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Even in endemic areas, the sternoclavicular joint (SCJ) is a rare site for tuberculosis (TB), with reported rates of only 1%–2%.[1 2][1] This rarity, accompanied by non-specific symptoms, minimal clinical signs, and complexity in interpreting the X-rays, causes many cases to be missed.[3][2]

BACKGROUND: Subacromial pain (SAP) is a common complaint of young athletes, independently of the sport engaged. The prevalence of SAP in some sports is up to 50%. OBJECTIVE: The study was aimed to investigate some new factors possibly associated to subacromial pain in young athletes. The factors considered were the grade of tightness of the clavicular portion of the pectoralis major, dysfunction of the sternoclavicular joint, and serratus anterior and lower trapezius strength. METHODS: This case-control study included 82 young athletes 9-15 years, 41 with the symptoms of SAP and 41 controls. All participants self-reported whether they had subacromial pain. In addition, Hawkins-Kennedy Test was performed to all the participants to evaluate the subacromial pressure. Main outcome measures were the grade of tightness of the clavicular portion of the pectoralis major, dysfunction of the sternoclavicular joint, and serratus anterior and lower trapezius strength. The grade of tightness of the clavicular portion of the pectoralis major and the dysfunction of the sternoclavicular joint were measured with an inclinometer. Serratus anterior and lower trapezius strength were measured by a handheld dynamometer with external belt-fixation. The data were analyzed using t-test for independent samples, Mann-Whitney U test, contingency coefficients and a stepwise binary logistic regression. RESULTS: Significant statistical difference was observed in the grade of tightness of the clavicular portion of the pectoralis major and in the variable representing the physiological functioning of the sternoclavicular joint, between the cases and the controls. There was no significant difference in serratus anterior and lower trapezius strength between the cases and the controls. Logistic regression analysis showed that the variable representing the physiological functioning of the sternoclavicular joint and the grade of shortening of the clavicular portion of the pectoralis major were good predictors for presence of SAP. CONCLUSIONS: A strong association was determined between subacromial pain in young athletes, clavicular portion of pectoralis major tightness and the dysfunction of the sternoclavicular joint. © 2022-IOS Press. All rights reserved.

Summary Background Using the subpectoral approach, animation deformity or breast distortion due to pectoralis muscle contraction is common. Although the anatomy of the pectoral nerves has been extensively studied, only few studies have related the location of these nerves to bony landmarks. Objective Our aim is to clarify the anatomy and possible variations of the innervation of the pectoralis major in relation to bony landmarks useful for surgery and to identify the preferred level for (selective) denervation by 1) transecting the nerves and 2) splitting the muscle in subpectoral breast implant surgery in cadavers. Methods Fourteen pectoral regions (both left and right side) were dissected on 7 formaldehyde-fixed cadavers. The origin, locations, and course were mapped and (distances to) landmarks were reported. Results The lateral pectoral nerve, medial pectoral nerve, and ansa pectoralis were identified in all cadavers. Nerve branches pierce the pectoralis minor or run along its upper or lower border. The piercing nerves vary from one to three branches and were consistently located lateral to the midclavicular line. The horizontal and vertical distances to bony landmarks varied greatly and depended on the size and location of the pectoralis minor, except for the nerve running along the upper border of the PMin, which was located consistently around 30% of the clavicular line from the acromioclavicular joint to the sternoclavicular joint. Conclusion We were unable to define a fixed landmark to mark pre- or peroperatively. However, we could define guidelines that help to identify and excise or preserve nerves of interest.

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

We report a case of complicated sternoclavicular joint septic arthritis in a previously healthy adult with no risk factors. An 83-year-old female presented to the emergency with a 1-week history of right shoulder pain followed by fever and prostration in the last 48 h. Computed tomography (CT) scan findings were consistent with right sternoclavicular joint (SCJ) septic arthritis complicated by periarticular abscess. Emergent surgical debridement was performed by a surgical team composed of orthopaedic and thoracic surgeons, followed by 6 weeks of antibiotic treatment. This case highlights the diagnosis and surgical treatment of a rare septic arthritis location but with frequent complications as well as the importance of multidisciplinary collaboration.

Medial clavicle excision is a rarely indicated procedure and may be performed in different pathologies affecting the medial clavicle. Excessive medial clavicle resection with an injury to the costoclavicular ligament often leads to poor postoperative results. The exact surgical treatment used in this kind of pathology when conservative treatment is unsuccessful remains unclear. The aim of this Technical Note is to describe our preferred surgical technique to treat this condition., Technique Video Video 1 Surgical technique demonstration of reconstruction of the SCJ after excessive medial clavicle resection. An iliac crest autograft is first harvested. The size of the graft is determined by the size of the clavicle defect. A 1/3 tubular plate can be applied after graft harvest onto the iliac crest to prevent cosmetic deformity. An incision is made over the medial clavicle and sternum, and the medial clavicle is exposed. It is revitalized with an oscillating saw and rongeur. The sternal portion of the SCJ is exposed, preserving the capsule. The first rib is exposed and two strands of Ethibond 5 are passed through it. Two tunnels are drilled from the anterior sternal edge to the sternal articular surface. The iliac crest bone graft is shaped to the defect size, with a horizontal tunnel drilled through it to pass the gracilis allograft. The iliac crest bone graft is fixed to the native clavicle with a 3.5mm limited-contact dynamic compression plate. The sutures from the first rib are passed around the clavicle. The gracilis allograft ends are introduced into the sternal tunnel in a figure-of-eight configuration. The joint is reduced, and the graft is sutured onto itself. The sutures from the first rib are tied around the clavicle for the final costoclavicular stabilization. Pooled saline solution is used to check for pneumothorax. The capsule and platysma are approximated and closed.

Posterior sternoclavicular dislocations are common in younger patients and are frequently due to high energy sporting incidents. We aim to demonstrate a novel technique that is safe and aims to provide good functional post-operative outcomes for patients with this injury. This was a single-surgeon case series of four young patients from October 2017 to July 2019. The operative technique involved relocating the joint and holding it in situ with nylon suture tape. The tape was anchored in holes drilled in the sternum and passed through tunnels drilled into the medial clavicle. All of the patients were contacted retrospectively and a Nottingham Clavicle Score (NCS) was performed for each patient on a post-operative basis. No intra-operative or post-operative complications were noted. All of the patients demonstrated a significant improvement in their functional outcomes after the operation. The average NCS for the four patients was 82/100. There are a variety of techniques described in the literature to repair this ligament using either plates or tendon grafts. All of these techniques describe the drilling of anteroposterior holes in the manubrium and clavicle which run the intra-operative risk of perforating a major vessel. This paper is the first one to describe a technique which uses superior inferior holes which minimizes the risks, making the procedure safer for the patient. We believe this novel technique is safer than the existing described techniques, and it does not compromise on functional outcomes.

Background SAPHO (Synovitis Acne Pustulosis Hyperostosis Osteitis) and CRMO (Chronic Recurrent Multifocal Osteomyelitis) are chronic relapsing osteoarticular disorders with common dermatological manifestations. Aim of the work To describe a case of SAPHO in an adult and CRMO in a child. Cases presentation Case 1: A 32-year old man presented with dull aching low back pain for 2 years with morning pain/stiffness. On examination there were acneform lesions on the face, tenderness over thoracic spine and swelling of left sternoclavicular joint. Plain x-rays showed sclerosis/widening/irregularity of sternoclavicular joint, sclerosis/irregularity of endplate, loss of disc space with syndesmophytes in mid/lower dorsal spine (D6-11) and sclerosis in middle of left tibia. Magnetic resonance imaging (MRI) spine showed cortical erosions and marrow edema (D6-L1) with findings suggestive of aseptic/inflammatory spondylodiscitis. A bone scan showed increased uptake D7-D12 and mid-third tibia (hyperostosis). Biopsy from D6/D7 showed normal histopathology. Case 2: A 10-year-old girl presented with pain/swelling of right foot for 2 months, pain/swelling of left shoulder and sternoclavicular joint with pustular acne on the face. There was swelling/tenderness over right 5th metatarsal base and left sternoclavicular joint as well as tenderness over proximal humerus. ESR was 65 mm/1sthr. Plain x-rays showed punched-out lytic lesions surrounded by sclerosis in metatarsal base and metaphysis of humerus. Patient was diagnosed as CRMO. Conclusion SAPHO and CRMO are rare and their diagnosis is sometimes not easy. SAPHO can present as aseptic spondylodiscitis. Both conditions can be diagnosed with clinical and radiological features. A biopsy is necessary for ruling out other conditions.

Mediale Klavikulafrakturen sind seltene Verletzungen, und ihre Behandlung ist eine Domane der konservativen Therapie. Dislozierte Frakturen hingegen weisen eine hohe Pseudarthroserate auf und konnen von einer operativen Behandlung profitieren. Fur die Wahl des optimalen Therapieverfahrens sind die Beurteilungen der Stabilitat und der Frakturmorphologie von entscheidender Bedeutung. Der Fall beschreibt die Diagnostik und operative Versorgung einer dislozierten, extraartikularen Schlusselbeinfraktur mit einem kleinen medialen Fragment unter Verwendung einer anatomisch vorgebogenen Radiusplatte.

BACKGROUND/AIMS To evaluate sternoclavicular joint distances and age-related degenerative changes in thorax computed tomography images. MATERIAL and METHODS Computed tomography (CT) was performed between April 2019 and October 2019 at the Department of Radiology of State Hospital for chest pain and lung parenchymal nodule follow-up. One hundred and forty-six sternoclavicular joints of 73 patients (38 males, 35 females, median 58 years, mean 57.23 +/- 13.25 years) aged 35-78 years were evaluated retrospectively. Measurements were taken for bilateral sternoclavicular joint from anterior, mid, and posterior in the axial plain and superior, mid, and inferior sections in the coronal plan. Measurements of sternoclavicular joint were compared according to gender for right and left sides. The presence of osteophyte, sclerosis, subchondral cyst, and gas showing degeneration in the sternoclavicular joint were compared according to age and sex. RESULTS Sternoclavicular joint distances measured in axial and coronal planes were found to be significantly lower in female gender group than in men. In the study group, there was statistically significant difference between the measurements made from the coronal plan superior section (P = .016). There was no statistically significant difference between mid and inferior measurements in coronal plane and anterior, mid and posterior measurements in axial plane. Sternal osteophytes were significantly more common in females than males (P = .021). Osteophyte located in the clavicle was significantly more frequent with increasing age. CONCLUSION There is no significant asymmetry in the sternoclavicular joint in asymptomatic individuals, and an increase in degenerative markers of the sternoclavicular joint is observed with the progression of age.

A combination of an anterior sternoclavicular (SC) joint dislocation with a midshaft clavicle fracture is an extremely rare injury. If left untreated, it can lead to severely impaired function of the shoulder with a high risk for complications. A 45-year-old male patient presented with pain and impaired range of motion (ROM) in the left shoulder after a mountain bike crash. Radiographs and a computed tomography scan showed an anterior dislocation of the left SC joint and an ipsilateral midshaft fracture of the clavicle. Open reduction and internal fixation (ORIF) of the clavicle combined with SC joint stabilization using transosseous sutures was performed. Postoperatively, a shoulder-arm bandage was applied with passive motion starting on the first postoperative day. During follow-up, the patient showed an improved clinical function and could return to work after three weeks. Radiographs at eight weeks showed fracture healing without any signs of recurrent SC dislocation. At the final follow-up at 12 weeks, the patient returned to his pre-injury activity level and recreational sports. Despite minimal redislocation in the SC joint, the Constant-Murley Score showed a continuous improvement with 93%, compared to the contralateral side. In conclusion, surgical treatment of anterior SC joint dislocation with a midshaft clavicle fracture can restore shoulder function with no surgery-associated complications.

Summary. Inflammatory lesion of the sternoclavicular joint (SCJ) is a rare disease that requires surgical treatment. Traditional radiography reveals osteolysis and osteosclerosis, however, at the onset of the disease, such changes are absent. Difficulties in diagnosing this disease require further study of the problem and the development of new therapeutic and diagnostic approaches. Aim of the work: to study the role of sonography in the diagnosis of purulent arthritis of SCJ and the choice of treatment tactics. Materials and methods. Prospective single-center study of 28 cases of acute nonspecific arthritis of SCJ. The patients were divided into 2 groups: the first included patients who received drug therapy, the second included patients subject to surgical treatment. Results and discussion. Ultrasound scanning of SCJ identified 3 sonographic variants of the lesion: exudative, destructive with synovial hyperperfusion, and destructive with synovial hypoperfusion. The duration of hospital stay in both groups did not differ statistically: 12 (12; 13.5) vs 14 (12; 14) days, p = 0.194. Analysis of long-term results in patients of the first group established the progression of the disease with the development of osteomyelitis or recurrence of arthritis in 3 cases (30 %). Among the patients of the second group, no complications or recurrence were detected during the indicated observation period. Conclusion. Sonography is diagnostically significant in the diagnosis of SCJ arthritis. It allows you to determine the group of patients subject to mandatory surgical correction. Intravenous drug addiction associated with bacteremia is a predictor of poor drug treatment outcomes and an indication for active surgical tactics.

We report a case of Sternoclavicular Joint (SCJ) infection in a 52-year-old male who developed an empyema over six days. During the first three visits, he had worsening pectoral and shoulder pain and was symptomatically treated and discharged. During the first ED visit, a computed tomography (CT) scan of the neck was negative. During the second ED visit, CTA chest was negative for pulmonary embolism. Three days later, CTA of the neck showed density from the left first rib to the left sternoclavicular joint, suggesting a hematoma. During the final ED visit, CT of the chest showed a left anterior chest wall abscess contiguous with a left upper lobe empyema. VATS confirmed empyema and revealed costochondral and SCJ abscess. Decortication, SCJ resection, and pectoralis muscle debridement were performed. Methicillin-susceptible Staphylococcus Aureus (MSSA) was isolated from surgical cultures. After the pectoralis muscle flap closure, he was treated with IV cefazolin for a total of six weeks. Health care professionals should have a high index of suspicion for SCJ infections in patients with a similar clinical presentation. This case highlights the importance of early and prompt diagnosis of MSSA SCJ infections to prevent sequelae of the disease.

Purpose The aim of this study was to assess the impact of arm position in computed tomography (CT) of the clavicle performed for forensic age estimation on clavicular position, image noise, and radiation dose. Methods and materials Forty-seven CT scans of the medial clavicular epiphysis performed for forensic age estimation were conducted with either hands and arms held upwards (CTHU, 28 persons) or positioned at the body (CTHD, 19 persons). Presets were identical for both positions (70 mAs/140 kVp; Brilliance iCT, Philips). Each CT scan was reconstructed with an iterative algorithm (i-Dose 4) and evaluated at the middle of the sternoclavicular joint. Clavicular angle was measured on a.p. topograms in relation to a horizontal line. Quantitative image noise was measured in air at the level of medial clavicular epiphysis. Effective dose and scan length were recorded. Results Hands-up position compared with hands-down position resulted in a lower lateral body diameter (CTHU 41.1 ± 3.6 cm vs. CTHD 44.6 ± 3.1 cm; P = 0.03), a reduced quantitative image noise (CTHU: 39.5 ± 9.2; CTHD: 46.2 ± 8.3; P = 0.02), and lower CTDIvol (5.1 ± 1.4 mGy vs. 6.7 ± 1.8 mGy; P = 0.001). Scan length was longer in patients examined with hands up (HU: 8.5 ± 3.4 cm; HD: 6.2 ± 2.1 cm; P = 0.006). Mean effective dose for CTHU was 0.79 ± 0.32 mSv compared with 0.95 ± 0.38 mSv in CTHD (P = 0.12). Clavicular angle was 17° ± 6° in patients with hands down and 32° ± 7° in patients with hands up (P < 0.001). Conclusion By elevated arm positioning, the image quality of clavicular CT scans can be improved while maintaining radiation dose compared with hands down. Clavicular position differs according to the hand position. Thus, positioning patients with elevated hands is advisable for forensic clavicular CT examinations, but multiplanar CT reconstructions should be adjusted to clavicular position and scan length should be reduced to a minimum.

Sternohyoid, sternothyroid, omohyoid, and thyrohyoid muscles are collectively known as infrahyoid muscles. These muscles frequently show variations in their attachments. Here, an extremely rare variant muscle belonging to this group has been presented. During cadaveric dissection for undergraduate medical students, an additional muscle was found between sternohyoid and superior belly of omohyoid muscles bilaterally in a male cadaver aged approximately 70 years. This muscle took its origin from posterior surface of the manubrium sterni, capsule of the sternoclavicular joint and the posterior surface of the medial part of the clavicle. It was inserted to the hyoid bone between the attachments of sternohyoid and superior belly of omohyoid muscles and was supplied by a branch of ansa cervicalis profunda. There is no report on such a muscle in the literature and it could be named as “sternocleidohyoid muscle”. Knowledge of this muscle could be useful in neck surgeries.

BACKGROUND The treatment of traumatic sternoclavicular joint (SCJ) dislocation (SCJD) with internal fixation has been reported with good short-term results, but data on its long-term results are scarce. METHODS Patients with traumatic SCJD treated with an SCJ-specific plate between January 2003 and January 2018 were evaluated retrospectively. All implants were routinely removed. Data from radiography, the American Shoulder and Elbow Surgeons score, the visual analogue scale and abduction and forward elevation of the shoulder were collected and evaluated before the index surgery, at implant removal and at the latest follow-up. RESULTS A total of 22 patients were included in this study with a mean follow-up period of 94.8 months. All patients maintained good reduction after the index surgery and implant removal. The visual analogue scale significantly improved from 7.1 ± 1.3 before the index surgery to 0.9 ± 1.0 at implant removal (P

Neonatal sepsis contributes significantly to neonatal morbidity and mortality. Group B streptococcus (GBS) is not a frequent cause of neonatal sepsis in India. Late onset sepsis by GBS presenting as focal infection like osteomyelitis is seen in only 3% of the total GBS sepsis profile in neonates. Here, we report a rare case of neonatal osteomyelitis with septic arthritis caused by GBS at an unusual site, the clavicle and sternoclavicular joint.

Anterior chest pain associated with sternoclavicular arthritis has been considered a symptom specific to SAPHO syndrome. Differentiating aseptic arthritis of the SAPHO syndrome from infectious sternoclavicular joint (SCJ) arthritis is often difficult. We reported a 55-year-old woman with left hip joint and right SCJ pain. Diagnosis and treatment were delayed because she was misdiagnosed with SAPHO syndrome, and haematogenous infection spread to the hip joint septic arthritis. She was diagnosed promptly after presenting to our hospital and underwent early debridement, and her hip joint and SCJ was found to have almost no dysfunction. Differentiation between sternoclavicular arthritis of the SAPHO syndrome and sternoclavicular septic arthritis is clinically important and requires careful attention.

A 12-year-old boy presented to the Children’s Emergency Department having sustained a left clavicular injury while playing rugby. Another player had fallen on him while he was scoring a try. On examination, there was a tender and painful protuberance over the left sternoclavicular joint (SCJ) but no tenderness or swelling over the acromioclavicular joint or distal clavicle. Left arm movement was limited due to pain. The limb was neurovascularly intact and cardiovascular examination was normal. A clavicular fracture was suspected and a radiograph requested (figure 1). Figure 1 Anteroposterior radiograph of left …

The sternoclavicular joint (SCJ), an important link between the appendicular and axial skeleton, though involved in 41% of rheumatoid arthritis patients, has not been studied in juvenile idiopathic arthritis (JIA). Hence, this cross-sectional study was done to delineate the magnetic resonance imaging (MRI) findings in SCJ in JIA and compare with the clinical examination to diagnose SCJ arthritis. Of the 116 JIA patients attending the pediatric rheumatology clinic, twenty-one patients (42 SC joints) were evaluated by 1.5 T MRI using the four components of early and late inflammatory changes—synovial hypertrophy, bone marrow edema (BME), cartilage lesions, and bone erosions. Results were compared with clinical assessment of SCJ arthritis. Of the 42 SCJ evaluated (21/116 patients), MRI changes were seen in 27 SCJs (15 patients, 12.9% of 116 JIA patients). Early MRI changes were seen in 60% of joints found normal on clinical examination, with as much as 1/4th of them revealing late destructive changes. Synovial hypertrophy, BME, cartilage lesions, and bone erosions were seen in 5, 15, 4, and 10 patients, respectively. Sensitivity and specificity of clinical examinations to evaluate SC joint involvement were 55.5% and 53.3%, respectively. MRI evaluation of the SCJ in JIA revealed findings in 15/21 enrolled patients. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. Clinical examination was found to be neither sensitive nor specific.

The manubrium stabilizes the shoulders and assists in movement of the chest wall during respiration. Thus, resection of the manubrium creates instability of the chest wall and exposes the underlying great vessels. The material utilized to reconstruct the manubrium should be durable, resistant to infection and rejection, and provide good cosmesis. Autologous iliac crest bone grafts have been successfully used for bone replacement by orthopaedic surgeons and have proven to be versatile and less prone to rejection. In this article, we describe our technique for reconstruction of the sternum utilizing iliac wing bone autograft.

We analyzed short-term results of personalized treatment of 31 patients with sternoclavicular septic arthritis. Sternoclavicular joint infection was spread hematogenously in 74,2 % of patients and staphylococcus was the most causative pathogen (87,1 %). Diagnostic work-up included computer tomography, ultrasound-guided aspiration and microbiological analyses of aspirate and blood culture. 16 patients with sternoclavicular joint infection underwent incision, debridement and drainage at the first stage of treatment. Three of them died. Negative pressure wound therapy was used in 11 patients. Antibiotic therapy was effective in 50 % of patients with serous arthritis of sternoclavicular joint. Antibiotic with drainage and/or negative pressure wound therapy was efficient in 33,3 % of cases. The final respective-reconstructive stage of treatment was performed in 48,1 % of patients with good results. Wide resection was performed including medial end of clavicular, part of manubrium sterni and medial end of first and second ribs followed by pectoralis muscle flap.

Septic arthritis of the sternoclavicular joint (SC) is rare. The most accepted technique for reconstruction of the defect after SC joint resection is the use of muscle flaps. We hypothesized that resection of ribs with the SC joint impacts timing, type and outcomes of reconstruction. This is a retrospective review of 44 patients who underwent wound closure with muscle flap following resection of the SC joint for septic arthritis over 14 years period from a single institution. Patients were divided into two groups based on the resection of the adjacent ribs with the SC joint. We found 18 (40.9%) patients with SC joint resection only and 26 (59.1%) with concomitant resection of the adjacent ribs. Patients in the rib resection group were younger, did not need SC joint fluid aspiration, and had higher tissue culture positivity (

Background Clostridium perfringens septic arthritis of the sternoclavicular joint has not been reported previously. Case Report: We present the case of a 70-year-old patient with a history of stage IV colon cancer who presented to the emergency department with chest and neck pain for 3 days. After assessment, he was discharged home on analgesics. Within 24 h he returned, critically ill with C. perfringens septic arthritis of the left sternoclavicular joint and septic shock. Why Should an Emergency Physician Be Aware of This? Emergency physicians should be aware of the possibility of C. perfringens sternoclavicular joint septic arthritis in patients with unexplained chest, shoulder, or neck pain, especially when associated with a history of colorectal carcinoma or immunosuppression. A finding of C. perfringens bacteremia should prompt a search for occult gastrointestinal malignancy.

Primary bone lymphoma is rare, among which commonly involved site at time of presentation are femur, pelvic bones, tibia and most common type is Large B cell lymphoma which usually occurs in adults. Cases of large B cell lymphoma in clavicle as primary bone lymphoma is extremely rare finding. According to our knowledge this case may be first reported case of world. We are here reporting a case of 62-year female presented as sternoclavicular joint swelling, without fever or pain in local area. Patient was diagnosed on X ray by radiologist, as well as by clinician as, osteosarcoma of right clavicle. Patient came to Department of Cytopathology for FNA for confirmation of X ray finding. On FNA diagnosis of Non-Hodgkin lymphoma was given, and advise for biopsy and immunohistochemistry (IHC) was given for confirmation of diagnosis and to subtype NHL. On IHC Ki67 index was 85%, with diffuse positivity noted for MUM1, CD79a, and CD138 along with cytoplasmic positivity for ALK 1 and patchy positivity for PAX 5. Tumor was negative for BCL6, BCL2, CD20, CD5, CD23, CD10, CD19, CD4, CD8, CD7, CD3. Diagnosis of ALK positive DLBCL was given on biopsy after IHC. Patients with PBL treated with combined modality were found to have a superior outcome, with a significantly better survival (5-year cause-specific survival 95%). So correct and timely pathological diagnosis of DLBCL as PBL is significantly important for prognosis.

The injury of acromioclavicular joint is one of the causes limitation function of the shoulder joint. Choice of fixation methods of acromioclavicular joint dislocation is actual topic to research. Objective: to study by a biomechanical experiment and to substantiate influence of different fixation methods of acromioclavicular joint dislocation on range of motion of acromioclavicular and sternoclavicular joints during the upper extremity elevation. Methods: 6 prototypes of a natural skeleton 3D technology from ADS plastic were used. The capsuloligamentous components, dynamic and static stabilizations of acromioclavicular and sternoclavicular joint were modeled from artificial materials. Each model of acromioclavicular dislocation was fixed by 6 different fixations methods: «intact joint», «fixation by Weber», «Bosworth screw», «Hook-plate», «DogBone», «External fixation». During the experimental study, the range of motions was fixed in acromioclavicular and sternoclavicular joints in 90 and 180 degrees of arm elevation, each experiment was repeated 5 times. Results: range of motion in acromioclavicular and sternoclavicular joints in position of 90 degree of arm elevation, with fixation of acromioclavicular joint dislocation by Hook-plate and system of 2 mini plates and suture material (DogBone), in position of 180 degree of arm elevation with fixation of «DogBone» was physiological. Other methods of fixation — «Bosworth screw», «Weber fixation», «External fixation», «Hook plate» limited the range of motion in the acromioclavicular joint and increase motion in the sternoclavicular joint at maximal arm elevation. Conclusions: fixation of acromioclavicular joint dislocation by 2 mini plates and suture material (DogBone) gives physiological range of motion in acromioclavicular and sternoclavicular joints during arm elevation.

Background A standardized treatment algorithm for sternoclavicular joint infection management is lacking in the literature. While major risk factors for sternoclavicular joint infection, including immunosuppression, rheumatoid arthritis, type 2 diabetes, indwelling catheters, and intravenous drug use have been identified, clear association with treatment outcome has not been established. As our safety net hospital treats a patient population with high incidence of intravenous drug use, we sought to identify risk factors associated with failure of non-operative management of sternoclavicular joint infection. Methods We conducted a retrospective cohort study, reviewing charts of patients diagnosed with sternoclavicular joint infection between January 2001 and December 2017 to collect demographic information as well as clinical risk factors and treatment patterns. A chi-square test was performed to determine any association between clinical variables and management, as well as relation to treatment outcome. Results The study cohort consisted of 35 patients with diagnosis of sternoclavicular joint infection and complete follow-up. Intravenous drug use was prevalent, seen in 45.6% (16/35) of subjects, though there was no association with failure of non-operative management (P=0.50). Operative management was the initial treatment for 25.7% (9/35) of subjects and was associated with abscess on presentation (P=0.03). Failure of non-operative management was seen in 26.9% (7/26). Type 2 diabetes was associated with failed initial non-operative management, present in 42.9% (3/7) of patients (P=0.03) experiencing failure. Conclusions This study constitutes the largest series of sternoclavicular joint infection with intravenous drug use. While intravenous drug use was not associated with failure of non-operative management, we observed that type 2 diabetes is associated with failure of non-operative management and could be considered in determining management of sternoclavicular joint infection patients.

Positional anterior sternoclavicular joint (SCJ) dislocation is relatively rare and needs careful treatment. We report our course of treatment and tips for surgery in a case. The patient was a 16-year-old male outfield baseball player. Three years ago, he had 3 recurrent episodes of right shoulder dislocation. During these injuries, there were forward dislocations of the proximal right clavicle edge accompanied by a creaking sound during the throw acceleration period. Thereafter, the anterior dislocation of the SCJ occurred during the acceleration phase of throwing, and the SCJ naturally repositioned on the shoulder resting position. This situation lingered and he often felt shoulder apprehension during throws, so he opted for surgical treatment just 1 month after the first injury. We performed a modified version of the figure-of-8 technique reported by Wang et al, using the ipsilateral palmaris longus (PL) tendon. The bilateral edge of the PL was attached to a Krackow suture and passed through the bone tunnels opened at the proximal clavicle and proximal sternum so that it became a figure of 8 on the anterior of the SCJ. The stability of the SCJ was confirmed after the surgery.

A bipolar clavicle separation is defined as a simultaneous dislocation of the ipsilateral sternoclavicular joint (SCJ) and acromioclavicular joint (ACJ). This rare injury pattern is usually the result of a high-energy mechanism, such as a motor vehicle collision or fall from height. While there are several treatment options such as screw fixation, sutures, or plate fixations, there is no single standard approach for this infrequent injury. We describe a unique case of bipolar clavicle dislocation, specifically an anteriorly displaced SCJ and posteriorly displaced ACJ, treated with a novel surgical technique—a TightRope technique (Arthex®) and semitendinosus allograft.

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.

INTRODUCTION To evaluate, factors associated with new ultrasonographic lesions of the anterior chest wall in spondyloarthritis (SpA) after a follow up of 5 years. METHODS SpA Patients included in 2013 in a first study were evaluated five years later. Ultrasound B mode and power Doppler examination of the two sternoclavicular joints and the manubrio-sternal joint were performed by the same two examinators at baseline and five years later. The presence of erosion, synovitis, ankylosis, power Doppler signal, joint effusion and joint space narrowing were assessed blind of the first evaluation. RESULTS Among the 131 patients at baseline, 58 patients were evaluated 5 years later. The mean age was 48.2±11.9 years old, with 86% of male and mainly an axial disease (78%). Patient characteristics are comparable to the original cohort. The most frequent lesions were ankylosis of the manubriosternal joint (38%) and erosions of the sternoclavicular joint (29%). 31 patients (53%) developed a new lesion of the ACW. There is a statistically significant association between new lesions of the ACW and higher ASDAS CRP (1,86±1,07 VS 3,0±2,17 P

Sternoclavicular joint (SCJ) instability is a rare condition and results from either a traumatic high energy impact, such as a motor vehicle crash or contact sports injury, or non-traumatically as a result of structural pathology. The infrequency of this injury has contributed to its diagnosis being missed as well as the paucity of literature on treatment and outcomes. Patients with SCJ instability often report diminished range of motion as well as shoulder girdle pain. The presentation of instability in the sternoclavicular joint can vary in severity and anterior or posterior directionality. Variation in severity of the instability changes the course of treatment regarding either operative or non-operative interventions to stabilize the SCJ. In general, anterior instability of the SCJ (the medial clavicle is displaced anterior to the sternum) is less urgent and generally manageable by symptom alleviation and rehabilitation, although some anterior instability cases require surgical intervention. In the case of posterior SCJ instability (the medial clavicle is displaced posterior to the sternum), patients require prompt joint reduction as they are at the greater risk of life-threatening injury due to the location of critical structures of the mediastinum posterior to the SCJ. Computed tomography visualization is useful to confirm dislocation or subluxation direction to better formulate a proper treatment plan. The purpose of this review is to report the clinical presentation and management of SCJ instability including pertinent symptoms, the diagnostic approaches to evaluating SCJ instability, as well as operative and non-operative management of the joint instability.

Introduction. Acquired heart defect affect people of different ages and lead to permanent disability, so this is important social problem. The single effective way to treat acquired heart defect, which can significantly increase the life expectancy of patients, is surgical correction aimed at eliminating severe hemodynamic disorders. Sternotomy mediates subsequent changes in the biomechanics of respiration, contributes to the appearance of pain in the thoracic region of the spinal column and ribs. In this regard, the possibility of osteopathic diagnosis and correction of such patients in the postoperative period is an actual question.The goal of research — is to investigate the possibility of osteopathic correction in the complex therapy of patients after sternotomy in the connection with the surgical treatment of acquired heart defect.Materials and methods. The study involved 80 patients after surgical treatment of acquired heart defect. Osteopathic diagnosis was performed before and after surgery. Then, the control (patients received standart treatment) and experimental (patients received standart treatment and osteopathic correction) groups were selected using a simple randomization method. The both group included 40 people. There were assessed the fl uid volume in the pleural cavities (as one of the heart failure indicators) using the ultrasound method for the study of pleural cavities, and the pain intensity (using pain verbal-analogue scale) in both groups before starting treatment. Then the osteopathic diagnostics and theassessment of pain intensity and fl uid volume in the pleural cavities were repeated in each group after completion of the treatment. The collected data was processed by the methods of parametric and nonparametric statistics.Results. Patients after median sternotomy connected with surgical treatment of acquired heart defect had characteristic somatic dysfunctions: global rhythmogenic (cardiac and respiratory) and biomechanical disorders, regional biomechanical disorders of the thoracic region, dura mater and pelvic region, local somatic dysfunctions of the sternoclavicular joint, sternum, ribs, mediastinum, pericardium and ligaments of the liver. Osteopathic correction in patients of the experimental group after median sternotomy leads to a statistically significant (pConclusion. There was revealed that patients after surgical treatment of acquired heart defect suffered from developed somatic dysfunctions of global, regional and local levels. It was established that osteopathic correction leads to a decrease in the detection frequency of some global and regional somatic dysfunctions, pain severity and fluid volume in the pleural cavities. So the obtained results allowrecommendingthe osteopathic correction as an effective complement to the standard methods of treating patients after surgical treatment of acquired heart defect.

BACKGROUND Sternoclavicular joint septic arthritis (SCJ SA) is a rare infectious disease process with reported life-threatening complications such as mediastinal abscess and mediastinitis. The available literature reports variable success of medical management and a predominance of surgical management, with a 58% rate of surgical washout/debridement and high rates (47%) of resection of the SCJ and medial third of the clavicle. METHODS A retrospective case series of radiologically or microbiologically confirmed cases of bacterial SCJ SA at Fiona Stanley Hospital was analysed. Demographic data, investigations, management and outcomes were assessed. RESULTS Eleven cases of bacterial SCJ SA were identified. Eight cases were of primary SCJ SA, whilst three cases were secondary to haematogenous seeding. Recognized risk factors such as intravenous drug use, diabetes mellitus, trauma, smoking and immunosuppression were present. The most common complication was clavicular osteomyelitis (64%). Life-threatening complications included mediastinal abscess and rapidly progressive necrotizing myositis. Nine patients (82%) were managed with primary medical therapy, with two patients failing antibiotic therapy and requiring joint washout. Two patients were taken for urgent washout on presentation. Four cases (36%) resulted in operative SCJ washout. There were no cases requiring resection of the SCJ or clavicle. CONCLUSION This series suggests that SCJ SA can be primarily treated medically in the absence of life-threatening complications. In addition, medical management may be sufficient for cases complicated by clavicular osteomyelitis. Need for surgical resection of the SCJ and medial third of the clavicle may be less than previously reported.

Venous thoracic outlet syndrome (VTOS) is a compressive disorder of subclavian vein (SCV); we aimed to investigate the role of costoclavicular ligament (CCL) in the pathogenesis of VTOS. A cadaver study was carried out to investigate the presence and morphology of CCL in thoracic outlet regions, as well as its relationship with the SCV. Six formalin-fixed adult cadavers were included, generating 12 dissections of costoclavicular regions (two sides per cadaver). Once CCL was identified, observation and measurement were made of its morphology and dimensions, and its relationship with SCV was studied. To take a step further, a clinical VTOS case was reported to prove the anatomical findings. Two out of twelve costoclavicular regions (2/12, 16.7%) were found to possess CCLs. Both ligaments were located in the left side of two male cadavers and were closely attached to the lateral aspect of sternoclavicular joint capsules. The lateral fibers of the ligament proceed in a superolateral-to-inferomedial manner, while the medial fibers proceed more vertically. Both ligaments were tightly adherent to the SCV, causing significant compression on the vein. In the clinical case, multiple bunches of CCLs were found to compress the SCV tightly intraoperatively. After removing the ligaments, the patient’s symptom kept relief during a follow-up period of 2 years. Our study demonstrated that CCL could be a novel cause of VTOS by severe compression of SCV. Patients diagnosed with this etiology could get less invasive surgical treatment by simply removing the ligament.

Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting primarily joints and an increased risk of developing malignant lymphomas in RA has been well reported. However, primary lymphoma in a joint in RA patient is rare. We report the case of a 65-year-old man with RA suffering from pain and swelling of left sternoclavicular (SC) joint, which was not relieved by adding low-dose glucocorticoid. Magnetic resonance imaging (MRI) showed a para-osseous soft tissue swelling around the SC joint and a fracture of proximal clavicle. Histology of the soft tissue demonstrated diffuse large B-cell lymphoma and the patient subsequently underwent R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. He was successfully treated with six cycles of R-CHOP chemotherapy, with discontinuation of MTX, resulting in a complete response. We performed a literature review and identified nine cases of lymphoma which involved joints in patients with rheumatoid arthritis. This is the first described case of a primary large B-cell lymphoma involving the unilateral SC joint in a patient with RA, which was initially confused with aggravation of RA. Therefore, malignant lymphoma should be considered in the differential diagnosis when a RA patient develops monoarthritis with spontaneous fracture, even without B symptoms.

Sternoclavicular joint (SCJ) infection is a rare disease and its management remains controversial. Our institution has adopted an aggressive surgical approach of radical SCJ resection combined with myocutaneous flap (MCF) closure whenever possible. We reviewed our experience with this approach in the management of this condition. From July 2004 to June 2018, 50 consecutive patients were treated surgically for SCJ infections. Patient demographics, imaging studies, microbiology, and operative variables were analyzed. All patients underwent ipsilateral SCJ resection. Wound closure was performed with primary pectoralis advancement MCF closure at the initial operation in 25 patients, delayed MCF closure following temporary wound vacuum therapy and redebridement in 19 patients, and definitive wound vacuum therapy (DWVT) in 6 patients. End points were recurrence of infection, perioperative morbidity, and mortality. Localized swelling (100%) and pain (100%) were the most common presenting symptoms. MSSA was isolated in 50% of tissue cultures. Comorbidities included tobacco smoking 52%, diabetes mellitus 50%, intravenous drug use 34%, poor dental hygiene 32%, and obesity 28%. We had no deaths within 90 days of operation. Complications; seroma in 1 patient (2%), chest wall hernia in 1 patient (2%), retained drains in 1 patient (2%), recurrent osteomyelitis infection in 3 patients (6%), and hematomas in 5 patients (10%). Patients treated with primary MCF closure at the initial operation had a 0% (0/25) rate of recurrence compared to 5.26% (1/19) in delayed MCF closure. Overall, there was only a 2.27% (1/44) recurrence of infection in primary and delayed MCF closure combined, compared to 33.33% (2/6) in patients treated with DWVT closure. SCJ infections require an aggressive approach. Wound closure with an MCF (primary or delayed) is associated with less recurrence of infections compared with DWVT closure. Radical resection of the entire SCJ with MCF (primary or delayed) should be considered the preferred management strategy in patients with SCJ infections.

Septic arthritis of the sternoclavicular joint is a rare and serious infection. A delay in the diagnosis may lead to serious complications. The appropriate medical and surgical treatment is crucial to the outcome. This article aims to report our experience in the successful management of sternoclavicular joint infection complicated with a lung infection. The authors present an unusual case of sternoclavicular joint infection extending into lung parenchyma with lung abscess formation in a diabetic patient, with uncontrolled diabetes that was successfully treated. At revaluation, he was asymptomatic with no evidence of relapse. Although sternoclavicular joint infection is a rare condition we highlight the importance of clinician’s awareness for an early diagnosis and treatment with broad-spectrum antibiotics and surgery.

Invasive infections due to Streptococcus dysgalactiae are uncommon in the adult population, and sternoclavicular joint septic arthritis (SCSA) is usually caused by other organisms such as Staphylococcus aureus and Pseudomonas aeruginosa. We hereby report a case of SCSA caused by this organism. The patient responded well to intravenous antibiotics and recovered fully without any surgical intervention.

Highlights • Surgical intervention is indicated in cases of SCJ osteomyelitis after failure of conservative management. It provide definitive management when the joint shows signs of destruction in CT scan. • SCJ debridement followed by delayed resection of the joint together with the surrounding infected tissue including bone and cartilages, offer better results than merely debridement alone. • Pectoralis muscle flap achieves best result in the management of sternoclavicular joint osteomyelitis after resection of the joint., Introduction Sternoclavicular joint (SCJ) osteomyelitis is a very rare condition. Here, we report an uncommon case of a complicated SCJ osteomyelitis in a patient with an anterior chest wall trauma. Presentation of case A 61-year-old male a known case of dyslipidemia, hypertension (HTN), and type II diabetes mellitus (T2DM). The patient presented with pain and erythema over the right SCJ following trauma to the same location. Two weeks later, the patient presented with erythematous swelling with a sinus discharging pus, although he was discharged on oral antibiotics, analgesics, and had underwent an incisional drainage. Computerized Tomography (CT) of the chest showed fluid collection surrounding the right SCJ together with joint effusion suggestive of SCJ osteomyelitis. The patient underwent initial debridement and a definitive bone resection with pectoralis muscle flap two weeks following. Five months later, the patient was seen in the outpatient clinic, the wound was completely healed, and he has a normal function of the right arm. Discussion The management of SCJ osteomyelitis is not well established, yet it can be approached medically, surgically, or both. Conclusion Surgical intervention is indicated in cases of SCJ osteomyelitis after the failure of antibiotic therapy trial. This is especially the case in the presence of abscess and bone destruction. SCJ debridement followed by delayed resection and pectoralis muscle flap might offer better results than merely debridement alone or with resection of the joint.

Highlights • Posterior sternoclavicular joint fracture-dislocations are a rare and often-missed injury in trauma. • Posterior displacement at the SCJ is a true emergency and can be associated with compression of vital structures and thoracic outlet syndrome. • Closed or open reduction of these injuries is generally advised but is associated with considerable risk. • Conservative management can be successful in the presence of physeal injury but has never been described in the setting of thoracic outlet syndrome., Introduction Posterior sternoclavicular joint fracture-dislocations are a rare and often missed diagnosis. They represent

The shoulder is one of the most complex joints in the body with the broadest range of motion. It is inherently unstable and therefore requires support by both bony and soft tissue structures. While the majority of shoulder anatomy and mechanics are similar between females and males, the female glenoid is smaller and slightly more anteverted. Although the shoulder is often thought of as the glenohumeral joint, there are many other articulations that are important in shoulder motion, including the scapulothoracic joint, the acromioclavicular joint, and the sternoclavicular joint.

Sternoclavicular joint instability is rare, but often described in the literature. Traumatic posterior dislocations are associated with injury to retrosternal structures and deserve special concern. Acute dislocations should undergo reduction. If reduction fails for anterior dislocations, the dislocated medial clavicle may be left in the dislocated position for many, especially relatively elderly patients with low demands. All acute and chronic posterior dislocations should be reduced. A variety of techniques have been described, but the figure-of-eight technique using tendon graft seems to have biomechanical properties that are superior, and as such, is often employed with good results.

The aim of this study is to investigate the variation of the glenohumeral and scapulothoracic motion in progressive severity of glenohumeral osteoarthritis using a 3-D-motion analysis. Moreover, the variation of the Constant Score is evaluated.The hypothesis is that the motion of the scapulothoracic joint may partly compensate for the loss of the glenohumeral joint movement in patients with increasing severity of glenohumeral osteoarthritis.A total of 21 patients with primary osteoarthritis of the glenohumeral joint were clinically examined, divided in three groups (SP1-SP3) according to size of their caudal osteophyte. The contribution of the scapulothoracic (acromioclavicular and sternoclavicular) joint to the total arm (humerothoracical) elevation in sagittal and frontal plane was measured with 3D motion analysis and the Constant Score was evaluated.In sagittal plane elevation (anteversion) the contribution of the scapulothoracic joint to the total elevation was while arm raising 32.7% (SD 8.0%) in Group SP1, 36.6% (SD 11.0%) in Group SP2 and 49.6% (SD 9.0%) in Group SP3 (p=0.002). The contribution of the scapulothoracic joint to the total elevation while arm lowering was 31.4% (SD 9.0%) in Group SP1, 39.0% (SD 13.0%) in Group SP2 and 49.7% (SD 12.0%) in Group SP3 (p=0.043). In frontal plane elevation (abduction) the contribution of the scapulothoracic joint was while arm raising 33.7% (SD 8.0%) in Group SP1, 34.0% (SD 10.0%) in Group SP2 and 42.3% (SD 9.0%) in Group SP3 (p=0.071). While arm lowering the contribution of the scapulothoracic joint was 30.8% (SD 10.0%) in Group SP1, 36.3% (SD 12.0%) in Group SP2 and 44.8% (SD 8.0%) in Group SP3 (p=0.022). The group SP1 achieved a Constant Score of 78.00 (SD 9.823) points. The group SP2 achieved a Constant Score of 53.57 (SD 13.92) and the group SP3 38.64 (SD 10.40). There is a significant difference between the three groups (p0.001). Increasing severity of glenohumeral osteoarthritis leads to a reduced motion of the glenohumeral joint. Instead the magnitude of the scapulothoracic motion increases.V, Case Series.

Background Chondrocalcinosis is a metabolic arthropathy rarely affecting the anterior chest wall (ACW). Aim of the work To report here a case of a polyarticular chondrocalcinosis with an uncommon localization in the sternoclavicular joints (SCJs), revealed by computed tomography (CT). Case report A 76-year old female presented to the Rheumatology outpatient clinic Kassab orthopedics institute with low back pain. The history goes back to 4 months prior to her presentation when she developed mechanical back pain that progressively worsened during the last month, becoming inflammatory with prolonged morning stiffness. She had no history of fever or weight loss and no symptoms in the cervical spine, shoulders, chest wall, hips or knees. Physical examination revealed limited range of motion of hips, cervical and lumbar spine and bilateral swelling of SCJs without tenderness on pressure or mobilization. Biochemical investigations showed normal levels of inflammatory markers, phosphorus and calcium. Conventional radiographs showed multiple areas of calcification in the intra-vertebral discs, joint space narrowing of sacroiliac (SI) and coxofemoral joints. Chest wall radiograph appeared normal. ACW and pelvic CT were done to further delineate the cause. It showed intra-cartilaginous bilateral calcifications of SCJs, sacroilliac, intervertebral discs, coxofemoral joints and pubic symphysis. The final diagnosis was polyarticular chondrocalcinosis. The patient received analgesics, non-steroidal anti-inflammatory drugs and had functional rehabilitation sessions. Conclusion: This case points to the rare localization of chondrocalcinosis in the SCJ and should be considered especially in an elderly female. Early recognition is necessary in order to initiate an appropriate and prompt treatment.