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Atraumatic Disorders of the Sternoclavicular Joint Thomas O. Higginbotham, MD, and John E. Kuhn, MD Abstract The sternoclavicular joint, a saddle- shaped synovial joint, is the only bony articulation between the axial and ap- pendicular skeletons (Fig. 1, A). The large medial clavicle articulates some- what incongruently with a shallow socket formed by the superomedial manubrium and the first costal cartilage, creating a joint with little in- herent bony stability. Between the two articular surfaces is a dense fibrocar- tilaginous articular disk separating the joint into two distinct synovial cav- ities. An intra-articular disk ligament originates from the junction of the first rib and sternum, passes through the sternoclavicular joint, and attaches on the posterior and superior medial clavicle. That ligament contributes to joint stability and pr events medial displace- ment of the clavicle. It is contiguous with the anterior and posterior sternoclavicular ligaments, which are thickenings of the fibrous joint capsule that function as the primary re- straints to anterior and posterior translation of the medial clavicle. 1 The joint capsule extends laterally to include the epiphysis of the clavicle. The sternoclavicular joint also is reinforced superiorly by the interclavicular ligament, which connects the superomedial margins of each clavicle. The ex- tracapsular costoclavicular (r homboid) ligament, extending from the first rib and costal cartilage to the inferome- dial margin of the clavicle, further sta- bilizes the sternoclavicular articulation (Fig. 1, A). Articular branches of the internal thoracic and suprascapular arteries provide the blood supply to the sternoclavicular joint. Innerva- tion is provided by branches of the medial suprascapular nerve and the nerve to the subclavius muscle. The great vessels of the brachiocephalic trunk, the common carotid artery, and the internal jugular vein lie directly posterior to the sternoclavicular joint (Fig. 1, B). The sur- geon must be knowledgeable about the relationship of these vascular structures to the sternoclavicular joint and plan the surgical approach accordingly. Patient Evaluation Because many of the conditions that affect the sternoclavicular joint are systemic, a careful history, including systemic complaints, family history of arthritis, and drug use should be done for all patients who pr esent with sternoclavicular joint complaints. The physician should pay careful atten- tion to warmth, fluctuance, bony enlargement, and sternoclavicular joint translation. Plain radiographs are indicated in the initial evaluation of sternoclavicular joint disorders, but other imaging modalities typically are required. Computed tomography (CT) scans are indicated for disease processes in which bony destruction or ossification may occur. Magnetic resonance imaging (MRI) provides more de- tailed and useful information when evaluating suspected pathology involving inflammation, a soft-tissue mass, or osteonecrosis of the medial clavicle (ie, Friedrich’s disease). Bone scans can help correlate active inflammation of the sternoclavicular joint Dr. Higginbotham is Resident, Department of Or- thopaedics, University of Michigan, Ann Arbor, MI. Dr. Kuhn is Chief of Shoulder Surgery, Vanderbilt Sports Medicine and Shoulder Surgery, Nashville, TN. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Higginbotham and Dr. Kuhn. Reprint requests: Dr. Kuhn, Vanderbilt Sports Medicine and Shoulder Surgery, 2601 Jess Neely Drive, Nashville, TN 37212. Copyright 2005 by the American Academy of Orthopaedic Surgeons. The sternoclavicular joint is the diarthrodial articulation between the axial and ap- pendicular skeletons. It is subject to the same disease processes that occur in joints, including degenerative arthritis, rheumatoid arthritis, infection, and subluxation. Most of these conditions present with swelling of the joint, which may be associated with pain and/or tenderness. Plain radiographs can demonstrate changes on both sides of the joint. Because of variations in anatomy, computed tomography scans and magnetic resonance images are often necessary to clarify the pathology. With the exception of acute infection, most conditions can be managed nonsurgically, with joint resection reserved for patients with persistent symptoms. J Am Acad Orthop Surg 2005;13:138-145 138 Journal of the American Academy of Orthopaedic Surgeons with symptoms of pain. Laboratory studies may help elucidate the diagnosis when infectious or inflammatory conditions are suspected. Several atraumatic pathologic conditions affect the sternoclavicular joint (Table 1). There may be subtle differ- ences in their presentation, findings on physical examination and radio- logic studies, and laboratory profiles. Osteoarthritis The most common condition affecting the sternoclavicular joint is osteoarthritis (OA), which can manifest as part of a systemic process or as arthritis affecting the sternoclavicular joint only. Degenerative changes in the sternoclavicular joint become increasing- ly common with advanced age. Kier et al 2 radiographically examined 55 cadaveric sternoclavicular joint specimens. Moderate to severe degenerative changes were uncommon in patients younger than age 40 years but were pr esent in 53% of specimens older than age 60 years. Postmenopausal women are more susceptible than either men or premenopausal women to OA of the sternoclavicular joint, but the etiology is unknown. A history of manual labor or a radical neck dissection are also risk factors for the de- velopment of OA of the sternoclavicular joint. Patients with OA may report pain and swelling at the sternoclavicular joint, which may be aggravated by pal- pation, ipsilateral shoulder abduction, or forward elevation of the shoulder beyond horizontal. Some patients, however, may lack pain, have normal motion, and have no discomfort with stress testing. Other physical findings include prominence at the medial end of the clavicle (caused by osteophytes), a fixed subluxation, or crepitus on range of motion. The increase in size or appearance of a mass may raise patient concern about neoplasia or metastatic disease, but these processes are exceedingly rare in the sternoclavicular joint and can be ruled out with appropriate imaging. Patients present- ing with an increase in the size of the medial clavicle should be imaged with plain radiographs. CT is often required to fully visualize the joint. Osteophytes indicative of OA may be seen on plain radiographs, but sclerosis and joint space narrowing may be difficult to see through variations in anatomy and overlap of bony shadows 3 (Fig. 2). CT scans are helpful in diagnosing subtle degenerative changes in the infe- rior medial aspect of the clavicle and are mor e effective than either plain radiographs or bone scans. Most patients with symptomatic OA of the sternoclavicular joint respond to nonsurgical treatment, such as rest, anti-inflammatory medica- tion, and local corticosteroid injection. Resection of the medial head of the clavicle is reserved for patients with severe symptoms who have been un- responsive to nonsurgical treatment for at least 6 months. With resection, the costoclavicular ligament must be preserved and the anterior capsule repaired to prevent residual joint instability. In their review of resection arthroplasty for the treatment of degenerative sternoclavicular arthritis, Pingsmann et al 4 reported good to excellent results in seven of eight patients (mean follow-up, 31 months). Figure 1 A, Bony and ligamentous anatomy of the sternoclavicular joint. The major supporting structures include the anterior capsule, the posterior capsule, the interclavicular ligament, the costoclavicular (rhomboid) ligament, and the intra-articular disk and ligament. B, Ret- rosternal anatomy. Note the proximity of the sternoclavicular joint to the trachea, aortic arch, and brachiocephalic vein. Thomas O. Higginbotham, MD, and John E. Kuhn, MD Vol 13, No 2, March/April 2005 139 Many individuals who develop changes in the sternoclavicular joint, such as enlargement, subchondral sclerosis, and osteophytes, are com- pletely asymptomatic. These patients may be referred for an evaluation of the asymmetry of the sternoclavicular joint. This condition would be bet- ter called osteoarthrosis because there does not seem to be an inflammatory component to the condition. In the absence of symptoms, no treatment other than counseling is required. Rheumatoid Arthritis Involvement of the sternoclavicular joint in rheumatoid arthritis (RA) is variable. One study indicated sternoclavicular joint involvement in 30% of 105 patients. 5 Changes were generally present within 1 year of diagnosis of RA, but plain radiographs were frequently unremarkable. The pathologic process of RA involves synovial inflammation, pannus formation, bony erosions, and degeneration of the intra-articular disk. Isolated involvement is rare, and ev- idence of polyarticular disease and bi- laterality are common. Patients may report swelling, tenderness, crepitus, and painful limitation of movement. The underlying process is treated, usually in conjunction with a rheu- matologist. As with degenerative arthritis, patients with symptoms refractory to medical management may benefit from medial clavicle excision. Table 1 Features and Test Results of Atraumatic Disorders of the Sternoclavicular Joint Disorder Age (yrs) Sex Pain Side Associated Conditions and Risk Factors Erythema Radiographic Findings Laboratory Values Osteoarthritis >40 M = F + B Manual labor, radical neck dissection, postmenopausal women Rare Sclerosis, osteophytes Normal Rheumatoid arthritis Any F > M + B Symmetric polyarthritis + Minimal change May have +RF, +ANA Septic arthritis Any M = F +++ U HIV, intravenous drug abuse, diabetes +++ Sclerotic, lytic, or mixed lesions ↑WBC, ↑ESR, ↑CRP Atraumatic subluxation 10-30 F > M Infrequent U Generalized ligamentous laxity − Normal Normal Seronegative spondyloarthropathies <40 M > F Occasional B Urethritis, uveitis, nail pitting − Marginal erosions, cysts +HLA-B27 Crystal deposition disease >40 M > F +++ during flare U Other joint involvement ++ Calcification of soft tissue +BRFC, −BRFC Sternocosto- clavicular hyperostosis 30-60 M > F + B Synovitis, acne, pustulosis, hyperostosis, osteitis − Hyperostosis, ossification of intercostal ligaments ↑ESR, other rheumatologic markers normal Condensing osteitis 25-40 F > M + U None − Medial clavicle enlargement, preserved joint space, marrow obliteration Normal Friedrich’s disease (aseptic osteonecrosis) Any F > M + U None − Irregular end of medial clavicle Normal ESR, normal WBC ANA = antinuclear antibodies, B = can present bilaterally, BRFC = birefringent crystals, CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, HIV = human immunodeficiency virus, RF = rheumatoid factor, U = typically presents unilaterally, WBC = white blood cell count. + = elevated levels or presence of, ++ = moderate elevation, +++ = marked elevation, − = not seen or absence of. Atraumatic Disorders of the Sternoclavicular Joint 140 Journal of the American Academy of Orthopaedic Surgeons Infection Isolated septic arthritis of the sternoclavicular joint is uncommon and frequently is associated with an underlying disease or other risk factors. Conditions known to be associated with infectious arthritis are RA, sep- sis, infected subclavian central lines, alcoholism, human immunodeficiency virus (HIV) infection, immunocompromised status, r enal dialysis, and intravenous drug abuse. Prompt diagnosis and treatment are crucial because untreated infection may lead to life-threatening consequences. Pain, swelling, and tenderness over the sternoclavicular joint, in association with fever, chills, or night sweats, are usual. Plain radiographs may disclose sclerotic, lytic, or mixed lesions but may be less sensitive than spiral CT, which is useful in the diagnosis of septic sternoclavicular joint arthritis 6 (Fig. 3). MRI may be particularly useful in identifying soft-tissue involvement and abscesses. Definitive diagnosis is achieved with aspiration or open biopsy and laboratory evaluation of the joint fluid. Although common organisms such as Staphylococ- cus aureus and Streptococcus species have been reported, 7 patients with risk factors may have other causative organisms. Pseudomonas aeruginosa has been associated with intravenous drug abuse. 8 Neisseria gonorrhoeae and fungal infections with Candida albicans have been reported in HIV-positive patients. 9,10 Infection with Mycobacte- rium tuberculosis has been reported in patients in third world countries as well as in immunocompromised patients. Diagnosis requires needle aspiration or biopsy, and infected patients are treated with appropriate antitubercular therapy. 11 Treatment of septic sternoclavicular joint arthritis is determined by the antibiotic sensitivity of the pathologic organism and the extent of the infection (ie, abscess). In most cases, prompt irrigation and drainage are done in the operating room, along with ad- ministration of appropriate par enteral antibiotics. Aggressive or ganisms may require resection of the sternoclavicular joint and involved portions of the first and second ribs with appropriate soft-tissue coverage. 12 In some patients, aspiration and parenteral antibiotics alone have produced success- ful outcomes. 13 Untreated infections of the sternoclavicular joint can develop into cutaneous, extrapleural, or intrathoracic abscess, which could become life threatening if the retrosternal vascular structures are involved. Spontaneous Anterior Subluxation Spontaneous atraumatic anterior subluxation of the sternoclavicular joint may occur during overhead elevation of the arm. Affected patients are generally in their teens or twenties, and many demonstrate signs of generalized ligamentous laxity on physical examination. Patients report a sudden subluxation of the medial end of the clavicle, and many remember feeling an associated pop. The majority of Figure 2 Axial computed tomography scan demonstrating osteoarthritis of the sternoclavicular joint. Note sclerosis on both sides of the joint with subchondral cysts in the clavicle, and anterior soft-tissue swelling. Figure 3 Axial computed tomography scan demonstrating septic arthritis of the sternoclavicular joint. Fluid has collected in the joint (arrow), and bony destruction is evident. Thomas O. Higginbotham, MD, and John E. Kuhn, MD Vol 13, No 2, March/April 2005 141 cases are not painful, and the subluxation usually reduces with lowering the arm. Most patients seek medical treatment because of initial pain and concern regarding the potential harm of the condition. In a review of 37 patients with spontaneous anterior subluxation of the sternoclavicular joint, subluxations were reproducible and painless in 29 patients. 14 Eighty per- cent of the patients demonstrated ev- idence of generalized ligamentous laxity. Twenty-nine patients were treated nonsurgically with strength- ening exercises and advancement to unrestricted activity as tolerated. Al- though many patients subsequently reported intermittent episodes, few reported discomfort, and most were able to participate successfully in ath- letics. The most common reason for surgery was the failure of a previous attempt at reconstruction. Surgery is rarely indicated. Nonsurgical management, including patient education of the benign nature of the condition, is recommended. 14 Atraumatic anterior pseudosub- luxation mimics atraumatic subluxation in the older patient. This anterior fullness of the medial clavicle is caused by a degenerative pr ocess. The subluxation generally is fixed rather than dynamic. Seronegative Spondyloarthropathies The sternoclavicular joint is involved in ser onegative spondyloarthr opathies, including ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, and colitic arthritis. These disorders are characterized by onset usually before age 40 years, inflammatory arthritis affecting large peripheral joints, absence of serum autoantibodies, and association with antigen HLA-B27. Em- ery et al 15 reported acute inflammatory arthropathy of the sternoclavicular joint in 2 of 52 patients with ankylosing spondylitis. Involvement was unilateral in both patients and con- sisted of symptoms of swelling and tenderness of the sternoclavicular joint as well as pain with full arm abduction, which responded to nonsurgical treatment with oral nonsteroidal anti-inflammatory drugs (NSAIDs). Approximately 15% to 20% of patients with psoriasis develop a symmetric polyarthritis that resembles RA. 16 Although psoriasis usually pre- cedes joint involvement, arthritis may precede the skin disease in up to 25% of patients. Affected joints include the sacroiliac joint, the spine, and the distal interphalangeal joint of the hands (ie, nail pitting, onycholysis). 16 Oligoar- ticular involvement is particularly destructive. Taccari et al 17 reported radiographic or scintigraphic abnormal- ity of the sternoclavicular joint in 9 of 10 patients admitted to the hospi- tal with psoriatic arthritis. Radiographs and CT scans demonstrate marginal erosions of the sternum, clavicle, or both, as well as subchondral cysts and sclerosis (Fig. 4). The sternoclavicular joint was clinically involved in only 5 of 10 patients in the series of Tac- cari et al. 17 Three patients reported spontaneous pain. NSAIDs are the treatment of choice for psoriatic arthritis; gold therapy and/or metho- trexate ar e used for resistant cases. Suc- cessful treatment of skin lesions is commonly associated with improve- ment in joint symptoms. Crystal Deposition Disease Gout, pseudogout, and tophaceous pseudogout have been described in the sternoclavicular joint. 18 Examina- tion of joint fluid with a polarizing light microscope r eveals characteristic positive (pseudogout) or negative (gout) birefringent crystals. NSAIDs and cor - ticosteroid injections typically are used to manage acute exacerbations. A va- riety of medical treatments exist to manage the underlying condition. These include medications to reduce uric acid production (eg, allopurinol) or to increase uric acid excretion (eg, probenecid, sulfinpyrazone). Sternocostoclavicular Hyperostosis Sternocostoclavicular hyperostosis, also known as intersternocostocla- Figure 4 Anteroposterior radiographic view of the chest demonstrating psoriatic arthritis of the sternoclavicular joint. Joint space narrowing, osteopenia, erosions, and irregularity of the joint surface are evident. Atraumatic Disorders of the Sternoclavicular Joint 142 Journal of the American Academy of Orthopaedic Surgeons vicular ossification or pustulotic arthro- osteitis, is a rare disor der that pr esents with soft-tissue ossification and hyperostosis between the clavicles. The anterior portions of the upper ribs and sternum, the distal femur and tibia, and the vertebral bodies also may be involved. The etiology of this disorder is unknown, but it is often encoun- tered in association with palmoplan- tar pustolosis and severe acne. Other manifestations include synovitis, hyperostosis, and osteitis. 19 Patients are generally males in their fourth to sixth decade of life. The disorder has been reported with more frequency in Ja- pan than in the United States or Eu- rope. Patients present with pain, swelling, and localized warmth over the sternoclavicular joint and upper chest wall. Symptoms are often bilateral. In advanced cases, range of motion of the shoulders may be severely limited. Radiographs demonstrate hyperostosis of the sternum, clavicles, and upper ribs as well as ossification of the costoclavicular, costosternal, and intercostal ligaments 20 (Fig. 5). Lab- oratory studies reveal an elevated erythrocyte sedimentation rate; however, other rheumatologic markers are generally negative. Biopsy specimens demonstrate chronic nonspecific inflammation with new bone formation. Although the causative factors in this condition are still unknown, it is thought that the clinical course of sternocostoclavicular hyperostosis is benign. Thus, treatment is directed at reducing pain and inflammation. NSAIDs have been used with some success, and immunosuppr essive ther - apy with cyclosporin Aalso has been effective in some series. Condensing Osteitis Condensing osteitis is a rare condition characterized by sclerosis and enlargement of the medial end of the clavicle with preservation of the sternoclavicular joint. Although its etiology is unknown, chronic mechanical stress at the sternoclavicular joint may play a role. 21 Patients with this disorder are usually women in their late childbearing years. Involvement typically is unilateral, and pain and swelling over the affected area, exac- erbated by shoulder abduction, is a typical presentation. Radiographs demonstrate sclerosis and enlargement of the medial clavicle; isolated increased uptake in this region is found on bone scan. MRI and CT scans will demonstrate obliteration of the marrow space (Fig. 6). The clinical course of condensing osteitis is thought to be benign. Most patients respond to NSAIDs. Partial resection of the involved clavicle may offer symptomatic relief in patients who fail nonsurgical treatment. 22 Friedrich’s Disease Aseptic osteonecrosis of the medial clavicle, also called Friedrich’s disease, is a rare condition characterized by discomfort, swelling, and crepitus of the sternoclavicular joint in the absence of trauma, infection, or other symptoms. Patients may report loss of ipsilateral shoulder motion. Laboratory values, such as erythrocyte sedimentation rate, white blood cell count, and rheumatologic factors, are normal. Plain radiographs demonstrate irregularity or curved deformation of the medial end of the clavicle; MRI demonstrates necrotic islands of bone in the meta- physis (Fig. 7). Although the pathology of this disorder is unknown, biopsy specimens typically demonstrate cystic degeneration with necr otic bone fragments surrounded by intact bone consistent with osteonecrosis. 23 The clinical course of Friedrich’s disease is not well understood; however, most authors report success with NSAIDs or local corticosteroid injection. 23 Sur- gical resection of the affected clavicle has been r eported to have poor r esults; however, these are generally isolated case reports. Other Conditions Sternoclavicular joint hypertrophy may occur after radical neck dissection for head and neck cancer, especially when the spinal accessory nerve has been damaged. Cantlon and Gluckman 24 reported sternoclavicular joint hypertrophy in 27 of 50 patients. Because most patients are asymptomatic, an extensive work-up may be required only when there is a concern for met- astasic disease. Metastases to this region are very rare, but this diagnosis should be considered when other features in the patient’s history are sug- gestive. 25 The few cases of metastatic disease to the sternoclavicular joint that have been reported include squamous cell carcinoma, lymphoma, and ad- enocarcinoma. Tietze’s syndrome is a benign, self- limiting nonsuppurative swelling of the anterior chest wall of sudden or gradual onset. Symptoms are unilat- Figure 5 Axial computed tomography scan of sternoclavicular hyperostosis. Note the ossification of the anterior capsule (arrow). Thomas O. Higginbotham, MD, and John E. Kuhn, MD Vol 13, No 2, March/April 2005 143 eral in most patients, and radiographs, laboratory studies, and other physical findings are normal. Physical examination reveals non- fluctuant, firm, tender swelling involving the articulations of the costosternal or sternoclavicular joints. Tietze’s syndrome seems to affect the second, third, and fourth costosternal articulations, with the sternoclavicular joint less commonly involved. Symptoms of discomfort are generally self-limited and usually resolve within days to weeks. Swelling may persist for months or years. Hemophilic pseudotumor, a com- plication of hemophilia, may affect the proximal clavicle. In this process, subperiosteal bleeding may cause a soft-tissue mass, leading to pressure necrosis and bone destruction. In- traosseous hemorrhage may lead to cyst formation within bone, with sub- sequent hemorrhagic episodes caus- ing enlargement of the cyst and thin- ning of the bony cortex. Even less common sternoclavicular joint conditions exist. Neuropath- ic arthropathy of the sternoclavicular joint occurs secondary to syringomyelia with massive joint destruction. 26 Erosion of the medial clavicle has been reported as a result of both primary and secondary hyperparathyroidism. 27 Hemodialysis-related amy- loidosis involving the deposition of β 2 -microglobulin has been reported in the sternoclavicular joint. It often mimics chronic infection in these immunocompromised patients. Sterno- clavicular joint involvement has been seen with leprosy. Ganglion cysts 28 and synovial osteochondromatosis of the sternoclavicular joint also have been described. 29 Surgical Treatment Indications for surgery are rare and include infection, for which an ar- Figure 6 Axial computed tomography scan (A) and computer reconstructed coronal view (B) of condensing osteitis of the sternoclavicular joint (arrow). Both views demonstrate ossification of the marrow space. Figure 7 T1- (A) and T2-weighted (B) magnetic resonance images of Friedrich’s aseptic osteonecrosis of the sternoclavicular joint. Note the area of necrosis in the medial clavicle (arrows). Atraumatic Disorders of the Sternoclavicular Joint 144 Journal of the American Academy of Orthopaedic Surgeons throtomy may be required, and severe pain refractory to nonsurgical management. 4,30 The vital retrosternal contents must be protected when per- forming a resection of the medial clavicle. In addition, it is imperative to maintain the integrity of the ligamentous supporting structur es of the sternoclavicular joint because pain and instability are frequently reported complications of medial clavicle excision. 30 Rockwood et al 30 recom- mend inserting the intra-articular disk and ligament into the intramed- ullary space of the resected clavicle to improve the stability of the resected joint. One clear contraindication for a medial clavicle excision is atraumatic joint instability. 30 Summary The sternoclavicular joint is subject to the same disease processes that affect other synovial joints. Degenerative, rheumatoid, and septic arthritis are relatively common and are likely to be seen in clinical practice. Patients also may present with spontaneous anterior subluxation, seronegative spondyloarthropathy, or crystal deposition disease. Rarer conditions with similar presentations may be encoun- tered, such as sternocostoclavicular hyperostosis, condensing osteitis, and Friedrich’s disease. Surgery is rarely indicated, except for patients with an infection who require arthrotomy or who present with severe pain unre- sponsive to nonsurgical management. References 1. Spencer EE, Kuhn JE, Huston LJ, Car- penter JE, Hughes RE: Ligamentous re- straints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47. 2. 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Teplick JG, Eftekhari F, Haskin ME: Erosion of the sternal ends of the clavicles: A new sign of primary and secondary hyperparathyroidism. Radiolo- gy 1974;113:323-326. 28. Haber LH, Waanders NA, Thompson GH, Petersilge C, Ballock RT: Sternoclavicu- lar joint ganglion cysts in young children. J Pediatr Orthop 2002;22:544-547. 29. Azouz EM: Synovial osteochondromatosis of the sternoclavicular joint. Pedi- atr Radiol 2000;30:720. 30. Rockwood CA Jr, Groh GI, Wirth MA, Grassi FA: Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg Am 1997;79:387-393. Thomas O. Higginbotham, MD, and John E. Kuhn, MD Vol 13, No 2, March/April 2005 145