Orthopedic Teaching Cases 2023, Jan, 18 | 12:00 am

Shoulder and Elbow cases Sternoclavicular (SC) joint osteoarthritis

A 65-year-old, right-hand-dominant female presents to clinic for evaluation of her right chest. She used to work as a manual laborer in the scrap metal business. She is particularly concerned about the bulging, but the pain is also becoming severe. She has tried ibuprofen without relief. On physical examination, she is afebrile with tenderness and a palpable bony protuberance over the right sternoclavicular joint that is asymmetrical when compared with the contralateral side. She has increased pain with forward flexion and abduction of the right shoulder.

Based on the information provided, the most likely diagnosis for the condition described is:

  1. Condensing osteitis of the sternoclavicular joint

  2. Sternoclaivcular joint rheumatoid arthritis

  3. Pseudogout of the sternoclavicular joint

  4. Sternoclavicular joint osteoarthritis

  5. Sternoclavicular septic arthritis

 

Discussion

The correct answer is (D). Sternoclavicular (SC) joint osteoarthritis is the most common condition affecting this joint. Moderate to severe degenerative changes may be asymptomatic and present in over 50% of individuals over 60 years of age. Postmenopausal women, patients with chronic SC joint instability, and manual laborers are at higher risk of developing SC joint osteoarthritis. Condensing osteitis is rare and characterized by aseptic enlargement and sclerosis of the medial end of the clavicle with obliteration of the medullary cavity. Rheumatoid arthritis (RA) is incorrect because there is no mention of RA in her history. It has been reported that 30% of people with RA have SC joint involvement. Crystal-deposition arthropathy has been described in the SC joint, but is uncommon. Septic arthritis of the SC joint is uncommon and associated with underlying disease or risk factors including RA, sepsis, infected subclavian lines, alcoholism, HIV, renal dialysis, and intravenous drug use (IVDU). It is important to take a careful history when dealing with complaints of the SC joint because many conditions are systemic.

Plain radiographs and a computed tomography (CT) scan are obtained. Neither shows signs of neoplasm or metastatic disease. The CT is shown in Figure 2–73. Which of the following treatment options is most likely to result in symptom relief for this patient?

  1. Rest, anti-inflammatory medication, and moist heat

  2. Intra-articular corticosteroid injection under computed tomography (CT) guidance

  3. Rest, activity modification, anti-inflammatory medication, and intra-articular corticosteroid injection

  4. Medial clavicle resection

  5. PT alone

 

 

 

Figure 2–73

 

Discussion

The correct answer is (C). Nonoperative treatment of SC joint osteoarthritis is the mainstay of initial treatment, and most symptomatic patients will respond to these nonsurgical treatments. The other conservative treatment options listed are incorrect in this case because they would be less likely to result in symptom relief. Answer D is incorrect because conservative measures should be attempted for at least 6 months before operative treatment is considered. When performing intra-articular injections under CT guidance, the clinician should have clear knowledge of the surrounding anatomy. Figure 2–74 demonstrates the relationships of the surrounding anatomy.

 

 

 

Figure 2–74 Reproduced with permission from Higginbotham TO, Kuhn JE. Atraumatic discorders of the sternoclavicular joint. J Am Acad Orthop Surg 2005;13(2):138–145.

 

Upon further questioning, the patient admits to having a history of diabetes mellitus and IVDU. Lab results show the following: WBC = 7.1, CRP = <3, ESR = 11. On closer inspection, pitting on her fingernails is noted.

What additional laboratory or physical examination finding should be pursued to rule-out a potential condition affecting her SC joint?

  1. Positive rheumatoid factor (RF)

  2. Presence of antinuclear antibodies (ANA)

  3. Human leukocyte antigen B27 (HLA-B27)

  4. Palmoplantar pustulosis

  5. Positively birefringent crystals

 

Discussion

The correct answer is (C). Less common pathologic processes can cause SC joint symptoms similar to this case. The treatment will vary greatly depending on the underlying disease process. Because the patient is found to have pitting of the finger nails, psoriatic arthritis should be considered as an underlying disease. Seronegative spondyloarthropathies can involve the SC joint, especially psoriatic arthritis. The SC joint has been reported to be involved in 90% of patients with severe psoriatic arthropathy. Detection of HLA-B27 is usually diagnostic for seronegative spondyloarthropathies. RF and ANA are not likely to help in this case. Answer D is a physical examination finding that can be found in association SC joint osteoarthritis. Palmoplantar pustulosis with SC joint arthritis is a rare constellation of findings that

is known by different names including sternocostoclavicular hyperostosis, intersternocostoclavicular ossification, pustulotic arthroosteitis, and SAPHO syndrome. Answer E is diagnostic of pseudogout. Other rare conditions that can affect the SC joint are condensing osteitis and Friedrich’s disease (aseptic necrosis of the medial clavicle).

Nonoperative management is usually sufficient for most etiologies of SC joint pain, however, the medical management and associated conditions can vary significantly. For this case, important aspects of the history would be whether the patient had any previous blood work done, a family history of seronegative spondyloarthropathies, and does she have a history of other joint pain, fevers, chills, or dermatologic conditions.

The patient is diagnosed with primary osteoarthritis of the SC joint and failed to improve after 6 months of nonsurgical treatment. The pain is quite severe and debilitating. Resection of the medial clavicle is recommended for this patient.

What structure(s) is preserved to help prevent instability postoperatively?

  1. Intra-articular disk

  2. Intra-articular disk ligament

  3. Interclavicular ligament

  4. Costoclavicular ligament

 

Discussion

The correct answer is (D). It is imperative that the costoclavicular ligament be preserved to maintain postoperative stabilization. It has been reported that patients who undergo medial clavicle resection arthroplasty without an intact costoclavicular ligament do poorly. Answers A and B are incorrect because these terms are used interchangeably. The structure can be a source of persistent pain when left in the joint and is usually degenerative at the age of this patient. The interclavicular ligament is usually ligated during the procedure. Figure 2–75 depicts the ligamentous structures of the SC joint.

 

 

Figure 2–75 SC joint anatomy and ligaments with the intra-articular ligament circled in black. (From Martetschlager F, Warth RJ, Millett PJ. Instability and degenerative arthritis of the sternoclavicular joint: A current concepts review. Am J Sports Med 2013;42(4):999–1007.)

 

Objectives: Did you learn...?

 

Identify SC joint osteoarthritis?

 

 

Understand the nonoperative management of SC joint osteoarthritis? Appreciate the danger of doing procedures involving the SC joint?

 

Consider and evaluate for other conditions associated with SC joint symptoms?

 

Understand the operative treatment of SC joint osteoarthritis and the important structures to preserve?