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
Trang 1Thomas 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
car-tilage, 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
clav-icle That ligament contributes to joint
stability and prevents medial
displace-ment of the clavicle It is contiguous
with the anterior and posterior
ster-noclavicular ligaments, which are
thickenings of the fibrous joint
cap-sule that function as the primary
re-straints to anterior and posterior
trans-lation of the medial clavicle.1The joint
capsule extends laterally to include
the epiphysis of the clavicle The
ster-noclavicular joint also is reinforced
superiorly by the interclavicular
lig-ament, which connects the superome-dial margins of each clavicle The ex-tracapsular costoclavicular (rhomboid) ligament, extending from the first rib and costal cartilage to the inferome-dial margin of the clavicle, further sta-bilizes the sternoclavicular articula-tion (Fig 1, A) Articular branches of the internal thoracic and suprascapu-lar 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 brachio-cephalic trunk, the common carotid artery, and the internal jugular vein lie directly posterior to the sterno-clavicular 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 present with sternoclavicular joint complaints The physician should pay careful atttion to warmth, fluctuance, bony en-largement, and sternoclavicular joint translation
Plain radiographs are indicated in the initial evaluation of sternoclavic-ular joint disorders, but other imag-ing modalities typically are required Computed tomography (CT) scans are indicated for disease processes in which bony destruction or ossifica-tion may occur Magnetic resonance imaging (MRI) provides more de-tailed and useful information when evaluating suspected pathology in-volving inflammation, a soft-tissue mass, or osteonecrosis of the medial clavicle (ie, Friedrich’s disease) Bone scans can help correlate active inflam-mation 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
Trang 2with symptoms of pain Laboratory
studies may help elucidate the
diag-nosis when infectious or
inflamma-tory conditions are suspected
Several atraumatic pathologic
con-ditions 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
affect-ing the sternoclavicular joint is
osteoar-thritis (OA), which can manifest as
part of a systemic process or as
arthri-tis affecting the sternoclavicular joint
only Degenerative changes in the
ster-noclavicular joint become
increasing-ly common with advanced age Kier
et al2radiographically examined 55
cadaveric sternoclavicular joint
spec-imens Moderate to severe
degener-ative changes were uncommon in
pa-tients younger than age 40 years but
were present in 53% of specimens
old-er than age 60 years Postmenopausal
women are more susceptible than
ei-ther men or premenopausal women
to OA of the sternoclavicular joint, but the etiology is unknown A history of manual labor or a radical neck dis-section are also risk factors for the de-velopment of OA of the sternocla-vicular 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 pa-tient concern about neoplasia or met-astatic disease, but these processes are exceedingly rare in the sternoclavicu-lar joint and can be ruled out with ap-propriate 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 shadows3(Fig 2) CT scans are helpful in diagnosing sub-tle degenerative changes in the infe-rior medial aspect of the clavicle and are more effective than either plain ra-diographs or bone scans
Most patients with symptomatic
OA of the sternoclavicular joint re-spond 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 arth-ritis, Pingsmann et al4 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.
Trang 3Many 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
sternoclavicu-lar joint This condition would be
bet-ter called osteoarthrosis because there
does not seem to be an inflammatory
component to the condition In the
ab-sence of symptoms, no treatment
oth-er than counseling is required
Rheumatoid Arthritis
Involvement of the sternoclavicular joint in rheumatoid arthritis (RA) is variable One study indicated ster-noclavicular joint involvement in 30%
of 105 patients.5Changes were gen-erally present within 1 year of diag-nosis of RA, but plain radiographs were frequently unremarkable The pathologic process of RA involves synovial inflammation, pannus for-mation, bony erosions, and
degener-ation 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 ar-thritis, patients with symptoms re-fractory to medical management may benefit from medial clavicle exci-sion
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
spondylo-arthropathies
<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.
Trang 4Isolated septic arthritis of the
sterno-clavicular joint is uncommon and
fre-quently is associated with an
under-lying disease or other risk factors
Conditions known to be associated
with infectious arthritis are RA,
sep-sis, infected subclavian central lines,
alcoholism, human
immunodefi-ciency virus (HIV) infection,
immu-nocompromised status, renal 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 arthritis6
(Fig 3) MRI may be particularly
use-ful in identifying soft-tissue
involve-ment and abscesses Definitive
diag-nosis is achieved with aspiration or
open biopsy and laboratory
evalua-tion of the joint fluid Although
com-mon organisms such as
Staphylococ-cus aureus and StreptococStaphylococ-cus species
have been reported,7 patients with
risk factors may have other causative
organisms Pseudomonas aeruginosa
has been associated with intravenous drug abuse.8Neisseria gonorrhoeae and
fungal infections with Candida albicans
have been reported in HIV-positive patients.9,10Infection with
Mycobacte-rium tuberculosis has been reported in
patients in third world countries as well as in immunocompromised pa-tients Diagnosis requires needle as-piration or biopsy, and infected pa-tients are treated with appropriate antitubercular therapy.11
Treatment of septic sternoclavicu-lar joint arthritis is determined by the
antibiotic sensitivity of the pathologic organism and the extent of the infec-tion (ie, abscess) In most cases, prompt irrigation and drainage are done in the operating room, along with ad-ministration of appropriate parenteral antibiotics Aggressive organisms may require resection of the sternoclavicu-lar joint and involved portions of the first and second ribs with appropri-ate soft-tissue coverage.12In some patients, aspiration and parenteral an-tibiotics alone have produced success-ful outcomes.13Untreated infections
of the sternoclavicular joint can de-velop into cutaneous, extrapleural, or intrathoracic abscess, which could be-come life threatening if the retroster-nal vascular structures are involved
Spontaneous Anterior Subluxation
Spontaneous atraumatic anterior sub-luxation of the sternoclavicular joint may occur during overhead elevation
of the arm Affected patients are gen-erally in their teens or twenties, and many demonstrate signs of general-ized 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
sternocla-vicular 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 sternocla-vicular joint Fluid has collected in the joint (arrow), and bony destruction is evident.
Trang 5cases are not painful, and the
sublux-ation 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
pa-tients with spontaneous anterior
sub-luxation of the sternoclavicular joint,
subluxations were reproducible and
painless in 29 patients.14Eighty
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
man-agement, including patient education
of the benign nature of the condition,
is recommended.14
Atraumatic anterior
pseudosub-luxation mimics atraumatic
sublux-ation in the older patient This
ante-rior fullness of the medial clavicle is
caused by a degenerative process The
subluxation generally is fixed rather
than dynamic
Seronegative
Spondyloarthropathies
The sternoclavicular joint is involved
in seronegative spondyloarthropathies,
including ankylosing spondylitis,
pso-riatic arthritis, Reiter’s syndrome, and
colitic arthritis These disorders are
characterized by onset usually before
age 40 years, inflammatory arthritis
affecting large peripheral joints,
ab-sence of serum autoantibodies, and
association with antigen HLA-B27
Em-ery et al15reported acute
inflamma-tory arthropathy of the
sternoclavicu-lar 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 abduc-tion, which responded to nonsurgi-cal treatment with oral nonsteroidal anti-inflammatory drugs (NSAIDs)
Approximately 15% to 20% of pa-tients with psoriasis develop a sym-metric polyarthritis that resembles
RA.16Although 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 dis-tal interphalangeal joint of the hands (ie, nail pitting, onycholysis).16 Oligoar-ticular involvement is parOligoar-ticularly destructive Taccari et al17reported ra-diographic 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 sternoclavicu-lar joint was clinically involved in only
5 of 10 patients in the series of Tac-cari et al.17Three patients reported spontaneous pain NSAIDs are the treatment of choice for psoriatic
ar-thritis; gold therapy and/or metho-trexate are 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 reveals characteristic pos-itive (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.
Trang 6vicular ossification or pustulotic
arthro-osteitis, is a rare disorder that presents
with soft-tissue ossification and
hy-perostosis 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
disor-der is unknown, but it is often
encoun-tered in association with
palmoplan-tar pustolosis and severe acne Other
manifestations include synovitis,
hy-perostosis, and osteitis.19Patients 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,
swell-ing, 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
limit-ed Radiographs demonstrate
hyper-ostosis of the sternum, clavicles, and
upper ribs as well as ossification of
the costoclavicular, costosternal, and
intercostal ligaments20(Fig 5)
Lab-oratory studies reveal an elevated
erythrocyte sedimentation rate;
how-ever, other rheumatologic markers are
generally negative Biopsy specimens
demonstrate chronic nonspecific
in-flammation 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 immunosuppressive ther-apy with cyclosporin A also has been effective in some series
Condensing Osteitis
Condensing osteitis is a rare condi-tion characterized by sclerosis and en-largement of the medial end of the clavicle with preservation of the ster-noclavicular joint Although its etiol-ogy is unknown, chronic mechanical stress at the sternoclavicular joint may play a role.21Patients with this dis-order are usually women in their late childbearing years Involvement typ-ically is unilateral, and pain and swelling over the affected area, exac-erbated by shoulder abduction, is a typical presentation Radiographs demonstrate sclerosis and enlarge-ment 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 clin-ical 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 symp-toms Patients may report loss of ip-silateral shoulder motion Laboratory values, such as erythrocyte sedimen-tation 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 pathol-ogy of this disorder is unknown, bi-opsy specimens typically demonstrate cystic degeneration with necrotic bone fragments surrounded by intact bone consistent with osteonecrosis.23The 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 reported to have poor results; 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 Gluckman24
reported sternoclavicular joint hyper-trophy 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 re-gion are very rare, but this diagnosis should be considered when other fea-tures in the patient’s history are sug-gestive.25The 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
os-sification of the anterior capsule (arrow).
Trang 7eral in most patients, and
radio-graphs, laboratory studies, and
oth-er physical findings are normal
Physical examination reveals
non-fluctuant, firm, tender swelling
in-volving the articulations of the
cos-tosternal or sternoclavicular joints
Tietze’s syndrome seems to affect the
second, third, and fourth costosternal
articulations, with the
sternoclavicu-lar joint less commonly involved
Symptoms of discomfort are
gener-ally self-limited and usugener-ally 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 sternoclavicu-lar joint conditions exist
Neuropath-ic arthropathy of the sternoclavNeuropath-icular joint occurs secondary to syringomy-elia with massive joint destruction.26
Erosion of the medial clavicle has been reported as a result of both pri-mary and secondary
hyperparathy-roidism.27Hemodialysis-related amy-loidosis involving the deposition of
β2-microglobulin has been reported
in the sternoclavicular joint It often mimics chronic infection in these im-munocompromised patients Sterno-clavicular joint involvement has been seen with leprosy Ganglion cysts28
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).
Trang 8throtomy may be required, and
se-vere pain refractory to nonsurgical
management.4,30The 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
liga-mentous supporting structures of the
sternoclavicular joint because pain
and instability are frequently
report-ed complications of mreport-edial clavicle
excision.30Rockwood et al30
recom-mend inserting the intra-articular
disk and ligament into the
intramed-ullary space of the resected clavicle
to improve the stability of the
resect-ed joint One clear contraindication for a medial clavicle excision is atrau-matic 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 dep-osition 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 manage-ment
References
1 Spencer EE, Kuhn JE, Huston LJ,
Car-penter JE, Hughes RE: Ligamentous
re-straints to anterior and posterior
trans-lation of the sternoclavicular joint.
J Shoulder Elbow Surg 2002;11:43-47.
2 Kier R, Wain SL, Apple J, Martinez S:
Os-teoarthritis of the sternoclavicular joint:
Radiographic features and pathologic
cor-relation Invest Radiol 1986;21:227-233.
3 Arlet J, Ficat P: Osteo-arthritis of the
sterno-clavicular joint Ann Rheum Dis
1958;17:97-100.
4 Pingsmann A, Patsalis T, Michiels I:
Re-section arthroplasty of the
sternoclavic-ular joint for the treatment of primary
degenerative sternoclavicular arthritis.
J Bone Joint Surg Br 2002;84:513-517.
5 Kalliomäki JL, Viitanen SM, Virtama P:
Radiological findings of
sternoclavicu-lar joints in rheumatoid arthritis Acta
Rheumatol Scand 1968;14:233-240.
6 Teece PM, Fishman EK: Spiral CT with
multiplanar reconstruction in the
diag-nosis of sternoclavicular osteomyelitis.
Skeletal Radiol 1995;24:275-281.
7 McCarroll JR: Isolated staphylococcal
infection of the sternoclavicular joint.
Clin Orthop 1981;156:149-150.
8 Goldin RH, Chow AW, Edwards JE Jr,
Louie JS, Guze LB: Sternoclavicular
septic arthritis in heroin users N Engl J
Med 1973;289:616-618.
9 Covelli M, Lapadula G, Pipitone N, Numo
R, Pipitone V: Isolated sternoclavicular
joint arthritis in heroin addicts and/or
HIV positive patients: Three cases Clin
Rheumatol 1993;12:422-425.
10 Strongin IS, Kale SA, Raymond MK,
Luskin RL, Weisberg GW, Jacobs JJ: An
unusual presentation of gonococcal
ar-thritis in an HIV positive patient Ann
Rheum Dis 1991;50:572-573.
11 Dhillon MS, Gupta RK, Bahadur R, Nagi ON: Tuberculosis of the
sternocla-vicular joints Acta Orthop Scand 2001;
72:514-517.
12 Song HK, Guy TS, Kaiser LR, Shrager JB: Current presentation and optimal surgical management of
sternoclavicu-lar joint infections Ann Thorac Surg
2002;73:427-431.
13 Bar-Natan M, Salai M, Sidi Y, Gur H: Ster-noclavicular infectious arthritis in
pre-viously healthy adults Semin Arthritis
Rheum 2002;32:189-195.
14 Rockwood CA Jr, Odor JM: Spontane-ous atraumatic anterior subluxation of
the sternoclavicular joint J Bone Joint
Surg Am 1989;71:1280-1288.
15 Emery RJH, Ho EKW, Leong JCY: The shoulder girdle in ankylosing
spon-dylitis J Bone Joint Surg Am 1991;73:
1526-1531.
16 Punzi L, Pianon M, Rossini P, Schiavon
F, Gambari PF: Clinical and laboratory manifestations of elderly psoriatic ar-thritis: A comparison with younger
onset disease Ann Rheum Dis 1999;58:
226-229.
17 Taccari E, Spadaro A, Riccieri V, Guer-risi R, GuerGuer-risi V, Zoppini A: Sterno-clavicular joint disease in psoriatic
ar-thritis Ann Rheum Dis 1992;51:372-374.
18 Richman KM, Boutin RD, Vaughan LM, Haghighi P, Resnick D: Tophaceous pseudogout of the sternoclavicular joint.
AJR Am J Roentgenol 1999;172:1587-1589.
19 Kahn MF, Bouvier M, Palazzo E, Tebib
JG, Colson F: Sternoclavicular pustulotic osteitis (SAPHO): 20-year interval between
skin and bone lesions J Rheumatol 1991;
18:1104-1108.
20 Davies AM, Marino AJ, Evans N,
Grim-er RJ, Deshmukh N, Mangham DC:
SAPHO syndrome: 20-year follow-up.
Skeletal Radiol 1999;28:159-162.
21 Brower AC, Sweet DE, Keats TE: Con-densing osteitis of the clavicle: A new
entity Am J Roentgenol Radium Ther
Nucl Med 1974;121:17-21.
22 Kruger GD, Rock MG, Munro TG: Con-densing osteitis of the clavicle: A review
of the literature and report of three
cas-es J Bone Joint Surg Am 1987;69:550-557.
23 Levy M, Goldberg I, Fischel RE, Frisch
E, Maor P: Friedrich’s disease: Aseptic necrosis of the sternal end of the
clav-icle J Bone Joint Surg Br 1981;63:539-541.
24 Cantlon GE, Gluckman JL: Sternocla-vicular joint hypertrophy following
radical neck dissection Head Neck Surg
1983;5:218-221.
25 Searle AE, Gluckman P, Sanders R, Breach NM: Sternoclavicular joint swellings:
Di-agnosis and management Br J Plast Surg
1991;44:403-405.
26 Chidgey LK, Szabo RM, Benson DR: Neuropathic sternoclavicular joint
sec-ondary to syringomyelia Orthopedics
1988;11:1571-1573.
27 Teplick JG, Eftekhari F, Haskin ME: Erosion of the sternal ends of the cla-vicles: A new sign of primary and
sec-ondary 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
osteochondroma-tosis 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.