The sternoclavicular joint: can imaging differentiate infection from degenerative change?

Normative Values for Sternoclavicular Joint and Clavicle Anatomy Based on MR Imaging: A Comprehensive Analysis of 1591 Healthy Participants

Background: The clavicle remains one of the most fractured bones in the human body, despite the fact that little is known about the MR imaging of it and the adjacent sternoclavicular joint. This study aims to establish standardized values for the diameters of the clavicle as well as the angles of the sternoclavicular joint using whole-body MRI scans of a large and healthy population and to examine further possible correlations between diameters and angles and influencing factors like BMI, weight, height, sex, and age. Methods: This study reviewed whole-body MRI scans from the Study of Health in Pomerania (SHIP), a German population-based cross-sectional study in Mecklenburg-Western Pomerania. Descriptive statistics, as well as median-based regression models, were used to evaluate the results. Results: We could establish reference values based on a shoulder-healthy population for each clavicle parameter. Substantial differences were found for sex. Small impacts were found for height, weight, and BMI. Less to no impact was found for age. Conclusions: This study provides valuable reference values for clavicle and sternoclavicular joint-related parameters and shows the effects of epidemiological features, laying the groundwork for future studies. Further research is mandatory to determine the clinical implications of these findings.

The Nomadic Bug: A Case Report of Salmonella Septic Arthritis of Sternoclavicular Joint in a Healthy Patient

In an otherwise healthy adult, septic arthritis of the sternoclavicular joint is very uncommon. Usually, individuals with a history of intravenous drug usage or those with impaired immune systems are affected. The usual mode of spread is hematogenous spread or direct spread via neighbouring sources of infection. We report a rare case of mediastinitis and lung empyema preceded by sternoclavicular septic arthritis in an otherwise healthy 49-year-old woman due to Salmonella sp. Radiological imaging showed left sternoclavicular joint collection with bone destruction. The literature only contained reports of two prior occurrences of sternoclavicular joint septic arthritis caused by Salmonella. If diagnosed early, patients usually respond to medical treatment such as aspiration and antibiotics, as was the case with our patient.

Anterior Chest Wall Non-traumatic Arthropathies: A Crucial but Often Overlooked Site

OBJECTIVE

The purpose of this study was to describe the distribution of Anterior Chest Wall (ACW) arthropathies in a tertiary care center and identify clinical, biological and imaging findings to differentiate osteoarthritis (OA) from non-osteoarthritis (N-OA) etiologies.

METHODS

Search from medical records from January 2009 to April 2022, including patients with manubriosternal and/or sternoclavicular and/or sternocostal joint changes confirmed by ultrasonography, computed tomography or magnetic resonance imaging. The final study group was divided into OA and N-OA subgroups.

RESULTS

A total of 108 patients (34 males and 74 females, mean age: 47.3 ± 13 years) were included. Twenty patients had findings of OA, while 88 were diagnosed with N-OA pathologies. SpA was the most common etiology in the N-OA group (n = 75). The other N-OA etiologies were less common: rheumatoid arthritis (n = 4), Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome (n = 3), infectious arthritis (n = 3) and microcrystalline arthropathies (n = 3). Regarding the distinctive features, ACW pain was the inaugural manifestation in 50% of patients in OA group and 18.2% of patients in N-OA group (p = 0.003); high inflammatory biomarkers were more common in N-OA group (p = 0.033). Imaging findings significantly associated with OA included subchondral bone cysts (p < 0.001) and intra-articular vacuum phenomenon (p < 0.001), while the presence of erosions was significantly associated with N-OA arthropathies (p = 0.019). OA was independently predicted by the presence of subchondral bone cysts (p = 0.026).

CONCLUSION

ACW pain is a common but often underestimated complaint. Knowledge of the different non-traumatic pathologies and differentiation between OA and N-OA etiologies is fundamental for appropriate therapeutic management.

Diagnosis and management of sternoclavicular joint infections: a literature review

The sternoclavicular joint (SCJ) is anatomically and clinically significant considering its proximity to important neuro-vascular structures like the subclavian vessels and the phrenic nerve. Infections of this joint masquerade multiple disorders, delay diagnosis and spread to the bone and deep tissues. There is no standardized workup and treatment protocol for sternoclavicular joint infections (SCJI) as defined in literature. Here, we review the existing literature to understand the current knowledge of the diagnosis and treatment of SCJI. We searched English publications in PubMed and included clinical trials, case reports, case series, retrospective cohort studies, literature and systematic reviews after excluding non-infectious etiology of SCJ pathologies. There are many risk factors for SCJI, such as immunocompromised status, intravenous drug use, trauma and arthropathies. But a large percentage of patients with disease have none of these risk factors. SCJIs can present with fever, joint swelling, immobility, and rarely with vocal cord palsy or dysphagia. While Staphylococcus aureus causes over 50% of SCJI cases, other pathogens such as Pseudomonas and Mycobacterium are frequently seen. When diagnosed early, the infection can be medically managed with antibiotics or joint aspirations. Most cases of SCJI, however, are diagnosed after extensive spread to soft tissue and bones requiring en-bloc resection with or without a muscle flap. Complications of undertreatment can range from simple abscess formation to mediastinitis, even sepsis. SCJIs are rare but serious infections prompting early detection and interventions. Most cases of SCJI treated adequately show complete resolution in months while retaining maximum functionality. Key features of proper healing include aggressive physiotherapy to prevent adhesive shoulder capsulitis and decreased range of motion.

MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis

OBJECTIVES

To analyze and identify magnetic resonance imaging (MRI) and clinical findings for the differentiation between infectious arthritis and spondyloarthritis in patients with unilateral sternoclavicular arthritis.

MATERIALS AND METHODS

We retrospectively collected and evaluated the magnetic resonance (MR) images of 21 patients diagnosed with unilateral sternoclavicular arthritis, including 12 with infection and nine with spondyloarthritis, between 2004 and 2017. Capsular distension, extracapsular fluid collection, periarticular muscle edema, the prevalence and distribution of bone marrow edema, and the prevalence and size of bone erosions were assessed on the MR images. Clinical data were also reviewed.

RESULTS

Capsular distension was more prominent in patients with infectious arthritis than those with spondyloarthritis (p = 0.002); extracapsular fluid collection and periarticular muscle edema were also more common in infectious arthritis than spondyloarthritis (p < 0.001, respectively); moreover, bone erosions were larger in infectious arthritis than spondyloarthritis (p = 0.023). Other findings significantly associated with infectious arthritis included advanced age (p = 0.007), an elevated C-reactive protein (CRP) level (p = 0.001), and erythrocyte sedimentation rate (ESR) (p < 0.001). The prevalence and distribution of bone marrow edema and the prevalence of bone erosions on MRI, the white blood cell count, and sex showed no significant differences between the two groups.

CONCLUSIONS

Capsular distension, extracapsular fluid collection, periarticular muscle edema, and the size of bone erosions on MRI, as well as the age, CRP level, and ESR of patients, could be helpful for differentiating infectious arthritis from spondyloarthritis involving the sternoclavicular joint.

Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies

The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome.

The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.

Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078

Surveillance Neck Sonography After Thyroidectomy for Papillary Thyroid Carcinoma: Pitfalls in the Diagnosis of Locally Recurrent and Metastatic Disease

A sonographic examination of the neck performed 6 to 12 months after thyroid surgery in patients with differentiated thyroid cancer is strongly recommended by the American Thyroid Association and considered mandatory by the European Thyroid Association for locoregional surveillance. The aim of this article is to review the normal anatomic changes expected after thyroid surgery and the pathologic mimics of thyroid carcinoma recurrence in post-thyroidectomy patients as they appear on neck sonography. We hope to offer some pearls to increase diagnostic confidence in this setting.

High-resolution CT of the sternoclavicular joint and first costochondral synchondrosis in asymptomatic individuals

OBJECTIVE

To assess CT features of the sternoclavicular joint (SCJ) and first costochondral junction in asymptomatic patients.

MATERIALS AND METHODS

In 66 patients transverse and coronal oblique high-resolution multiple detector CT images of the SCJ and first costochondral junction were obtained. Images were reviewed by consensus of two radiologists. Joint space width was measured at three levels, and osteophytes, geodes, and erosions were evaluated. Variants and degree of ossification were noted. Statistical analysis consisted of Shapiro-Wilk test, Pearson's test, and paired sample t test.

RESULTS

There were 34 men and 32 women with a mean age of 60 years (age range, 17-98 years). The width of the joint spaces showed a normal distribution. There was no significant difference between the left and right sides. On coronal images the joint space was wider superiorly and on transverse images posteriorly. There was a trend toward decreasing joint space with age, although it did not reach significance (p > 0.05). Clavicular osteophytes were seen in 16 out of 66 patients (24 %) and sternal osteophytes in 16 out of 66 patients. Clavicular geodes were seen in 10 out of 66 patients (15 %) and sternal geodes in 14 out of 66 patients (14 %). No erosions were seen. Clefts of the first costochondral junction were seen in 31 out of 66 patients (47 %).

CONCLUSION

In asymptomatic patients, there is no significant asymmetry of the SCJ. The joint spaces did not significantly decrease with age, although such a trend could be observed. Pronounced joint space narrowing with large geodes and osteophytes was not seen. Clefts of the first costochondral junction are common and not significant.

Sternoclavicular joint surgery: how far does danger lurk below?

BACKGROUND

Surgical stabilization of the sternoclavicular joint (SCJ) is infrequent, and cardiothoracic surgery assistance is often recommended. Patient safety and surgeon efficiency may be improved by greater understanding of the anatomic relationships near the SCJ. The purpose of this study is to determine the distances from the SCJ to critical structures in the superior mediastinum.

MATERIALS AND METHODS

Distances from the posterior SCJ to adjacent mediastinal structures were recorded using contrast computed tomography scans of 49 consecutive patients. Patient sex, height, body mass index, side, age, and thickness of the sternum and medial clavicle were also recorded.

RESULTS

The mean distance to the nearest anatomic structure deep to the clavicular region of the SCJ was 6.6 mm and was 12.5 mm for the sternal region. The clavicle was an average thickness of 18 mm, and the sternum was an average thickness of 17 mm. The closest structure was the brachiocephalic vein. An artery was identified as the closest structure in 21.2% of patients. Distance differences between the right and left sides were noted, but sex had no bearing on distance to structures.

CONCLUSION

Multiple mediastinal structures are close to the SCJ. The most frequent structure at risk of injury deep to the SCJ is the brachiocephalic vein. Such knowledge may improve patient safety.

Diagnostic yield of CT-guided sampling in suspected sternoclavicular joint infection

OBJECTIVE

To determine the prevalence of infection diagnosed by percutaneous computed tomography (CT)-guided sternoclavicular (SC) sampling in cases of suspected joint infection.

MATERIALS AND METHODS

A retrospective search was performed in reports of SC joint CT-guided biopsies in adults from July 1992 to July 2012. We reviewed medical records, radiology, microbiology, laboratory, and surgical reports. A positive result was defined as demonstration of a pathogenic organism, either by microscopy or growth in culture, confirming the diagnosis of SC joint infection. A negative result was defined as the absence of such findings. Patients in whom sampling was unsuccessful or not subjected to microbiology were excluded. In addition, CT images were reviewed by the consensus of two musculoskeletal radiologists.

RESULTS

A total of 41 patients (mean age 57.1 years) underwent CT-guided SC joint sampling, 27 of whom underwent microbiology studies. Sampling was performed using core biopsy alone in 19%, fine needle aspiration alone in 44%, and aspiration combined with core biopsy in 37%. Positive results were found in 52% (14/27) of patients. Related diseases and predisposing conditions for infection were found in 79% of positive patients. Negative results were found in 48% (13/27) of patients. There were no procedure-related complications. The dominant CT findings were soft tissue swelling (negative group), and effusion and/or capsular hypertrophy/distension (positive group).

CONCLUSIONS

CT-guided sampling is a safe procedure with positive microbiological cultures in slightly more than half of cases.

Sternoclavicular joint infection: a comparison of two surgical approaches

BACKGROUND

This study compares conventional open debridement with the recently proposed flap closure technique for sternoclavicular joint infection.

METHODS

This is a retrospective review of patients undergoing surgery for sternoclavicular joint infection during the last 7 years.

RESULTS

Twenty patients underwent 35 operations for sternoclavicular joint infection from 2002 to 2009. The debridement and open wound procedure (10 of 20 patients, 50%) involved debridement of the clavicle, manubrium, and first rib and open wound care. The joint resection and flap closure procedure (10 of 20 patients, 50%) involved partial resection of the clavicle, manubrium, and first rib, with immediate (9 of 10) or early (1 of 10) wound closure with pectoralis major advancement flap. The two groups were comparable in comorbidities, duration of symptoms, radiologic findings, and microbiologic results. Despite an approach of planned reoperation for wound care, the open group had fewer mean procedures performed per patient (1.6±0.7 versus 1.9±1.6), owing to fewer unplanned procedures (0 versus 0.8 procedures/patient) than the flap group. The incidence of wound complications (hematoma, seroma) was lower in open patients (0 of 10 versus 5 of 10). The median length of hospitalization was shorter in the open group (5.5 versus 10.5 days), but all open patients (10 of 10; 100%) required prolonged wound care compared with 2 of 10 (20%) in the flap group. The only hospital mortality occurred in the flap group. Eventual wound healing was satisfactory in all survivors.

CONCLUSIONS

For sternoclavicular joint infection, a single-stage resection and muscle advancement flap leads to a higher incidence of complications. Debridement with open wound care provides satisfactory outcomes with minimal perioperative complications but requires prolonged wound care.