthesternoclavicu-lar joint and involved portions of the first and second ribs with appropri-ate soft-tissue coverage.12 In some patients,aspirationandparenteralan-tibioticsalonehaveproducedsuccess-ful outcomes.13 Untreated infections of the sternoclavicular joint can de-velopintocutaneous,extrapleural,or intrathoracicabscess,whichcouldbe-come life threatening if the retroster-nal vascular structures are involved. Infection Isolated septic arthritis of the sterno-clavicularjointisuncommonandfre-quently is associated with an under-lying disease or other risk factors. Conditions known to be associated with infectious arthritis are RA, sep-sis, infected subclavian central lines, alcoholism, human immunodefi-ciency virus (HIV) infection, immu-nocompromisedstatus,renaldialysis, andintravenousdrugabuse.Prompt diagnosis and treatment are crucial becauseuntreatedinfectionmaylead tolife-threateningconsequences.Pain, swelling, and tenderness over the sternoclavicular joint, in association withfever,chills,ornightsweats,are usual.Plainradiographsmaydisclose sclerotic, lytic, or mixed lesions but may be less sensitive than spiral CT, which is useful in the diagnosis of septic sternoclavicular joint arthritis6 (Fig.3).MRImaybeparticularlyuse-ful in identifying soft-tissue involve-ment and abscesses. Definitive diag-nosis is achieved with aspiration or open biopsy and laboratory evalua-tion of the joint fluid.Although com-mon organisms such as Staphylococ-cus aureus and Streptococcus species have been reported,7 patients with riskfactorsmayhaveothercausative Vol 13, No 2, March/April 2005 organisms. Pseudomonas aeruginosa hasbeenassociatedwithintravenous Spontaneous Anterior drugabuse.8 Neisseriagonorrhoeaeand Subluxation fungalinfectionswithCandidaalbicans have been reported in HIV-positive Spontaneousatraumaticanteriorsub-patients.9,10 InfectionwithMycobacte- luxation of the sternoclavicular joint riumtuberculosishasbeenreportedin mayoccurduringoverheadelevation patients in third world countries as of the arm.Affected patients are gen-well as in immunocompromised pa- erally in their teens or twenties, and tients. Diagnosis requires needle as- many demonstrate signs of general-piration or biopsy, and infected pa- ized ligamentous laxity on physical tients are treated with appropriate examination.Patientsreportasudden antitubercular therapy.11 subluxation of the medial end of the Treatment of septic sternoclavicu- clavicle, and many remember feeling larjointarthritisisdeterminedbythe an associated pop. The majority of Figure 3 Axial computed tomography scan demonstrating septic arthritis of the sternocla-vicular joint. Fluid has collected in the joint (arrow), and bony destruction is evident. 141 Atraumatic Disorders of the Sternoclavicular Joint cases are not painful, and the sublux-ation usually reduces with lowering the arm. Most patients seek medical treatment because of initial pain and concern regarding the potential harm ofthecondition.Inareviewof37pa-tients with spontaneous anterior sub-luxationofthesternoclavicularjoint, subluxations were reproducible and painless in 29 patients.14 Eighty per-cent of the patients demonstrated ev-idence of generalized ligamentous laxity. Twenty-nine patients were treated nonsurgically with strength-ening exercises and advancement to unrestricted activity as tolerated.Al-though many patients subsequently reported intermittent episodes, few reported discomfort, and most were able to participate successfully in ath-letics. The most common reason for surgery was the failure of a previous attempt at reconstruction. Surgery is rarely indicated. Nonsurgical man-agement,includingpatienteducation ofthebenignnatureofthecondition, is recommended.14 Atraumatic anterior pseudosub-luxation mimics atraumatic sublux-ation in the older patient. This ante-rior fullness of the medial clavicle is causedbyadegenerativeprocess.The subluxation generally is fixed rather than dynamic. sisted of symptoms of swelling and tendernessofthesternoclavicularjoint as well as pain with full arm abduc-tion, which responded to nonsurgi-cal treatment with oral nonsteroidal anti-inflammatory drugs (NSAIDs). Approximately 15% to 20% of pa-tients with psoriasis develop a sym-metric polyarthritis that resembles RA.16 Althoughpsoriasisusuallypre-cedesjointinvolvement,arthritismay precedetheskindiseaseinupto25% ofpatients.Affectedjointsincludethe sacroiliacjoint,thespine,andthedis-tal interphalangeal joint of the hands (ie,nailpitting,onycholysis).16 Oligoar-ticular involvement is particularly destructive.Taccarietal17 reportedra-diographicorscintigraphicabnormal-ity of the sternoclavicular joint in 9 of 10 patients admitted to the hospi-talwithpsoriaticarthritis.Radiographs and CT scans demonstrate marginal erosions of the sternum, clavicle, or both,aswellassubchondralcystsand sclerosis (Fig. 4). The sternoclavicu-larjointwasclinicallyinvolvedinonly 5 of 10 patients in the series of Tac-cari et al.17 Three patients reported spontaneous pain. NSAIDs are the treatment of choice for psoriatic ar- thritis; gold therapy and/or metho-trexateareusedforresistantcases.Suc-cessful treatment of skin lesions is commonly associated with improve-ment in joint symptoms. Crystal Deposition Disease Gout, pseudogout, and tophaceous pseudogout have been described in thesternoclavicularjoint.18 Examina-tionofjointfluidwithapolarizinglight microscoperevealscharacteristicpos-itive(pseudogout)ornegative(gout) birefringentcrystals.NSAIDsandcor-ticosteroidinjectionstypicallyareused tomanageacuteexacerbations.Ava-riety of medical treatments exist to manage the underlying condition. These include medications to reduce uricacidproduction(eg,allopurinol) or to increase uric acid excretion (eg, probenecid, sulfinpyrazone). Sternocostoclavicular Hyperostosis Sternocostoclavicular hyperostosis, also known as intersternocostocla- Seronegative Spondyloarthropathies Thesternoclavicularjointisinvolved inseronegativespondyloarthropathies, includingankylosingspondylitis,pso-riaticarthritis,Reiter’ssyndrome,and colitic arthritis. These disorders are characterizedbyonsetusuallybefore age 40 years, inflammatory arthritis affecting large peripheral joints, ab-sence of serum autoantibodies, and associationwithantigenHLA-B27.Em-ery et al15 reported acute inflamma-toryarthropathyofthesternoclavicu-lar joint in 2 of 52 patients with ankylosingspondylitis.Involvement wasunilateralinbothpatientsandcon- 142 Figure 4 Anteroposterior radiographic view of the chest demonstrating psoriatic arthritis of the sternoclavicular joint. Joint space narrowing, osteopenia, erosions, and irregularity of the joint surface are evident. ... - tailieumienphi.vn
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