99mTc-MDP scintigraphy in ankylosing spondylitis

99mTechnetium-MDP bone scintigrams in 11 patients with ankylosing spondylitis were reviewed. Increased activity in sacroiliac joints was present in five of 11 cases, all of whom had symptoms of less than 5 years duration. Patients with longstanding disease had normal or low sacroiliac joint activity. In the spine, appearances included diffuse symmetrical, unifocal or multifocal asymmetrical increased uptake involving the costovertebral, costotransverse and facet joints as well as the spinous processes. In advanced disease with extensive ankylosis, the lumbar spine was featureless on scintigraphy, except for focal increased activity at the site of previous fracture in one patient. Of six available views of the sternum, increased uptake was present in five at the manubriosternal joint and five at the sternoclavicular joints. Increased peripheral uptake was mainly in the hips and knees in advanced cases. Plain radiographic changes correlated poorly with scintigraphic changes, scintigraphy detecting considerably more lesions than radiography. Awareness of the scintigraphic appearances of ankylosing spondylitis may lead to diagnosis before the development of radiographic changes and avoid confusion with other pathology. Clinical indications for bone scintigraphy in ankylosing spondylitis are suggested.

Pathogenesis of discovertebral and manubriosternal joint abnormalities in rheumatoid arthritis: a cadaveric study

The precise pathogenesis of discovertebral lesions in rheumatoid arthritis has long been debated with the emergence of 2 conflicting theories: discovertebral extension of synovial inflammation from a neighboring articulation (Luschka, costovertebral joint) and repetitive discal trauma with Schmorl's nodes. In order to address this controversy, we performed a radiographic-pathologic correlation of a rheumatoid cadaver and compared the alterations seen in the cervical and lumbar discovertebral junction; we further included an evaluation of the manubriosternal joint, another cartilaginous articulation. Our data confirmed that advanced discovertebral lesions in the cervical and lumbar spine are related primarily to endplate failure that itself is caused by apophyseal joint destruction and segmental spinal instability, although inflammatory rheumatoid lesions of the cervical intervertebral discs probably arising from the Luschka joints are also evident. Conversely, the lesions of the manubriosternal joint were produced by inflammatory changes related to the development of a synovial cavity in the articulation.

Persistent sternum synchondroses on bone scintigraphy

This report describes the case history of two patients who showed a hyperactive midsternal area on bone scintigraphy due to a persistent sternal synchondrosis. Whereas this anatomical variant is diagnosed infrequently, midsternal hotspots can sometimes be related to arthrotic degeneration of these extra joint spaces. In the differential diagnosis of midsternal hotspots on bone scintigraphy, persistent sternum synchondroses should be considered.

Monarthritis of the manubriosternal joint. A follow-up study

Six women and three males, who initially had seronegative monarticular arthritis of the manubriosternal joint (MSJ) were followed for a mean period of 7.1 years (range 0.8-17 years). Rather severe, progressive disease occurred in five patients, three of whom had pustulosis palmoplantaris (PPP) and one acne vulgaris. The course was milder in four patients who had either psoriasis vulgaris, psoriasis in the family or HLA-B27, and the disease remained localized to the MSJ in these patients. None of the patients developed sacroiliitis or peripheral erosive joint changes, but one patient with PPP developed paravertebral ossification.

Septic manubriosternal arthritis in a patient with Reiter's disease

A man with a quiescent Reiter's disease presented with abrupt upper chest pain. This symptom resulted from a septic arthritis of the manubriosternal joint due to staphylococcus aureus cultured from the synovial fluid.

Psoriatic arthritis affecting the manubriosternal joint

Manubriosternal synovitis in the absence of peripheral arthritis or spondylitis, in a patient with pustular psoriasis, is described. The radiologic changes noted on lateral chest radiograph consisted of erosions, sclerosis, and joint space widening. This coincidence of manubriosternal joint arthritis and pustular psoriasis is unusual in western populations.

Manubriosternal joint dislocation in rheumatoid arthritis: the role of thoracic kyphosis

A case report of manubriosternal joint (MSJ) dislocation in a rheumatoid patient with thoracic kyphosis is presented together with a review of the relevant literature. Variations in the anatomical nature of the MSJ between normal individuals are described. In 43% of the population its characteristics are noted to be such that it may be involved in rheumatoid arthritis (RA). A joint thus involved can be dislocated by forces generated by longstanding thoracic kyphosis and transmitted to the manubrium via the first rib. Xeroradiographs of the MSJ region in our patient showed dislocation of the joint in the upright position and its subsequent reduction on lying the patient flat. We suggest that this demonstrated reduction is secondary to the lessening of the thoracic kyphosis that occurs in the supine position. It is concluded that in RA MSJ dislocation is a function of thoracic kyphosis.

Sclerosis and hyperostosis of the manubrium sterni

Seven females and one male with almost identical sclerotic and hyperostotic changes of the manubrium sterni are reported. The clinical course was prolonged and characterized by intermittent periods of exacerbation followed by improvement. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. Pustulosis-palmoplantaris was present in four patients and one had psoriasis vulgaris. None of the patients had sacroiliitis or peripheral joint changes, but the three youngest patients had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle. This may indicate that this is an adult disease analogous to "chronic recurrent multifocal osteomyelitis", a disease mainly present in children and adolescents.

Primary septic arthritis of the manubriosternal joint in a heroin user

A 20-year-old heroin user developed staphylococcus septic arthritis of the manubrium joint. The diagnosis was established by a culture of the infected tissue and blood culture. The clinical impression was aided by 99mTc radionuclide scintimetry. Early diagnosis localized the infection. Immediate antibiotic therapy solved a problem in the sternum that seems not to have been reported in the English literature.

Septic arthritis involving the manubriosternal joint

Infection of the manubriosternal joint is an exceedingly rare event. We report a case of a 38-year-old patient with systemic lupus erythematosus who developed staphylococcal septic arthritis of this joint after bacteremia. Pathogenic factors are discussed. Physicians should be aware of this unusual complication of staphylococcal bacteremia.

Monarticular involvement of the manubriosternal joint

Four females and two males with seronegative monoarthritis of the manubriosternal joint are reported. Two patients had pustulosis palmoplantaris, one psoriasis vulgaris, and one HLA-B27. The arthritis is considered to be a monoarticular manifestation of seronegative spondylarthritis. Two patients had no other diseases or signs. Four patients were followed for a mean of 8.5 years (range 2-16 years) during which time affection of other joints or the spine was not seen.

Sclerotic changes of the manubrium sterni

Six females with nearly identical sclerotic and hyperostotic changes of the manubrium sterni are reported. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. The youngest patients also had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle, and may be classified as having "chronic recurrent multifocal osteomyelitis" (CRMO). The two oldest patients had ossification of the costoclavicular ligament(s) and may be classified as having "inter-sterno-costo-clavicular ossification" (ISCCO). One had only hyperostotic and sclerotic changes as seen in "sterno-costo-clavicular hyperostosis" (SCCH). The pathogenesis of these uncommon diseases is unknown, but they are all frequently associated with pustulosis palmo-plantaris and have similar clinical courses and laboratory abnormalities. None of the present patients had HLA-B27. The similarity of the radiological abnormalities of the manubrium sterni suggests that the diseases themselves may be similar, but with different courses depending on age, CRMO being present in children and young adults and ISCCO or SCCH in older adults.

The Angle of Louis. A potential pitfall ("Louie's Hot Spot") in bone scan interpretation

Evaluation of 100 consecutive Tc-99m MDP bone scans revealed in 36 patients a well defined area of increased accumulation of radiotracer at the Angle of Louis--the palpable ridge along the anterior surface of the sternum at the fibrocartilaginous junction of the sternum and manubrium. Twenty-five of the 36 patients had comparison radiographs; all were normal. None had sternal pain or a prior history of chest trauma. Increased uptake at the Angle of Louis ("Louie's Hot Spot") is a relatively common finding (36%) and should be recognized as a normal bone scan finding. It should not be confused with increased uptake due to an osseous abnormality, i.e., metastasis, degenerative disease, trauma, etc.

Computed tomography of the normal sternum

The normal CT anatomy of the sternum was studied in 35 patients. In addition to the normal appearance of the sternum, normal variants that may mimic disease were often noted. In the manubrium, part of the posterior cortical margin was unsharp and irregular in 34 of 35 patients. Part of the anterior cortical margin was indistinct in 20 of the 35 patients. Angulation of the CT gantry to a position more nearly perpendicular to the manubrium improved the definition of the cortical margins. The body of the sternum was ovoid to rectangular and usually had sharp cortical margins. Sections through the manubriosternal joint and xyphoid often demonstrated irregular mottled calcifications and indistinct margins again simulating bony lesions. The rib insertions, sternal clavicular joints, and adjacent soft-tissue appearance also were evaluated.

The manubriosternal joint in rheumatoid disease

Manubriosternal joint abnormalities are often undetected causes of chest pain. Twenty-five normal patients and 40 cadaver specimens were evaluated to establish the normal radiographic anatomy of this articulation. Analysis of the manubriosternal joint was carried out in rheumatoid diseases in order to ascertain the incidence and variety of abnormalities. Twenty-seven of 100 manubriosternal joints were abnormal in rheumatoid arthritis. Of 25 patients with ankylosing spondylitis 20 (80%) revealed abnormalities either with erosions or fusion. None of 25 patients with psoriatic arthritis and none of 20 with Reiter syndrome showed erosions or ankylosis. The articulation should be evaluated in rheumatoid diseases and in non-arthritic patients with chest and/or shoulder pain.

Unusual personal identification with characteristic features in chest roentgenograms

This case illustrates the unexpected aspects of radiographic personal identification. A skeletonized body without the neck and head, upper extremities, and feet was discovered on a seashore. No positive results were obtained from the remains concerning either the cause of death, the manner of death, or precise identification of the body. Roentgenologic examinations of the remains revealed a marked eminence of the manubrium sterni with characteristic crossing shadows. A successful partial superimposition of the ante- and postmortem lateral chest x-ray films helped to place the personal identification as that of a fisherman, 58 years old, missing in the sea for 21 days.

[Partial sternectomy for metastatic tumor with reconstruction using a methylmethacrylate plate]

A case of partial sternectomy for metastatic thyroid carcinoma is reported. En bloc excision was followed by reconstruction using a molded plate of methylmethacrylate. Sternal tumours are rare and operations for cure of metastases are justified only if the general condition of the patient permits and in the patient with a single metastasis whose primary cancer operation was a radical one. Extensive en bloc excision is based on preoperative investigation in which computerized axial tomography has an important place in delineating the extent of the tumour and providing accurate knowledge of the margins of the section. Reconstruction with methyl-methacrylate allows a rigid setting with a material that can be molded, is radiolucent, inert and well tolerated. In the upper sternum it contributes to the stability of the shoulder girdle and protects the underlying mediastinal structures in a cosmetically acceptable way.