Sternoclavicular Research Articles

Open sternal fracture with bilateral dislocation of the sternoclavicular joints after a high-speed bicycle accident: a case report

BackgroundOnly a few cases of bilateral traumatic sternoclavicular dislocations have been reported in the literature. This injury is considered one of the rarest injuries of the human musculoskeletal system. Therefore, we present the first documented case of a cyclist with a third-degree open thoracic trauma (Gustilo–Anderson 3a) associated with a dislocated manubrium sterni fracture in the upper thoracic aperture, bilateral anterior dislocations of the sternoclavicular joints, rib fractures, and pleural ruptures.Case presentationThe patient, a 27-year-old Caucasian male, incurred this injury while participating in a professional cycling race at Nürburgring, Germany and received immediate interdisciplinary surgical treatment and has encountered no complications. We conducted a 1-year follow-up and present the clinical findings of this follow up. Additionally, we conducted a comprehensive review of the existing literature on this injury.ConclusionsImmediate interdisciplinary intervention, including surgical repair and meticulous postoperative care, facilitated successful patient recovery. This underscores the critical role of comprehensive trauma management in complex polytrauma cases. In conclusion, this case report highlights the rarity and complexity of a traumatic injury involving bilateral sternoclavicular dislocation, with this case being the first case reported with concomitant open thorax trauma. Our patient benefited greatly from immediate air-bound transportation to an interdisciplinary care provider, which houses both thoracic and trauma surgery departments.

Enhancing positioning accuracy in adjuvant radiotherapy for left breast cancer using cervical-thoracic integrated bracket combined with deep inspiration breath holding.

This study aimed to investigate the accuracy of three fixation methods in patients with left breast cancer receiving whole breast radiotherapy: conventional breast bracket (BB), breast bracket combined with deep inspiration breath holding (DIBH), and cervical-thoracic integrated bracket (CTIB) combined with DIBH. From January 2023 to September 2023, 84 patients who underwent left breast cancer radiotherapy with supraclavicular radiation after conservative surgery were included in this study, of which 25 patients were fixed by conventional BB, 34 patients by BB & DIBH, and 25 patients by CTIB & DIBH. Image registration was conducted around the treatment area, using the sternoclavicular joint and acromioclavicular joint as landmarks. Systematic and random errors were calculated to assess the accuracy of these fixation methods. Compared to the conventional BB group, the CTIB & DIBH group demonstrated significant improvements in accuracy across multiple dimensions, including left-right, superior-posterior, and anterior-posterior directions, as well as rotational errors in the sagittal and coronal planes. The CTIB & DIBH group showed a significant reduction of setup error in the anterior-posterior direction compared to the BB & DIBH group. The displacement of the acromioclavicular joint varied, with the CTIB & DIBH method showing more favorable outcomes. DIBH method exhibited lower setup errors and more effective fixation of the acromioclavicular joint, especially when combined with CTIB, making it a recommended fixation method in adjuvant radiotherapy following breast-conserving surgery.

The Operative Treatment of Sternoclavicular Joint Dislocations in Adults: A Systematic Review

The Operative Treatment of Sternoclavicular Joint Dislocations in Adults: A Systematic Review

Treatment and management approaches in sternoclavicular joint dislocation

Sternoclavicular joint (SCJ) dislocations, while rare, pose significant risks due to the joint’s proximity to critical thoracic structures. This letter discusses the treatment and management approaches for SCJ dislocations, particularly focusing on the higher risk of complications with posterior dislocations, which may lead to neurovascular or mediastinal injuries. Surgical intervention is often required, and multidisciplinary collaboration is crucial in such cases. The importance of accurate diagnosis through imaging, such as CT scans, and the benefits of graft-based reconstructions for joint stabilization are emphasized to improve patient outcomes.

Lateral Sternoclavicular Joint Dislocation

Case: We report a case of a 29-year-old woman who sustained a left lateral sternoclavicular joint (SCJ) dislocation. Imaging demonstrated a 30-mm gap between the sternum and medial clavicle. Given well-preserved shoulder range of motion and well-controlled pain, she was ultimately treated nonoperatively. Conclusion: SCJ dislocations are rare injuries, comprising 1% of all traumatic joint dislocations. They are typically classified into anterior and posterior dislocations. A direct lateral SCJ dislocation is considered to be a lesser-known type. This case is presented to discuss the rarity of this injury along with the clinical findings, diagnosis, associated injuries, and treatment parameters.

Management Options for Traumatic Posterior Sternoclavicular Joint Dislocation: A Narrative Review with a Single Institution's Experience.

Background: Posterior sternoclavicular joint (SCJ) dislocations are rare events that can evolve into real emergencies due to the vital structures in the mediastinum. When closed reduction maneuvers fail, open SCJ reconstruction becomes mandatory, with literature proposing several stabilization techniques that either preserve or remove the SCJ's mobility. This study is a narrative review of the most recent literature regarding posterior trauma to the SCJ along with a single institution's experience of this pathology, managed either conservatively or surgically, with a figure-of-eight autologous semitendinosus graft in case of closed reduction failure. Methods: This article provides an overview of posterior traumatic SCJ dislocation, and it describes five cases of patients managed for traumatic posterior SCJ dislocation treated either conservatively or surgically with a figure-of-eight semitendinosus tendon autograft reinforced with high-strength suture tape. A comparison with the most recent literature is performed, focusing on biomechanics. Results: The demographics, the mechanism of injury, the management algorithm and the surgical strategy align with the most recent literature. Despite the final treatment, at one year of follow-up, the ROM was restored with full strength throughout the range of motion of the shoulder with no neurological deficits. The reduced joint successfully healed in imaging, and patients returned to their daily lives. The surgical site wounds and donor harvest sites were perfectly healed. Conclusions: Although recent recommendations for treating posterior traumatic SCJ dislocation have advanced, no universally accepted method of stabilization exists, and the surgical strategy is generally entrusted to the surgeon's experience. The literature still increasingly supports figure-of-eight ligament reconstruction with a biological or synthetic graft. This work further implements the literature by reporting good outcomes at follow-up.

Predictors of Clinical Outcomes and Quality of Life After Sternoclavicular Joint Reconstruction With Hamstring Tendon Autograft

Background: Anterior instability of the sternoclavicular joint (SCJ) is a rare but potentially devastating pathological condition, particularly when it occurs in young or active patients. SCJ reconstruction using hamstring tendon autograft is a commonly used treatment option, yet to date results are limited to small case series. Studies on baseline, preoperative factors and their association with postoperative outcome are limited. Purpose: To assess the midterm clinical outcomes and survivorship after SCJ reconstruction using hamstring tendon autograft in patients experiencing anterior SCJ instability and to determine whether baseline patient or causative factors are associated with postoperative outcomes or patient satisfaction. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent SCJ reconstruction with a hamstring tendon autograft for anterior SCJ instability between October 2005 and October 2020 were included in this retrospective single-center study. At a minimum of 2 years postoperatively, clinical outcomes were collected, including the following patient-reported outcomes (PROs): the 12-Item Short Form Survey (SF-12) score; American Shoulder and Elbow Surgeons (ASES) score; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Single Assessment Numeric Evaluation (SANE) score; and visual analog scale (VAS) pain score. Subjective postoperative satisfaction with the procedure was quantified on a scale from 0 (very unsatisfied) to 10 (very satisfied). The predictive role of patient factors, including age, sex, and injury in dominant arm, on postoperative PROs and satisfaction at short-term follow-up was evaluated using multiple linear regression. Results: A total of 49 patients (mean age, 29.6 ± 16.2 years; range 13.8-67.1 years; 27 females) were included in the final analysis. At a mean follow-up of 3.9 ± 2.1 years, all PROs had significantly improved, including the mean SF-12 Physical Component Summary score (40.4 ± 6.8 to 52.6 ± 6.9; P < .001), ASES score (54.9 ± 20.4 to 91.0 ± 11.3; P < .001), QuickDASH score (41.2 ± 18.5 to 10.2 ± 9.1; P < .001); SANE score (50.2 ± 21.1 to 88.3 ± 8.8; P < .001), VAS pain score (4.4 ± 2.6 to 0.8 ± 1.4; P < .001), and VAS pain score at its worst (7.4 ± 2.5 to 3.3 ± 2.6; P < .001). The median postoperative satisfaction score was 9 (range, 1-10). Revision-free survivorship was 95.9%. Male patients had a significantly lower VAS pain score at its worst compared with female patients (2.6 ± 2.6 vs 4.1 ± 2.4; P = .045); higher age was significantly correlated with a worse QuickDASH score (correlation coefficient, 0.314; P = .036). Overhead athletes had a significantly lower propensity to return to sport compared with nonoverhead athletes (P = .043), with only 45% of the overhead athletes returning to a level similar to their preinjury level, whereas 81% of the nonoverhead athletes were able to do so. Conclusion: The significant improvements in clinical and sport-specific outcomes and high patient satisfaction after SCJ reconstruction with a hamstring tendon autograft demonstrate the success of this procedure in treating anterior SCJ instability. Male sex and younger patient age are associated with superior outcomes, while overhead athletes have to be counseled about difficulties of returning to preinjury level of sport postoperatively.

Spondyloarthritis and Tietze's syndrome: A Re-evaluation.

Spondyloarthritis comprises a number of related but different disorders with distinct phenotypes: psoriatic arthritis, reactive arthritis, arthritis related to inflammatory bowel disease, undifferentiated arthritis, and ankylosing spondylitis (the well-known prototypic subtype). Differentiating rheumatic diseases, such as rheumatoid arthritis, synovitis-acne-pustulosis-hyperostosis-osteitis syndrome, pustulotic arthro-osteitis, gout and spondyloarthritis, is difficult because they all may manifest swelling at the upper anterior chest wall, often involve the sternocostal and/or sternoclavicular joints, and clearly show cutaneous nodular symptoms, so that they may mimic Tietze's syndrome in the presentation. Tietze's syndrome is a benign, self-limiting entity with tender, non-suppurative swelling in the upper anterior chest wall, especially at the second and third costosternal junctions and the sternoclavicular joint. Therefore, distinguishing spondyloarthritis from Tietze's syndrome during an entire disease course is important, even after an initial tentative diagnosis. This article aims to re-evaluate the importance of Tietze's syndrome in the differential diagnosis of spondyloarthritis, while keeping in mind information about rheumatic diseases affecting the upper anterior chest wall.

Sternoclavicular Joint Tubercular Abscess in a Patient with Spondyloarthritis on Tofacitinib: A Case Report.

Sternoclavicular Joint Tubercular Abscess in a Patient with Spondyloarthritis on Tofacitinib: A Case Report.

Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report

BackgroundSternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy.Case presentationA 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up.ConclusionsThis case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

The Ultrasound Perspective for Sternoclavicular Joint in Spondyloarthritis.

Spondyloarthritis (SpA) is a prevalent genetic disorder that significantly impairs mobility, particularly in the spine, sacroiliac, and peripheral joints. Recent evidence highlights early involvement of the sternoclavicular joint in SpA, which may serve as an initial indicator. Diagnosis often relies on CT and MRI, neglecting ultrasound's potential in identifying SpA-related sternoclavicular arthritis. This review focuses on the joint's anatomy, exploring ultrasound's diagnostic and therapeutic role in SpA-related sternoclavicular arthritis, aiming to provide insights for future ultrasound applications in SpA management.

Innervation of the human sternoclavicular joint.

The sternoclavicular joint (SCJ) functions as the basal joint of the entire upper limb and must move in the proper pattern for normal scapular motion. Afferent sensations from joints, such as proprioception and pain sensation, are important for maintaining the proper motion and condition of joints. Detailed anatomical data are useful for discussing injuries or surgeries that impair the afferent nerve to the SCJ. Nerve branches to SCJs were examined on 12 sides, and the subclavian nerve was investigated on six sides to clarify whether it innervates this joint. On seven of the 12 sides, the SCJ was innervated by two nerves, (1) a branch from the medial supraclavicular nerve that ran medially along the clavicle and (2) a branch from the lateral pectoral nerve that innervated the clavicular head and upper part of the sternocostal head of the pectoralis major. This branch ran medially behind the clavicular head of the pectoralis major and reached the SCJ. In the remaining five sides, the SCJ was innervated solely by the branch from the medial supraclavicular nerve. Subclavian nerves ended within the subclavius muscle or periosteum of the clavicle and were separate from the SCJs. Our data on the route of nerve branches to the SCJ suggest that injury or surgery, such as clavicle fracture or resection of the clavicular head of the pectoralis major for myocutaneous flap transfer, can impair the SCJ's afferent nerve supply.

Treatment concepts for the medial clavicle and the sternoclavicular joint

Medial clavicle fractures and injuries to the sternoclavicular joint are rare injuries but can have life-threatening consequences. There are no standardized treatment algorithms or guidelines for the diagnostics and treatment. This article provides an overview of the individual topographies as well as the conservative and surgical treatment strategies.Conservative treatment is preferred for medial clavicle fractures. The indications for surgical treatment are variable but this is frequently carried out if there is a fracture displacement > 1 cm or1 shaft width and high functional demands. In the case of accompanying injuries to neurovascular structures, an open fracture or the threat of perforation of the skin, surgical treatment is mandatory. Open reduction and internal fixation using (locking) plates is currently the preferred form of treatment.In the case of posterior dislocation of the sternoclavicular joint, an immediate closed reduction must be attempted with the patient under analgosedation and with emergency treatment on standby. This temporal urgency does not exist for anterior and superior dislocations. Surgical treatment is indicated in cases of unsuccessful reduction, persistent symptomatic instability or injuries of the neurovascular bundle. From a multitude of treatment options, arthrodesis with suture cerclage has shown good results. Tendon grafts as well as special hook plates are increasingly being used due to better biomechanical qualities. The surgical treatment of combined injuries is determined by the individual injury pattern.Despite the variety of treatment strategies, the long-term outcome has consistently been positively described.

Easy and safe: A new surgical fixation -technique for acute and chronic anterior instabilities of the sternoclavicular joint: technique and results

Instabilities of the SC joint are a rare injury, accounting for only 3% of all injuries of the shoulder-girdle. While acute posterior dislocations are an emergency and require immediate surgical intervention, anterior instabilities (first and second degree according to Allman) can mostly be treated conservatively. Chronic and highly instable acute anterior instabilities often imposes a significant limitation on the lives of affected patients. Currently, there is no established therapeutic algorithm in place. This retrospective case series with prospective collection of data was performed at a level-I trauma centre. Patients treated surgically for anterior SC joint instabilities between January 2013 and December 2019 and with a minimum follow-up of 24 months were included. The injuries comprised of six acute anterior dislocations treated with tape-cerclage in a "figure-of-8" configuration; twelve patients with chronic anterior SC instabilities were treated with autologous tendon grafts. For one highly unstable chronic anterior instability in addition to the tendon graft synthetic suture material was applied. The clinical evaluation consisted of a physical examination and a standardized questionnaire, which included subjective and objective shoulder scores. Out of 24, 19 patients (79%) with an average age of 32 years ± 15 were available for follow-up. 63% of the patients were male. After a mean follow-up of 57 months, the mean age- and sex-adapted Constant-Murley Shoulder Score (CS) of acute anterior luxations amounted to 90 points ± 20, Nottingham Clavicle Score (NCS) to 81 points ± 22 and DASH Score to 11 points ± 18. Chronic anterior instabilities had a mean CS of 90 points ± 12, NCS of 83 points ± 17 and DASH Score of 4 points ± 5. The study shows a complication rate of 10%. Two patients underwent revision surgery. To conlude, monocortical SCJ fixation in a "figure-of-8" fashion presents a low risk for complication and a low revision rate and can achieve equally good functional outcome after the treatment of highly unstable acute and chronic anterior SCJ instabilities than other published techniques. Our approach presents less risk to the neurovascular structures of the mediastinum than other published techniques requiring bicortical drilling, therefore making the technique more accessible to hospitals without a cardiothoracic surgical background.

Poster 382: Predictors of Clinical Outcomes and Quality of Life after Sternoclavicular Joint Reconstruction with Hamstring Tendon Autograft

Objectives: Instability of the sternoclavicular joint (SCJ) is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients. SCJ reconstruction using hamstring tendon autograft is a commonly used treatment option, yet results are limited to small case series, to date. To date, studies on baseline preoperative demographic factors and their association with postoperative outcome are limited. The objective was to assess the clinical and sport specific outcomes and survivorship after SCJ reconstruction using hamstring tendon autograft in patients suffering from SCJ instability and to determine whether baseline demographic factors were associated with postoperative outcomes or patient satisfaction. Methods: Patients who underwent SCJ reconstruction with a hamstring tendon autograft for SCJ instability between October 2005 and October 2020 were enrolled in this retrospective, monocentric study. At a minimum of 2-years postoperatively, clinical outcomes were collected, including the following patient reported outcomes (PROs): the 12-Item Short Form Survey (SF-12) physical component summary (PCS) and mental component summary (MCS) scores, American Shoulder and Elbow Surgeons (ASES) score, Quick Disabilities of the Arm, Shoulder and Hand (DASH) score, Single Assessment Numeric Evaluation (SANE) score, VAS pain score, VAS pain at worst and subjective postoperative satisfaction with the procedure (0 = very unsatisfied to 10 = very satisfied). Sport specific parameters were investigated via questionnaire. The predictive role of patient demographic factors, including age, sex, and injury in dominant arm, on postoperative PROs and satisfaction at short term follow-up was evaluated using bivariate analysis. According to their respective distribution, continuous variables were compared employing a parametric unpaired t test or the non-parametric Mann–Whitney U test. Categorical variables were compared performing the binary Fisher’s exact test or the Chi-square test. The non-parametric Wilcoxon test for two related samples was used to compare pre- and postoperative values of each outcome parameter. Spearman rank correlations coefficients were calculated in the predictive factor analysis. Results: A total of 49 patients (age: 29.6 ± 16.2 years, range 13.8-67.1, 27 females) were included in the final analysis. Surgery was performed on the dominant shoulder in 26 (63.4%) of the cases. At a mean follow-up of 3.9 ± 2.1 years, all PROs had significantly improved. These included the SF12 PCS (40.4 ± 6.8 to 52.6 ± 6.9, p&lt;0.001), ASES (54.9 ± 20.4 to 91.0 ± 11.3, p&lt;0.001), QuickDASH (41.2 ± 18.5 to 10.2 ± 9.1, p&lt;0.001); SANE (50.2 ± 21.1 to 88.3 ± 8.8, p&lt;0.001), VAS pain (4.4 ± 2.6 to 0.8 ± 1.4, p&lt;0.001) and VAS pain at its worst (7.4 ± 2.5 to 3.3 ± 2.6, p&lt;0.001). The median postoperative satisfaction score was 9 (1-10). Revision-free survivorship was 95.9%. Of those, all patients returned to athletic activity. However only 45% of the overhead athletes returned to their preinjury level. Male patients had a significantly lower VAS pain at worst compared to female patients (2.6 ± 2.6 vs. 4.1 ± 2.4; p=0.045), higher age was significantly correlated with a worse Quick-DASH score (correlation coefficient: 0.314*; p=0.036) and overhead athletes had a significantly lower propensity to return to sports compared to non-overhead athletes (p=0.043). Conclusions: The significant improvements in clinical and sports specific outcomes and high patient satisfaction after SCJ reconstruction with a hamstring autograft demonstrate the success of this procedure in treating SCJ instability. Male sex and younger patient age are associated with superior outcomes, while overhead athletes have to be counseled about difficulties of returning to preinjury level of sport, postoperatively.

Ultrasound imaging for sternoclavicular joint involvement in enthesitis-related arthritis: A closer look at capsular enthesitis

Introduction: Enthesitis-related arthritis is a specific subtype of juvenile idiopathic arthritis characterised by the co-presence of arthritis and enthesitis or the evidence of one of them coupled with at least two among sacroiliac joint tenderness, inflammatory back pain, presence of human leukocyte antigen-B27, acute symptomatic anterior uveitis, onset in a male child aged 6 years or older or history of spondyloarthropathy in a first-degree relative. Small joints like the sternoclavicular joint are rarely affected, and the prevalence of their involvement in enthesitis-related arthritis has been poorly assessed in the pertinent literature. Case report: The authors report an atypical case of left sternoclavicular joint arthritis/enthesitis in a 12-year-old male child with juvenile idiopathic arthritis. The B-mode sonographic findings of articular effusion, synovial hypertrophy and capsular bulging, coupled with the microvascular mapping with colour Doppler of the sternoclavicular joint, have been crucial to optimising the pharmacological approach in clinical practice. In this sense, the sonographic examination presented as a natural extension of the physical examination to accurately define the poor control of disease activity using first-line pharmacological agents. Discussion: The present case report can be considered the first to accurately report the B-mode and the colour Doppler findings of a pathological sternoclavicular joint in a patient enthesitis-related arthritis. Ultrasound imaging demonstrated intra-articular effusion, capsular bulging and synovial hypertrophy clearly defining sternoclavicular joint arthritis. Interestingly, the hypervascularisation involved both the synovial tissue and the capsule–bone interface – that is, the enthesis of the joint capsule – suggesting a potential co-existence of arthritis and enthesitis of the sternoclavicular joint in enthesitis-related arthritis patients. Conclusion: The high-resolution point-of-care ultrasound seems to be a potential ‘game changer’ in paediatrics to promptly optimise the pharmacological management in enthesitis-related arthritis patients. Indeed, unlike other imaging modalities such as magnetic resonance imaging, modern high-frequency ultrasound transducers guarantee a superior spatial resolution of superficial joints and allow an accurate mapping of small-size and low-flow vascular elements of synovial and capsular tissues optimising the grading of disease activity and avoiding the use of contrast agent.

Traumatic Dislocations of the Sternoclavicular Joint, Methods of their Conservative and Surgical Treatment (Literature Review)

Traumatic Dislocations of the Sternoclavicular Joint, Methods of their Conservative and Surgical Treatment (Literature Review)

Normative Values for Sternoclavicular Joint and Clavicle Anatomy Based on MR Imaging: A Comprehensive Analysis of 1591 Healthy Participants.

Background: The clavicle remains one of the most fractured bones in the human body, despite the fact that little is known about the MR imaging of it and the adjacent sternoclavicular joint. This study aims to establish standardized values for the diameters of the clavicle as well as the angles of the sternoclavicular joint using whole-body MRI scans of a large and healthy population and to examine further possible correlations between diameters and angles and influencing factors like BMI, weight, height, sex, and age. Methods: This study reviewed whole-body MRI scans from the Study of Health in Pomerania (SHIP), a German population-based cross-sectional study in Mecklenburg-Western Pomerania. Descriptive statistics, as well as median-based regression models, were used to evaluate the results. Results: We could establish reference values based on a shoulder-healthy population for each clavicle parameter. Substantial differences were found for sex. Small impacts were found for height, weight, and BMI. Less to no impact was found for age. Conclusions: This study provides valuable reference values for clavicle and sternoclavicular joint-related parameters and shows the effects of epidemiological features, laying the groundwork for future studies. Further research is mandatory to determine the clinical implications of these findings.

Disseminated septic arthritis caused by Ureaplasma urealyticum in an immunocompromised patient with hypogammaglobulinemia after rituximab therapy

Abstract Purpose Ureaplasma urealyticum is a rare pathogen associated with septic arthritis that predominantly affects patients with hypogammaglobulinemia. Bacterial identification of fastidious organisms is challenging because they are undetectable by routine culture testing. To the best of our knowledge, this is the first report of septic arthritis induced by U. urealyticum infection in Japan. Case description We describe the case of a 23-year-old Japanese female with secondary hypogammaglobulinemia (serum immunoglobulin level &lt; 500 mg/dL), identified 8 years after treatment with rituximab. The patient presented with persistent fever and polyarthritis that were unresponsive to ceftriaxone and prednisolone. Contrast-enhanced computed tomography and gallium-67 scintigraphy revealed effusion and inflammation in the left sternoclavicular, hip, wrist, knee, and ankle joints. Although Gram staining and bacterial culture of the drainage fluid from the left hip joint were negative, the condition exhibited characteristics of purulent bacterial infection. The patient underwent empirical treatment with doxycycline, and her symptoms promptly resolved. Subsequent 16S ribosomal RNA (rRNA) gene sequencing of the joint fluid confirmed the presence of U. urealyticum, leading to the diagnosis of septic arthritis. Combination therapy with doxycycline and azithromycin yielded a favorable recovery from the inflammatory status and severe arthritic pain. Conclusion This case highlights U. urealyticum as a potential causative agent of disseminated septic arthritis, particularly in patients with hypogammaglobulinaemia. The 16S rRNA gene analysis proved beneficial for identifying pathogens in culture-negative specimens, such as synovial fluid, in suspected bacterial infections.

A Case Report of Hematogenous Osteomyelitis of the Manubrium Caused by Seeding from a Colovesicular Fistula.

Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical. Workup should include identifying the source, imaging, and surgical cultures. A 60-year-old male with hypertension and diabetes presented with atraumatic right shoulder and chest pain. The patient presented twice to the ED for clavicle pain five days prior. Computed tomography (CT) of the chest detected osseous infection of the manubrium and upper sternum, right clavicle, and mediastinal phlegmon. A CT of the abdomen and pelvis revealed osteomyelitis and discitis of the 12th thoracic and first lumbar vertebral body with gas at the psoas muscle, as well as sigmoid diverticulitis with colovesicular fistula. The patient was started on broad spectrum antibiotics and 1,500 milliliters of lactated Ringer's in the ED. After evaluation by cardiothoracic surgery, the patient was taken to the operating room for neck exploration, incision/drainage, manubriectomy, and right sternoclavicular joint resection. Surgical, blood, urine, and respiratory cultures grew Klebsiella pneumoniae. After a 34-day hospital course, the patient was discharged on two weeks of oral levofloxacin and follow-up appointments with cardiothoracic surgery and infectious disease. The patient had good prognosis and recovery. Hematogenous osteomyelitis to the manubrium is rare and may present with only chest pain. It is important to consider other sources that seed in the manubrium and imaging to evaluate multisite infection. Treatment should include intravenous antibiotics and/or surgical intervention for debridement with washout or manubriectomy.