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Abstract
Abstract
Sternoclavicular osteoarthritis is a painful multifactorial joint disease, which affects the cartilage and has typical radiological findings.
Factors contributing to cartilage damage may be: instability, clavicular deformities, inflammatory arthritis and septic arthritis.
Clinically, patients might present with pain in the shoulder that is accentuated in abduction and flexion of the shoulder over 90°.
Osteoarthritis is suspected because of clinical signs such as slowly progredient course of disease as well as other typical findings for osteoarthritis. Diagnosis is made with x-ray images.
Physical therapy as well as analgesia are considered first line of therapy. Addiotoinally, patients might profit from corticosteroid injections. If indicated, surgical removal of the proximal end of the clavicula might be necessary.
General considerations
General considerations
Definition
Definition
Sternoclavicular osteoarthritis (SCOA) is a painful multifactorial joint disease, which affects the cartilage and has typical radiological findings.
Aetiology
Aetiology
Osteoarthritis of the sternoclavicular joint (SCJ) can be divided into primary (rare) and secondary causes. In primary osteoarthritis no underlying cause can be identified, whereas in secondary osteoarthritis there are explicit pathologies that osteoarthritis stems from. These pathologies may be:
SCJ instability
Traumatic
Atraumatic
Clavicular deformities
Inflammatory arthritis
Rheumatoid arthritis
Spondyloarthropathies
Pseudogout, gout
Septic arthritis
Epidemiology
Epidemiology
SCOA is a very common pathology, with post-mortem studies suggesting that in patients aged over 60 more than 50% show radiographic findings in accordance with osteoarthritis [1]. Postmenopausal women and manual labourers were found to have an increased prevalence of SCOA [1]. However, in most cases patients do not report any symptoms.
Clinical presentation
Clinical presentation
Clinically, patients present with pain and swelling around the SCJ, which is accentuated in abduction and flexion in the shoulder over 90° [1]. The joint may be inflamed with typical accompanying signs. The typical patient is also over 50 years of age and might have a history of manual labour as mentioned beforehand [1].
In earlier stages, patients complain about activity induced pain that ameliorates with continued movement, whereas in later stages rest pain can be present.
Diagnosis
Diagnosis
History
History
When taking the history of a patient, one should look for typical signs of osteoarthritis such as:
Slowly progredient course of disease
Pain after mechanical stress of the joint
Limited functionality of the joint
Disease specific diagnosis
Disease specific diagnosis
In order to diagnose SCOA, imaging methods such as x-ray, ultrasound and computed tomography (CT) are needed. Typical radiographic findings for osteoarthritis are also found in the sternoclavicular joint:
Loss of joint space
Subchondral cysts
Subchondral sclerosis
Marginal osteophytes, located over the inferior aspect of the medial clavicula
Osteopenia is typically not found in patients with SCOA [1]. Magnetic resonance imaging (MRI) and high-resolution ultrasound can be of value if inflammatory arthritides are suspected, as e.g. MRI is superior in detecting inflammatory soft tissue. Magnetic resonance imaging also allows the assessment of intraosseous changes such as osteitis. Secondary osteoarthritis is always in need of medical clarification and should be evaluated accordingly. For example, aspiration of joint fluid in septic or inflammatory arthritis, which is usually performed under visual ultrasound control.
Differential Diagnosis
Differential Diagnosis
Not yet progressed inflammatory pathologies
Treatment
Treatment
It is important to notice that in secondary osteoarthritis the root cause itself should be treated first as to not progress joint destruction.
Initially, SCOA is always treated conservatively with a combination of physical therapy and anti-inflammatory drugs and/or corticosteroid-injections. The authors are of the opinion that steroid infiltrations in the area of the sternoclavicular joint should be carried out with extreme caution and restraint because complications, especially infections, occur very frequently in this area. If symptoms persist surgical treatment should be considered. Typically, a resection of the medial end of the clavicula is performed in an open setting [1].
Prognosis and progressive course of disease
Prognosis and progressive course of disease
If not treated accordingly, sternoclavicular osteoarthritis progresses to the point where the joint stiffens, and the functionality is limited immensely. However, results of medial clavicula resection seem to be promising as the outcomes in one-year follow-up studies were satisfactory [1].
Since data is limited on the long-term outcome of SCOA treatment, these results should be taken with a pinch of salt.
References
References
Dhawan, Rohit, Rohit Amol Singh, Bernhard Tins, and Stuart M. Hay. 2018. "Sternoclavicular Joint". Shoulder & Elbow 10 (4): 296-305. doi:10.1177/1758573218756880.
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