Diagnosis and management of sternoclavicular joint infections: a literature review

Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report

BACKGROUND

Sternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy.

CASE PRESENTATION

A 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up.

CONCLUSIONS

This case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

A challenging case of severe bilateral septic arthritis with osteomyelitis of the sternoclavicular joint in a patient with end-stage renal disease

Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition that comprises <1% of all joint infections. We report a case of severe bilateral septic arthritis of the SCJ in a patient with end-stage renal disease on peritoneal dialysis. A 44-year-old female presented with right SCJ infection 1 month after recovering from a tenckhoff catheter exit-site infection. She completed 6 weeks of antibiotics however this progressed to bilateral SCJ septic arthritis with osteomyelitis necessitating multiple surgical debridement and excision of bilateral clavicular heads. Further imaging showed signs of renal osteodystrophy and degenerative joint changes resembling calcium pyrophosphate deposition. Patients with end-stage renal disease have multiple risk factors including immune system dysfunction, renal osteodystrophy and dialysis access sites that increase susceptibility to bacteraemia and seeding. Therefore in such patients, prompt assessment is necessary to ensure expeditious diagnosis and treatment of this potentially debilitating condition. A multidisciplinary team involving various specialties is crucial for the holistic care for such patients and to reduce the risk of recurrence.

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.

Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach

OBJECTIVES

Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining.

METHODS

An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes.

RESULTS

A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis.

CONCLUSIONS

This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Sternoclavicular Septic Arthritis and Surgical Intervention: A Case Report

Management of septic arthritis is an area of controversy, especially in rare locations like the sternoclavicular joints. In this case report, we present a case of septic sternoclavicular joint, which was resistant to medical treatment and deteriorated during the treatment course. Although medical treatment has proven effective based on previous literature, some cases will still not benefit from it. In this case, our patient responded significantly to surgical treatment regarding upper limb function, faster infection eradication and rehabilitation, and shorter hospitalization and antibiotics duration.

Septic Sternoclavicular Arthritis: An Uncommon Manifestation in the Context of Immunosuppression Following SARS-CoV-2 Infection

This case report discusses a rare occurrence of septic arthritis in the sternoclavicular joint (SCJ) following SARS-CoV-2 infection-induced immunosuppression in a 94-year-old patient. Despite its rarity, the case underscores the importance of recognizing unusual manifestations of COVID-19, emphasizing the need for healthcare providers to consider COVID-19-induced immunosuppression in differential diagnoses. Swift diagnosis, surgical intervention, and appropriate antibiotics led to a favorable outcome, highlighting the significance of a multidisciplinary approach.

Sternoclavicular Septic Arthritis: A Case Report

We report a case of a 47-year-old male who presented with concerns for a "mass" on the right side of his chest and low-grade fevers for the last month. The patient was found to have an induration, erythema, and warmth at the right sternoclavicular joint, with tenderness to palpation and pain in the movement of the right arm. The patient was found to have septic arthritis of the sternoclavicular joint based on CT imaging. Sternoclavicular joint septic arthritis is a rare diagnosis and accounts for very few diagnosed septic joints. Most patients have some sort of risk factors, such as diabetes, immunosuppression, rheumatoid arthritis, or intravenous drug use. The most common pathogen is Staphylococcus aureus. Our patient did not consent to joint aspiration for a definitive diagnosis of the causative organism and was therefore empirically treated for S. aureus with trimethoprim-sulfamethoxazole. The patient also did not consent to any surgical management. Septic arthritis has been successfully treated with antibiotic therapy alone in the past, and in conjunction with the patient's choices, this was the treatment plan that was chosen for the patient. The patient responded to antibiotic therapy and followed up with a thoracic surgery clinic outpatient. This case depicts the importance of retaining a high index of suspicion for a rare diagnosis in the emergency department (ED). This case also depicts the successful treatment of sternoclavicular septic arthritis with outpatient oral trimethoprim-sulfamethoxazole, which, to the best of our knowledge, has not been done previously.

Acute Sternoclavicular Joint Sepsis With Medial Clavicle Osteomyelitis (Staphylococcus aureus) and Cervical-Thoracic Epidural Phlegmon in an Adult Female With No Apparent Risk Factors

This is a case of a 71-year-old female with a history of only one known medical problem (hypertension) who presented with a right sternoclavicular joint (SCJ) infection in addition to (1) a contiguous lower cervical and upper thoracic epidural phlegmon and (2) cellulitis and a phlegmon in her posterior neck, which was subcutaneous and near the lower cervical and upper thoracic spinous processes. These loci of infection developed several days after she had pricked her fingers when cutting rose bushes and were initially considered to be epidural abscesses. However, after the patient was transferred to our tertiary medical center, a neurosurgeon and radiologist determined that the cervicothoracic infections were phlegmons rather than fully developed abscesses. The phlegmons were treated with only IV antibiotics. The SCJ infection was surgically debrided, and the medial clavicle was excised. Bone and fluid cultures grew methicillin-sensitive Staphylococcus aureus (S. aureus). The patient recovered uneventfully (the final follow-up was four years later). This case is uncommon because of the concurrent SCJ infection with medial clavicle osteomyelitis, cervical-thoracic epidural, and paraspinous phlegmons.

Salmonella Sternoclavicular Septic Arthritis in a Non-sickle Cell Disease Patient

Septic arthritis is one of the most common orthopedic emergencies. In most cases, the joints affected are large (e.g., knees, hips, and ankles). The presentation of septic arthritis in the sternoclavicular joint (SCJ) has a relatively low prevalence rate, most commonly found in intravenous drug users. Staphylococcus aureus is the most common pathogen identified. We report a case of a 57-year-old male with a known case of diabetes mellitus, hypertension, and ischemic heart disease who complained of chest pain and was later found to have right-side SCJ septic arthritis. The procedure involves aspiration of pus using ultrasound guidance as well as irrigation of the right SCJ. The result of a pus culture from the right SCJ (a rare joint to be affected) was Salmonella, which is an atypical infection, specifically in non-sickle cell disease patients. The patient was treated with a specific antibiotic covering this pathogen.

Bemoan My Collarbone: A Case of Costocondral Junction Syndrome Complicated by Methicillin Sensitive Staphylococcus aureus Sternoclavicular Osteomyelitis and Septic Arthritis

A 35-year-old female with a past medical history of untreated Hepatitis-C, and a history of intravenous (IV) drug use initially presented to the emergency department with chief complaints of gradual worsening sharp, constant left-sided chest pain with no radiation starting three weeks before presentation. In the emergency department (ED), she was afebrile, normotensive, and tachycardia with 99% oxygen saturation on room air. A physical exam revealed a well-developed Caucasian female, alert and oriented with moderate distress. Respiratory exam with symmetrical bilateral excursions without wheezes, crackles, or rhonchi. On cardiovascular exam, she was tachycardic with a regular rhythm without murmurs, rubs, or gallops. There was a 2 x 2 cm tender erythematous swelling on the left sternal border inferior to the clavicle. The neck was supple and negative for Jugular Venous Distension (JVD). Neurologically grossly intact. Abnormal laboratory findings included leukocytosis with neutrophilic predominance. The patient received intravenous (IV) antibiotics with broad-spectrum vancomycin, cefepime, and azithromycin and underwent computed tomography angiography (CTA) chest, revealing a 26.8 mm x 26.5 mm left anterior subapical pleural-based pulmonary mass-like lesion with central hypoattenuation in surrounding ground-glass changes. Biopsy of the left subapical pulmonary lesion results showed chronic inflammatory infiltrate. Unfortunately, the patient left the hospital against medical advice after supportive care and pain control. Our patient's history of intravenous drug use and active Hepatitis-C infection were typical risk factors associated with invasive infections. In the clinical context, leukocytosis with hypo-attenuated pulmonary lesion should raise suspicion for septic emboli, localized abscess pocket, infection by atypical organisms, infective endocarditis, and malignancy which was considered upon initial assessment.

Minimally Invasive Surgery for Sternoclavicular Joint Infection with Osteomyelitis, Large Abscesses, and Mediastinitis

Background

Sternoclavicular joint infections require en bloc resection for radical cure; however, this aggressive procedure may result in multiple adverse events. Therefore, performing minimally invasive surgery is desirable. In this report, we describe a case of sternoclavicular joint infection complicated by osteomyelitis, large abscesses, and mediastinitis that was successfully treated with incision and drainage. Case Presentation. A 42-year-old man with no medical history presented to our hospital with complaints of painful swelling in the left chest wall and acute dyspnea. Computed tomography revealed arthritis of the left sternoclavicular joint, osteomyelitis of the clavicle and sternum, anterior mediastinitis, and abscesses in the neck, chest wall, and retrosternal and extrapleural spaces. Gram staining of the aspirated pus revealed clusters of gram-positive cocci. A diagnosis of Staphylococcus aureus sternoclavicular joint infection with locoregional spread was made. Emergency surgery was performed following adequate resuscitation. A skin incision was made in the second intercostal space. The joint capsule was widely opened, necrotic tissue was curetted, and closed suction drains were placed in the abscess cavities and connected to a negative pressure system. The wound was then closed using primary sutures. The postoperative course was uneventful. Methicillin-sensitive Staphylococcus aureus was cultured from the pus. The patient was discharged on postoperative day 14. Osteomyelitis worsened within a few weeks after surgery but recovered with wound management and six weeks of antibiotic therapy. The patient has had no recurrence of infection for two years.

Conclusions

Incision and drainage proved to be an effective minimally invasive surgical treatment for sternoclavicular joint infection with osteomyelitis, large abscesses, and mediastinitis caused by methicillin-sensitive Staphylococcus aureus.

Functional Disability Associated With Proximal Clavicle Resection and Pectoralis Flap Transposition for Sternoclavicular Joint Infections

BACKGROUND

Sternoclavicular joint infections (SCJI) are increasing with the opioid crisis and increased intravenous drug abuse (IVDA). Proximal clavicle resection with subsequent pectoralis muscle transposition is part of the treatment of such infections, but the long-term effects on shoulder function are not clear.

METHODS

This report presents a consecutive series of 15 cases of SCJI treated with proximal clavicle resection and pectoralis muscle flap coverage. Patient-reported outcomes were recorded using the Shoulder Disability Questionnaire (SDQ) developed by van der Heijden et al.

RESULTS

The average age of patients was 50 years (range, 23-73 years), with nearly half being male (7/15). Of these patients, 3 were lost to follow-up, 1 was excluded due to subsequent shoulder surgery for an unrelated problem, and another was excluded due to subsequent medical issues that precluded a reliable history. Recurrence was noted in 1 patient with ongoing IVDA. Average length of follow-up was 12 months (range, 8-19 months). The long-term shoulder disability was minimal (mean score of 6 ± 9). Among patients with IVDA, however, the long-term shoulder disability was significantly higher (mean score of 33 ± 16, P < .05).

CONCLUSIONS

In cases where the SCJI was attributed to IVDA, the long-term shoulder disability score was significantly higher, despite resolution of infection. Possible explanations include the self-reporting nature of the SDQ and the well-documented issues with chronic pain in patients with opioid dependency.  Of the patients lost to follow-up, 2 of 3 had infections attributed to IVDA, highlighting the difficulty of meaningful follow-up in this vulnerable patient population.

An unusual site of articular tuberculosis-A series of three conservatively managed cases

Tuberculosis (TB) infection of the Sternoclavicular joint (SCJ) is a rare entity, with 1-2% of all osteo-articular cases reported. We report a series of three cases of TB of the SCJ, in the patients presented with swelling of SCJ. Cytology showed chronic granulomatous pathology in all three cases, with one patient having Cartridge base nucleic acid amplification test positive for TB and another one having acid fast bacilli positive on Ziehl Neelsen staining. All three were put on antitubercular treatment (ATT) that resulted in significant improvement. A high index of suspicion of TB to be maintained in cases with swellings at unusual sites especially in high burden countries like India. Similarly, gradually progressive osteoarticular swellings without systemic features should also raise suspicion of tubercular etiology, as diagnosis was delayed for about 4 months in two of our cases and about 1 year in the third case. The application of newer technologies such as CBNAAT can help in early microbiological confirmation of paucibacillary disease leading to early diagnosis and prevention of possible complications.

Sternoclavicular Septic Arthritis: Partial Resection is Still an Option - A Case Report

Introduction

Sternoclavicular joint (SCJ) infection is rare. Delayed diagnosis might lead to severe complications. Optimal surgical management is still under debate however extended resection of the joint requiring muscle flap coverage appears to be the favored approach nowadays in the cases with bony involvement.

Case Presentation

A 58-year-old man complained of isolated left shoulder and anterior chest pain for over a month. Careful examination revealed a mass over the SCJ. A Computed tomography scan confirmed joint effusion and adjacent bone erosion, with no retrosternal involvement, consistent with SCJ septic arthritis with significant bony involvement.

Conclusion

This case illustrates how a heightened index of suspicion is essential for diagnosis and prompt treatment, and how partial resection was effective and resulted in complete recovery of range of motion and pain resolution, despite bony involvement. There were no signs of recurrence 1 year after surgery.

Cutibacterium acnes sternoclavicular joint osteomyelitis in an otherwise healthy 55-year-old man

Sternoclavicular joint osteomyelitis is extremely rare, with only 225 reported cases in the last 45 years. We present an unusual case in an otherwise healthy 55-year-old man with a history of well-controlled type 2 diabetes mellitus and hypertension. He presented to the emergency department after a week of left knee pain that worsened to full-body joint pain with left sternoclavicular swelling. He was started on antibiotics with multiple washouts of the left knee and treated for septic arthritis. By MRI and CT, he was found to have left sternoclavicular joint osteomyelitis and abscess and underwent debridement and resection. We believe that the initial joint injection resulted in haematogenous spread to the left sternoclavicular joint, stressing the importance of a sterile field for joint procedures.

Sternoclavicular Septic Arthritis Caused by Cutibacterium acnes in a Previously Healthy 13-Year-Old Male: A Case Report

CASE

A 13-year-old boy presented with 3 weeks of atraumatic left-sided sternoclavicular (SC) joint pain, swelling, and decreased range of motion. After imaging and laboratory workup, he underwent operative irrigation, debridement, and antibiotic therapy with complete resolution of his symptoms. Surgical cultures were consistent with SC septic arthritis.

CONCLUSION

The management of septic arthritis in pediatric patients remains varied. Here, we present the only report of SC septic arthritis due to Cutibacterium acnes in a healthy pediatric patient. Given the similar clinical findings of pain and swelling to affected bones and joints, differentiating SC septic arthritis from other conditions within the clinical spectrum of chronic nonbacterial osteomyelitis remains challenging. Clinicians should maintain a high index of suspicion when patients present with pain and swelling over the SC joint.