EDUCATIONAL REVIEW ER 024 · Seronegative arthritides may affect the manubriosternal and...
Transcript of EDUCATIONAL REVIEW ER 024 · Seronegative arthritides may affect the manubriosternal and...
Pictorial essay.
ZATTAR-RAMOS, L.C.1*
LEÃO, R.V.1
CAVALCANTI, C.F.A.1
BORDALO-RODRIGUES, M.1
LEITE, C.C.1
CERRI, G.G.1
HOSPITAL SÍRIO-LIBANÊS,
São Paulo – SP, Brazil. *[email protected]
1Department of Radiology
ER_024 EDUCATIONAL REVIEW
▶ DISCLOSURE PARAGRAPHS:
- The authors of this educational review declare no relationships with any companies, whose products or services may be related to the subject matter of the article. - The authors state that this work has not received any funding.
▶ INTRODUCTION:
- Sternal abnormalities are commonly seen in clinical practice.
- In addition to the numerous anatomical variations and congenital anomalies, the sternum and sternoclavicular joints can be affected by various pathological conditions such as trauma, infection, tumors, degenerative and inflammatory changes.
- This study aims to demonstrate and illustrate such conditions, as the knowledge of its characteristics and imaging findings are essential for correct diagnosis and patient management.
▶ DISCUSSION:
- Sternum injuries are common and should be properly recognized and characterized; using different imaging methods we will illustrate the variations of normality, congenital abnormalities and characteristic radiographic findings of sternal lesions highlighting: psoriatic arthritis, inflammatory osteitis, SAPHO syndrome, neoplastic, traumatic and degenerative lesions.
▶ ANATOMY: STERNUM:
*MANUBRIUM: superior central (jugular) notch and 2 lateral fossae that articulate with the clavicles. Also articulates with the 1o and 2o ribs and the body of the sternum. - Atachments: sternohyoideus, sternothyroideus, subclavius, pectoralis major, transversus thoracis and sternocleidomastoideus muscles.
*BODY OF THE STERNUM: articulates with the manubrium, xiphoid process and with the 2o through 7o ribs. - Attachments: transversus thoracis and pectoralis major.
*XIPHOID PROCESS: cartilaginous or ossified / fused to the sternal body. - Attachments: rectus abdominis, diaphragm and transversis thoracis.
MANUBRIUM
BODY OF THE
STERNUM
XIPHOID PROCESS
Flat bone, with 3 parts:
Convex anteriorly and concave posteriorly
▶ ANATOMY: STERNUM: *STERNOCLAVICULAR JOINT: synovial joint, connects the axial skeleton to upper extremity. - Components: anterior sternoclavicular, interclavicular and costoclavicular ligaments, articular disk and articular cavities.
*MANUBRIOSTERNAL JOINT: synchondrosis covered with hyaline cartilage and separated by a disk of fibrocartilage (dorsal and ventral ligaments), forming the sternal angle. - Conversion to synovial joint in 30% (disk absorption) / Ossification of the disk in 10% (synostosis).
*XIPHISTERNAL JOINT: synchondrosis, usually ossifies to form a synostosis.
STERNOCLAVICULAR JOINT
MANUBRIOSTERNAL JOINT
XIPHISTERNAL JOINT
1. SUBCLAVIUS
2. STERNOCLEIDOMASTOIDEUS
3. PECTORALIS MAJOR
4. RECTUS ABDOMINIS
5. STERNOHYOIDEUS
6. STERNOTHYROIDEUS
7. TRANSVERSUS THORACIS
8. DIAPHRAGM and TRANSVERSIS THORACIS
▶ ANATOMY: STERNUM: JUGULAR NOTCH
CLAVICULAR NOTCH
1st RIB ARTICULATION
2st RIB ARTICULATION 2nd
3nd
4nd
5nd 6nd 7nd
COSTAL NOTCHES
TRANSVERSE RIDGES
STERNAL ANGLE
1 2
3
3
3
5
6
7
4 8
*ATACHMENTS:
I. CONGENITAL ABNORMALITIES / ANATOMICAL VARIANTS
III. TRAUMA
II. DEGENERATIVE CHANGES
V. INFLAMMATORY CHANGES
VI. INFECTION
VII. OTHERS
IV. TUMORS
*SPECTRUM OF THE STERNAL LESIONS:
- Sternum is displaced posteriorly and, as a consequence, the ribs protrude anteriorly. - Genetic component (45% familial) - May result in decreased cardiac stroke volume and decreased total lung capacity.
*TILTED STERNUM: sternum that is oriented obliquely, determining unilateral irregularity / asymmetry of the chest wall
I. CONGENITAL ABNORMALITIES / ANATOMICAL VARIANTS: *CASE 1: PECTUS EXCAVATUM: most common congenital deformity of the sternum.
15-years-old male patient: (A) Lateral chest radiograph; (B) Sagittal CT image; (C) Axial CT image: showing
vertical orientation of the anterior aspect of the ribs and the depressed (red arrows) and tilted sternum
(white arrow).
A B C
- PECTUS INDEX: axial CT/MR: dividing the transverse diameter of the chest by the anteroposterior diameter. Normal: 2.56 (+-0.35). Surgical > 3.25.
*CASE 2: PECTUS EXCAVATUM TREATMENT:
15-years-old male patient: Axial CT image before (A) and after (B) 5 minutes of vacuum; (C) Posteroanterior chest radiograph image; (D) CT reconstruction:
showing the depressed sternum (with a pectus index of 5.1 before and 3.9 after the vacuum) and the vacuum bell system where a suction cup is used to create a vacuum
at the chest wall.
A
B
C D
I. CONGENITAL ABNORMALITIES / ANATOMICAL VARIANTS:
- The sternum in pectus carinatum is displaced anteriorly. - More than 30% are associated with scoliosis; 25% familial. - Clinical manifestations include exercise intolerance / shortness of breath.
*PECTUS INDEX : 1.42-1.98.
*CASE 3: PECTUS CARINATUM:
16-years-old male patient: (A) Axial CT image and (B) Lateral chest radiograph;;
showing manubrial and upper sternal protrusion
(red arrows).
I. CONGENITAL ABNORMALITIES / ANATOMICAL VARIANTS:
A B
*CASE 4: STERNALIS MUSCLE: - Uncommom anatomic variant. - Superficially and perpendicular to the pectoralis major muscle, paralel to the sternum. - Runs from the infraclavicular region inferiorly to the caudal aspect oh the sternum. *Reports of the sternalis muscle simulating breast nodules in mammography.
I. CONGENITAL ABNORMALITIES / ANATOMICAL VARIANTS:
56-years-old male patient: (A) Axial CT image, (B) Coronal CT reconstruction and (C) Sagittal CT image: showing bilateral sternalis muscle
(red arrows).
A
B C
II. DEGENERATIVE CHANGES:
95-years-old female patient. (A) Sagittal; (B) Coronal and (C) Axial CT images: showing degenerative changes in
right sternoclavicular joints with bone sclerosis, narrowing of the joint space and gas within the joint space
(red arrows).
C
A B
*CASE 5: OSTEOARTHRITIS: STERNOCLAVICULAR JOINT: - Most common abnormality affecting the sternoclavicular joint. - Also occur in the manubriosternal joint.
II. DEGENERATIVE CHANGES: *CASE 6: OSTEOARTHRITIS: COSTOSTERNAL JOINT:
81-years-old male patient. (A) Axial MRI T1-WI; (B) Axial MRI STIR WI; (C) Coronal CT
image; (D) Axial CT image: showing degenerative changes in the right costosternal
joint with osteophytes and sclerosis in CT images (white arrows), and soft-tissue swelling of the joint and intra-articular
effusion in MRI (red arrows).
A
B
A
B C
D
II. DEGENERATIVE CHANGES: *CASE 7: OSTEOARTHRITIS: MANUBRIOSTERNAL JOINT:
71-years-old male patient. (A) Sagittal CT image and (B) Coronal CT image: showing degenerative changes in the manubriosternal joint with sclerosis of both articular surfaces and a subchondral cyst on the body of the sternum (red arrows).
A B
III. TRAUMA: *CASE 8: STERNAL FRACTURE:
- High-energy trauma – most commonly on the sternal body. - IMPORTANT: high frequency of associated injuries: pulmonary and cardiac trauma, craniocerebral injuries, ribs, thoracic and lumbar spinal fractures.
52-years-old female patient after a motor vehicle accident. (A and C) Coronal and (B) Sagittal
reconstruction CT images: showing manubrium fracture with soft tissue swelling (red arrows).
A B C
IV. TUMORS: *CASE 9: METASTASIS:
- Most common neoplasms of the sternum: METASTASIS. - Direct infiltration or hematogenous spread. - Common sources: lung, breast, thyroid, kidney, colon and hematologic malignancies.
62-years-old male patient with multiple myeloma. (A) Axial, (B) Coronal and (C) Sagittal CT images: showing a large ill-defined lytic lesion in the manubrium (red arrows). Another lesion with the same characteristics is seen in the 6th left lateral costal arch (white arrow), with cortical
destruction.
A B C
IV. TUMORS: *CASE 10: METASTASIS:
69-years-old male patient with thymic carcinoma and myeloproliferative disease. (A) Axial, (B) Sagittal and (C) Coronal CT images: showing a multiple blastic lesions in the sternum (red arrows).
A B C
- Apperance may be lytic (multiple myeloma) or blastic / sclerotic (prostate or breast cancer).
IV. TUMORS: *CASE 11: OSTEOSARCOMA:
22-years-old female patient who previously underwent radiation therapy . MRI images: (A) Axial T2-WI; (B) Axial T1-WI; (C) Coronal T1-WI; (D) Coronal T2-WI; (E) Coronal enhanced
T1-WI; (F) Sagital T1-WI; (G) Sagittal T2-WI; (H) Sagittal enhanced T1-WI: showing an osseous lesion with mixed signal /predominantly hyoerintense on T2-WI with heterogeneous
enhancement after intravenous contrast administration (red arrows).
- More commonly in older patients. - Secondary malignancy following radiotherapy.
A
B C D E
F G H
IV. TUMORS: *CASE 12: PLASMOCYTOMA:
- Localized proliferation / solitary mass of neoplastic monoclonal plasma cells. - Diffuse proliferetion: MULTIPLE MYELOMA
70-years-old female patient with multiple myeloma. CT images: (A and B) Axial, (C and D) Coronal and (E and F) Sagittal reconstructions: showing an intramedullary expansile lesion of the sternum with cortical bone erosion (red arrows).
A B
C D E F
V. INFLAMMATORY CHANGES: *CASE 13: CRYSTAL INDUCED ARTHROPATHY:
- GOUT: rare: typically well marginated paraarticular erosions, and appositional bone deposition with expansion of bone ends - PSEUDOGOUT: CALCIUM PYROPHOSPHATE DIHYDRATE CRYSTAL DEPOSITION: occasional: typically chondrocalcinosis and tophaceous pseudogout formation.
93-years-old female patient.
(A and B) Axial CT images: showing
crystal deposition in the
sternoclavicular joint (red arrows).
A B
V. INFLAMMATORY CHANGES: *CASE 14: SERONEGATIVE ARTHRITIS: PSORIATIC ARTHRITIS:
- Seronegative arthritides may affect the manubriosternal and sternoclavicular joints. - Common radiographic fidings: Erosions or fusion of the manubriosternal joint and sternoclavicular joint hyperostosis.
35-years-old female patient with psoriatic arthritis. MRI
Sagittal (A) T1-WI, (B) T2-WI and (C) enhanced T1-WI:
showing cortical erosion of the manubriumsternal joint with cortical bone sclerosis (low
signal intensity on both T1 and T2 images: white arrows) and
joint enhancement after intravenous contrast
administration (red arrow).
A B C
V. INFLAMMATORY CHANGES: *CASE 15: SAPHO SYNDROME:
- SAPHO: synovitis, acne, palmoplantar pustulosis, hyperostosis, and osteitis - Wide spectrum of aseptic neutrophilic dermatoses with aseptic osteoarticular lesions. - The sternoclavicular joint is most frequently affected (65%-90%).
52-years-old female patient with psoriatic arthritis. MRI Coronal (A) T1-WI, (B) T2-WI and (C) enhanced T1-WI: showing joint erosion and bone marrow edema of the sternoclavicular joint (red arrows) and an arthrosynovial cyst (white arrow).
A B C
V. INFLAMMATORY CHANGES: *CASE 16: TIETZE SYNDROME:
- Painful costochondritis of unknown cause – mainly in young women. - Characterized by mineralized and swollen costal cartilage.
A B C
30-years-old female patient with left sternoclavicular joint pain. CT (A) Sagittal, (B) Coronal and (C) Axial images: showing mineralized and sclerotic bone of the left sternoclavicular joint (red arrows).
V. INFECTION: IATROGENIC *CASE 17: POST STERNOTOMY:
- Primary osteomyelitis of the sternum is uncommon. - Related to intravenous drug abuse, immune deficiency states, hemoglobinopathy.
A B
C
78-years-old female patient with secondary osteomyelitis after median sternotomy and myocardial revascularization. CT (A-B) Sagittal and (C-D) Axial images: showing erosive changes of the sternum (white arrows), soft tissue edema and fluid collection (red arrows).
D
- Complications after sternotomy is rare. - Include: dehiscence, nonunion, secondary osteomyelitis /mediastinitis.
V. OTHERS: POST OPERATORY *CASE 18: STERNOTOMY DEHISCENCE:
A B
C
78-years-old female patient with 20 days history of sternotomy and myocardial revascularization. CT (A and B) Coronal and (C) Axial
images: showing sternal dehiscence with displacement of
the wires (red arrows).
V. OTHERS: *CASE 19: MYONECROSIS:
24-years-old male patient with sternal pain after excercise. MRI (A and B) Axial T1-WI ,(C) Coronal T-WI and (D) Coronal enhanced T1-WI: showing heterogeneous peripheral enhencement with central necrosis of the pectoralis major sternal insertion (red arrows).
A
B C D
- Myopathy involving infarcted muscle. - Causes: idiopathic, diabetic, post-traumatic, crush, ischaemia, rhabdomyolisis.
V. OTHERS: *CASE 20: PAGET DISEASE:
A B
75-years-old male patient with Paget disease. (A) Coronal and
(B) Sagittal CT images: showing mixed lytic and
sclerotic changes involving the stenum. Classic findings
include: osteolysis, trabecular coarsening, cortical thickening,
and osseous expansion (red arrows).
- Chronic skeletal disorder characterized by abnormal and excessive remodeling of bone. - Abnormal osseous resorption /apposition: variable clinical and imaging manifestations.
▶ CONCLUSION:
*To achieve accurate and timely diagnoses that facilitate the management and appropriate treatment, radiologists should be
familiar with the appearances of the diseases that may affect the sternum.
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