The Clinical Syndrome

The manubrium articulates with the body of the sternum by way of the manubriosternal joint at the angle of Louis. The manubriosternal joint is a fibrocartilaginous joint or synchondrosis, which lacks a true joint cavity. The joint allows protraction and retraction of the thorax.

Pain originating from the manubriosternal joint can mimic pain of cardiac origin. The manubriosternal joint is susceptible to the development of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome, and psoriatic arthritis. The joint can also be traumatized during acceleration-deceleration injuries and blunt trauma to the chest ( Fig. 62.1 ). With severe trauma, the joint may subluxate or dislocate. Overuse or misuse can result in acute inflammation of the manubriosternal joint, which can be quite debilitating. The joint is also subject to invasion by tumor from primary malignant tumors, including thymoma, or from metastatic disease. Rarely, septic arthritis of the manubriosternal joint can occur ( Fig. 62.2 ).

The manubriosternal joint is susceptible to the development of arthritis. It is often traumatized during acceleration-deceleration injuries and blunt trauma to the chest.

Sagittal reformat image of the sternum in mediastinal window demonstrates a more prominent soft-tissue presternal mass (long arrow) and a smaller posterior mass (short arrow) centered on the manubriosternal joint.

(From Gorospe L, Ayala-Carbonero AM, Rodríguez-Díaz R, Latorre RG, Muñoz-Molina GM, Cabañero-Sánchez A. Tuberculosis of the manubriosternal joint and concurrent asymptomatic active pulmonary tuberculosis in a patient presenting with a chest wall mass. Clin Imaging . 2015;39(2):311–314.)

Signs and Symptoms

Physical examination reveals that the patient vigorously attempts to splint the joint by keeping the shoulders stiffly in a neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder may also reproduce the pain. Coughing may be difficult, leading to inadequate pulmonary toilet in patients who have sustained trauma to the anterior chest wall. The manubriosternal joint may be tender to palpation. The patient may also complain of a clicking sensation with movement of the joint.

Testing

Plain radiographs are indicated for all patients who present with pain thought to be emanating from the manubriosternal joint, to rule out occult bony disorders, including tumor. If trauma is present, radionuclide bone scanning may be useful to exclude occult fractures of the ribs or sternum. Based on the patient’s clinical presentation, additional testing may be indicated, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Laboratory evaluation for collagen vascular disease is indicated in patients suffering from manubriosternal joint pain if other joints are involved. Magnetic resonance imaging, ultrasound imaging, and/or computed tomography (CT) of the joint is indicated if joint instability, infection, or occult mass is suspected or to further elucidate the cause of the pain ( Figs. 62.3, 62.4, and 62.5 ). The use of multidetector CT for patients presenting to the emergency room with acute chest pain has led to more rapid and accurate diagnosis of chest wall pain syndromes. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

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