Ultrasound-Guided Injection Technique for Costosternal Joint Pain
The costosternal joint is susceptible to injury from acute blunt trauma from motor vehicle accidents and contact sports such as football and rugby as well as repetitive microtrauma from chronic coughing and activities that require active protraction and retraction of the shoulders. Left untreated, the acute inflammation associated with the injury may result in arthritis with its associated pain and functional disability. Acute onset of severe costosternal pain and swelling, especially of the second and third costal cartilages that is associated with acute upper respiratory tract infection, is known as Tietze syndrome. Tietze syndrome was first described in 1921 and most commonly occurs in the second and third decade of life.
Patients suffering from costosternal joint dysfunction or inflammation will complain of a marked exacerbation of pain when they perform activities that require thrusting the arm forward and retracting or shrugging the shoulder and with deep inspiration. A clicking sensation with joint movement is often noted, and the patient frequently is unable to sleep on the affected side. Patients with costosternal joint dysfunction and inflammation will exhibit pain on active protraction or retraction of the shoulder as well as with raising of the arm high above the head. Palpation of the costosternal joint often reveals swelling or enlargement of the joint secondary to joint inflammation. If there is disruption of the ligaments that surround and support the costosternal joint, joint instability and a cosmetic defect may be evident on physical examination.
Plain radiographs are indicated in patients suffering from costosternal joint pain. They may reveal psoriatic arthritis, ankylosing spondylitis, costochondritis, and Tietze syndrome or widening of the joint consistent with ligamentous injury (Fig. 83.1). They may also reveal occult fractures or primary or metastatic tumors of the joint. If joint instability, infection, or tumor is suspected or detected on physical examination, magnetic resonance imaging, computerized tomography, and/or ultrasound scanning is a reasonable next step. Ultrasoundguided costosternal joint injection can aid the clinician in both the diagnosis and treatment of costosternal joint pain and dysfunction.
CLINICALLY RELEVANT ANATOMY
The costosternal joints are the articulations between the cartilage of the true ribs and the sternum (Fig. 83.2). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding movement. The cartilages of the second through sixth ribs articulate with the body of the sternum and are true arthrodial joints. The costosternal joints are surrounded by a thin articular capsule. The costosternal joints are strengthened by ligaments but can be subluxed or dislocated by blunt trauma to the anterior chest wall (Fig. 83.3). Posterior to the costosternal joint are the structures of the mediastinum. These structures are susceptible to needle-induced trauma if the needle is placed too deeply. The pleural space may be entered if the needle is placed too deeply, and laterally, pneumothorax may result.
FIGURE 83.1. A 49-year-old man presented with pustulosis on his palms and soles and anterior chest wall pain consistent with SAPHO syndrome. Coronal reformatted CT image of the sternum shows sclerotic changes and erosions of the sternoclavicular and costosternal joints (arrows). (Greenspan A, Gershwin ME. Imaging in Rheumatology. Philadelphia: Wolters Kluwer; 2018.)
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