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Rheumatology 2001; 40: 170-177
© 2001 British Society for Rheumatology
The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey
Departments of Rheumatology and
1 Radiology, Southend General Hospital, Westcliff-on-Sea, Essex SS0 0RY, UK
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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Objective. To report our local experience of the sternoclavicular syndrome and sample the experience of other rheumatologists in the UK.
Methods. We studied case records of 23 patients referred to the Southend rheumatology clinic and data obtained from a postal questionnaire survey of British rheumatologists.
Results. We describe 58 cases (20 males and 38 females, mean age 47.2 yr). The disease was unilateral in 40 patients. Shoulder and/or arm pain (38 cases) with limitation of shoulder movements was an important presenting feature; other presenting features were anterior chest wall pain (14 cases) and neck pain (15 cases). Peripheral joint involvement was seen in 12 cases. Skin rash was reported in 12 cases (psoriasis, 6; acne, 2; none had pustulosis). No patients had symptoms or signs of sacroiliitis, and HLA-B27 was negative in 22 out of 23 patients. 99Technetium scintiscanning showed increased uptake in the sternoclavicular region in 31/34 patients (91.1%), but not in the sacroiliac areas. Plain radiographs were abnormal in 18 cases (sclerosis, 9; erosions, 2; soft tissue swelling, 2; bony expansion, 5). CT and/or MRI scans (available in 27 cases) showed erosions in 12 and osteitis in 18. Available histology showed a variable picture, including inflammation, bone erosion, sterile osteomyelitis and fibrosis. The majority of patients (45) were treated with non-steroidal anti-inflammatory drugs: 12 received steroids and 10 received disease-modifying anti-rheumatic drugs (methotrexate, 4; sulphasalazine, 6). Follow-up information was available for 38 patients, of whom 14 became asymptomatic and 24 had chronic disease with intermittent flares.
Conclusion. Sternoclavicular disease is not uncommon in the UK. It can present with pain in the shoulder, neck or anterior chest wall, and may be underdiagnosed. Our results do not show a link with acne or pustulosis. Features of spondyloarthropathies, such as sacroiliitis and HLA-B27 positivity, were rare in this survey.
KEY WORDS: SAPHO syndrome, Hyperostosis, Sternoclavicular joint.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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The sternoclavicular syndrome (reported under synonyms such as SAPHO syndrome, arthro-osteitis and sternoclavicular hyperostosis) is a group of ill-understood chronic inflammatory disorders. It can present acutely with neck, shoulder, arm or chest pain with high levels of inflammatory markers, or it may be of a chronically remitting and relapsing type. It is characterized by erosive or non-erosive arthritis, hyperostosis and ossifying lesions at the sites of tendinous and ligamentary insertions. The hyperostosis mainly involves the sternoclavicular region, though involvement of the spine, pelvis and appendicular skeleton has been described. It is reported to be associated with skin lesions (acne fulminans, acne conglobata, palmoplantar pustulosis and psoriasis) in 20–60% of cases [1–3].
There is a lot of variation in terminology, probably reflecting our lack of understanding of this condition. There is also controversy regarding its presentation, association with skin conditions, findings on imaging, and its association with spondyloarthropathy and HLA-B27 positivity. Most descriptions are from Japan, Scandinavia, France, Germany, Switzerland and Belgium, with only 10 case reports from the UK [1–10].
We have recently seen a spate of several patients with sternoclavicular inflammation at our own centre. This stimulated us to describe our own experience and carry out a national postal survey to sample the clinical experience of other British rheumatologists.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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We undertook a national survey, which consisted of a standard questionnaire sent to all consultant rheumatologists working in the UK. We also report our experience of 23 cases seen at Southend Hospital over last 5 yr (1993–1998) and we describe three of these cases in detail.
The questionnaire asked for detailed clinical information on patients seen with sternoclavicular inflammation. Details requested included demographic data, type of onset (acute, <4 weeks; subacute, <12 weeks; chronic, >12 weeks) and the duration of symptoms. There were specific questions regarding fever, diarrhoea and skin lesions (acne, psoriasis, pustulosis, others). Details of sternoclavicular swelling and/or tenderness, shoulder pain, limitation of shoulder movements, neck pain, anterior chest wall swelling, peripheral joint involvement, back pain and other bony or spinal abnormalities were requested.
Investigations included blood tests [full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), biochemistry, autoantibodies], cultures, imaging [plain radiographs, 99technetium (99Tc) scintiscanning, computed tomography (CT) and magnetic resonance imaging (MRI)], cytology and histology. The management and follow-up of the patients and any other comments were noted.
Case 1
A 34-yr-old Caucasian female was seen in the out-patient department in October 1995 with severe pain in the left sternoclavicular joint (SCJ), left clavicle and shoulder with limitation of shoulder movement of 1 month's duration. On examination she had diffuse soft tissue swelling around the clavicle, which was extremely tender on palpation. The shoulder and neck movements were painful and very limited. Pain was worsened by retraction of the shoulder.
Investigations showed normal full blood count and bone profile, renal and liver function tests. ESR was 88 mm/h and HLA-B27 was negative. CT and MRI scans of the region showed soft tissue thickening around the left clavicle with no abscess or bony abnormality (Fig. 1
). A 99Tc scan showed increased uptake at the medial end of the left SCJ and first rib. Surgical exploration showed a mass adhering to the anterior chest wall, and the histology revealed fibrosis with neutrophilic infiltrate. Cultures of the sternoclavicular aspirates and biopsy were sterile.
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She was treated with antibiotics for 2 weeks with no response. Addition of oral prednisolone 30 mg/day brought about dramatic relief of symptoms and signs. Steroids were tapered gradually to 2.5 mg/day over the next 12 months. Over the next year, she remained well, with only slight restriction of shoulder movements and a normal ESR. Repeat CT in July 1996 showed resolution of the soft tissue mass but evidence of hyperostosis of the clavicle (Fig. 2
).
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Case 2
A 36-yr-old Caucasian female was seen in November 1995 with severe pain in the left shoulder of 2 weeks’ duration. Symptoms started with a high temperature and chills, and she was treated with antibiotics. The fever settled but she had persistent shoulder pain. She had also noticed pain in the left supraclavicular area and stiffness in the neck. She had gastroenteritis 4 weeks before developing shoulder pain. There was no history of arthritis, back pain, eye symptoms or skin lesions. On examination, she had diffuse swelling of the left clavicle, with tenderness over the left supraclavicular area and limitation of active shoulder movements due to pain.
The full blood count and biochemical investigations were normal, and ESR was 111 mm/h. Chest radiograph was normal. The 99Tc scan showed increased uptake in the left SCJ and the medial clavicle (Fig. 3). The CT scan showed erosions of the left sternoclavicular joint and clavicle (Fig. 4), and the MRI scan additionally showed an associated soft tissue mass extending into the anterior mediastinum. Aspirate from this mass yielded a very light growth of coliform bacilli (thought to be a contaminant) and biopsy showed marked inflammatory infiltrate. HLA-B27 was negative and Yersinia serology showed a rising titre from 1:80 to 1:320. The patient was treated successfully with 60 mg prednisolone (as she did not respond to a smaller dose), which was gradually tapered and stopped over 2 yr. At 3 yr of follow-up, she is asymptomatic but CRP remains slightly raised at 24 mg/l.
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Case 3
A 42-yr-old Afro-Caribbean male was referred in March 1992 with intermittent chest symptoms of 3 yr duration. The pain was thought to be non-cardiac in origin but would wake him at night, and was aggravated by sneezing and exertion. There was no history of neck or back pain. He had a history of arthritis with onset in late adolescence, involving the knees, metacarpophalangeal joints and feet, without systemic features. Examination showed a normal range of movements in the neck, thoracic spine and shoulders, but there was pain on stressing the SCJs. The patient also had sycosis barbae.
Investigations, including full blood count, renal and liver function tests, autoantibody screen and HbS, were normal. Plain radiographs and the CT scan of the sternum were normal. The 99Tc scan showed increased uptake at the manubriosternum and costochondral joints.
Alhough initial treatment consisted of local steroid injections, non-steroidal anti-inflammatory drugs and low-dose oral steroids, he subsequently required methotrexate and sulphasalazine for the control of sternoclavicular as well as peripheral joint symptoms. There was an episode of plantar fasciitis in March 1995 and extensor tenosynovitis of the right wrist in March 1996. After 8 yr of follow-up, he still complains of intermittent manubriosternal pain.
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Results |
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TopAbstractIntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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Forty rheumatologists returned the questionnaire, of whom 19 reported 35 cases. Twelve replied that they had never seen a case, and four had seen sternoclavicular inflammation associated with psoriatic arthritis but did not have further details. Five reported cases in association with rheumatoid arthritis, infection, lymphoma and sternoclavicular subluxation. These cases are not included in the present analysis. The clinical data, investigations, management and follow-up are summarized in Tables 1
–3.
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Peripheral joint involvement in our own group occurred in five patients. These involved mainly the large joints, such as the knee (four patients), ankle (two patients) and wrist (two patients), and there were single cases with involvement of the proximal interphalangeal, metacarpophalangeal and mid-tarsal joints. From the postal survey, seven patients had involvement of peripheral joints, including the knee (three patients), ankle (two patients), hip (one patient) and subtalar joints (one patient).
99Tc scans in our patients showed increased uptake in 14 patients, of whom 10 had increased uptake in the SCJ. Increased uptake was also seen in the manubriosternal (three patients) and costochondral joints (three patients), the first rib (one patient) and the medial end of the clavicle (three patients), and there were single cases with uptake in the ischial ramus, foot, tibia and lateral malleolus. In the postal survey, increased uptake was reported in the sternoclavicular joint (seven patients), manubriosternal joint (five patients), sternum (three patients), clavicle (three patients), ribs (two patients) and the right tibia (one patient).
Additional CT/MRI findings were retroclavicular soft tissue swelling (two patients), hypertrophy of the medial end of the clavicle (one patient) and reactive bone formation (one patient). In the postal survey, clavicular soft tissue swelling was reported in four patients, cortical thickening in one patient, and expansion and sclerosis of the scapula in one patient.
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Review of the literature |
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TopAbstractIntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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In 1959, Bremner [4] treated six patients with synovectomy and excision of the medial inch of the clavicle for monoarticular, non-infective subacute arthritis of the SCJ. However, this condition was first described as a definite clinical entity by Kato et al. in 1968 [11]. He described bilateral clavicular osteomyelitis with palmoplantar pustulosis. Histology of the lesions was suggestive of chronic inflammation. In 1977, Kohler et al. [12] named the condition ‘sternoclavicular hyperostosis’. In 1979, Sonozaki et al. [13] reported an association of arthro-osteitis of the anterior chest wall with pustulosis and sacroiliac involvement. The term ‘SAPHO’ (synovitis, acne, pustulosis, hyperostosis and osteitis) was coined by Kahn et al. in 1987 [3]. Arthro-osteitis was reported in 10% of patients with palmoplantar pustulosis [14]. The association is considered rare in the UK [5].
Clinical features
In 1993, Saghafi et al. [15] reviewed the English literature from 1977 to 1990 and summarized findings in 253 patients with SAPHO. The average age was 47 yr (8–88 yr) with a male:female ratio of 1:1.3. Upper chest wall pain occurred in 70% of patients, pain and limitation of movement of the shoulder in 27% and peripheral arthritis in 14%. Palmoplantar pustulosis was present in 51% of the patients.
Helliwell et al. [6] reported clinical involvement of the SCJ in 13% of patients with psoriasis. The proportion of patients with increased uptake on radioisotope scan was much higher (22/41). He reported that these patients had more severe psoriasis overall and had higher frequencies of enthesitis, nail involvement and dactylitis. The condition has also been described in association with ankylosing spondylitis, ulcerative colitis, sacroiliitis and diffuse idiopathic skeletal hyperostasis [2].
Laboratory investigations
Saghafi et al. [15] reported elevated ESR in 35%, whereas CRP was elevated in 10% of patients. HLA-B27 was positive in only 4%. The review by Kahn and Chamot [3] reports HLA-B27 positivity in one-third of their patients, and it was more closely correlated with anterior chest wall involvement (41.7%) than with palmoplantar pustulosis (12.8%) and acne (9%). Japanese patients with axial disease were HLA-B27 negative [16]. Propionibacterium acne has been isolated from bone cultures of one patient with the SAPHO syndrome [17].
Imaging
The review by Saghafi et al. [15] showed clavicular hyperostosis in 45% of patients and sternal hyperostosis in 38%. The manubriosternal and sternoclavicular joints were involved in 25 and 44% of patients respectively. Costoclavicular ligamental ossification was present in 25% and rib or sternocostal involvement in 48% of patients. A parasternal soft tissue mass and sacroiliitis were each found in 13% of patients.
Histological features reported by Resnick and Niwayama in 1983 [18] were enthesopathy of the sternoclavicular and costoclavicular ligaments, which can also involve enthesis around the manubrium.
Treatment
Because of the rarity of this condition, there have been no controlled clinical trials. There is some evidence that NSAIDs and corticosteroids are useful [12–14]. Some workers have used antibiotics [19]. There are reports of successful treatment with calcitonin and pamidronate [20, 21]. Surgery has been considered for patients not responding to conservative treatment, and consists of partial or wide resection of the ossified mass and the medial end of the clavicle and/or the first rib [4, 13].
Prognosis
A recent study by Hayem et al. [22] with a review of 120 patients from 1974 to 1997 indicated that this disease has a good long-term prognosis. No severe, disabling complications were noted. Patients were treated with NSAIDs (94%), corticosteroids (19%), disease-modifying drugs (sulphasalazine, 15%; methotrexate, 8.1%) and colchicine and intra-articular injections (23% each).
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsReview of the literatureDiscussionReferences |
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SCJ arthritis and anterior chest wall involvement are seen uncommonly in inflammatory arthritis, except psoriatic arthritis. There are very few case reports about this condition from the UK [1–10]. A possible reason for this under-reporting is lack of clinical awareness, as the main complaint is often pain of the anterior chest wall, shoulder and/or neck rather than sternoclavicular pain. We have therefore highlighted the differential diagnosis in Fig. 5
, and in the following discussion we will suggest a clinical approach.
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The acute presentation
In our patients who presented acutely with fever, soft tissue swelling and high ESR/CRP, the most important differential diagnosis was infection (septic SCJ arthritis or osteomyelitis), as sepsis is common in this area. It usually occurs in contiguity with an adjacent focus of infection in patients with predisposing factors such as diabetes, rheumatoid arthritis, systemic steroid therapy, alcoholism and heroin addiction. The causative agent is Staphylococcus aureus, but other bacteria, such as haemolytic streptococci and Pseudomonas, have been reported [23]. We recommend that sepsis should be excluded by aspiration and biopsy before the possibility of a non-infective inflammatory cause is entertained. However, if microbial cultures are sterile, active treatment with oral steroids should be commenced early to obtain quick control of the inflammatory symptoms and prevent erosive damage.
Apart from infection, other initial diagnoses in our acute cases with bilateral symptoms were polymyalgia rheumatica and inflammatory muscle disease. In the acute presentation, cardiac and pulmonary causes may also form differential diagnoses. On the other hand, it is also important to consider the SCJ as a cause of acute non-cardiac chest pain.
Chronic presentation
The common initial diagnoses in our series were capsulitis, costochondritis and cervical spondylosis. We therefore feel that this condition should be considered in patients with chronic pain of the shoulder, neck and anterior chest wall. Two useful localizing clinical signs are (i) SCJ pain on shrugging the shoulder and (ii) SCJ pain on shoulder retraction. In addition, swelling and tenderness at the SCJ are often present on examination. SCJ osteoarthritis is known, but most of our patients were relatively young and had no other osteoarthritic complaints, and imaging with CT/MRI did not suggest osteoarthritis. Tietze syndrome, a disorder of poorly understood and perhaps multifactorial causation, can be considered but tends not to involve the SCJ predominantly [24, 25].
Ewing's sarcoma and other primary or secondary neoplasms may arise uncommonly in this area [7]. Paget's disease of the clavicle is well known but can be excluded by typical radiology, a high concentration of alkaline phosphatase, and other areas of pagetoid involvement.
Rarer differential diagnoses include osteitis condensans of the clavicle, a benign and often painful disorder of unknown causation manifested by bony sclerosis with an uninvolved SCJ [26, 27]. Mediastinal fibrosis (also considered as a differential diagnosis in one of our cases) presents with fibrosis of superior mediastinal structures, and can mimic this condition.
Dermatological associations with the sternoclavicular syndrome have been described in 20–60% of patients. These generally consist of psoriasis, palmoplantar pustulosis and, acutely, in association with acne conglobata and acne fulminans [3, 6]. Although our series did not find any major associated condition other than psoriasis, dermatologists and other physicians clearly need to be aware of the rheumatological manifestations of these skin diseases.
The relationship with spondyloarthropathies and HLA-B27 has been reviewed in an earlier section of this article. We found no association between our cases and spondyloarthropathy. Only one patient was HLA-B27 positive.
As we state in our Introduction, this condition suffers from a plethora of names [3]. This is understandable in view of the wide variation in clinical presentation (as also seen in our series), and the occurrence of associated conditions, such as palmoplantar pustulosis, psoriasis and acne. Some authors even classify it as a component of seronegative spondyloarthropathy [1, 3, 26]. The differing patterns of joint and bone involvement on imaging introduce yet another dimension of variability. For example, Chamot et al. [28] suggest that multiple non-infectious osteitis, sternoclavicular hyperostosis, palmoplantar pustulosis and severe acne represent different but overlapping clinical presentations of the same condition. Some also regard osteitis condensans and Tietze syndrome as part of the condition [24].
We feel that bone scintigraphy is the most useful investigation for assessing the extent and intensity of the disease. CT/MRI may help in the early diagnosis of erosions and differentiation from osteomyelitis and bone tumours. Plain radiographic changes are usually seen relatively late in the course of the disease.
Our own experience and the postal survey suggests that inflammatory involvement of the SCJ, the clavicle and anatomically contiguous areas is not uncommon in the UK. Unlike other authors, we did not see any association with HLA-B27, spondyloarthropathies or specific skin diseases apart from psoriasis. We found a high incidence of shoulder and arm pain, and heterogeneous presentations with acute, subacute or chronic onset of symptoms.
Our study raises several interesting questions. Are these separate diseases? Are these manifestations of the same disease with different severities? Are these different pathophysiological stages of the same disease? Or are they merely different diseases affecting common anatomical areas?
In our view it may be more meaningful to acknowledge that SCJ and clavicular bone involvement can be seen in multiple conditions and can have various associations. A national or even international registry of these cases with long-term follow-up and rigorous clinical and pathogenic studies will help to improve our understanding and classification of this very interesting clinical condition.
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Acknowledgments |
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We are grateful to all the rheumatologists (especially Dr Daunt, Dr Hull, Dr Newton and Dr Daves who sent us many cases) who participated in the postal survey. We also thank the audit department at our hospital.
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Notes |
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Correspondence to: B. Dasgupta.
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References |
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- Dihlmann W, Schnabel A, Gross WL. The acquired hyperostosis syndrome: a little known skeletal disorder with distinctive radiological and clinical features. Clin Invest1993;72:4–11.[Medline]
- Economou G, Jones PB, Adams JE, Bernstein RM. Computed tomography in sternoclavicular hyperostosis. Br J Radiol1993;66:1118–24.
[Abstract/Free Full Text] - Kahn MF, Chamot AM. SAPHO syndrome. Rheum Dis Clin North Am1992;18:225–46.[Web of Science][Medline]
- Bremner RA. Monoarticular, non-infective subacute arthritis of the sternoclavicular joint. J Bone Joint Surg1959;41B:749–53.
- Sloan RL, Kemmet D, Merrick MV, Nuki G. Arthro-osteitis is a rare complication of palmoplantar pustulosis in UK population. Br J Rheumatol1989;28(Suppl.):1–18.
- Helliwell P, Marchesoni A, Peters M, Barker M, Wright V. A re-evaluation of osteoarticular manifestations of psoriasis. Br J Rheumatol1991;30:339–45.
[Abstract/Free Full Text] - Watts RA, Crisp AJ, Hazleman BL, Daunt SO, Jenner JR. Arthro-osteitis—a clinical spectrum (clinical review). Br J Rheumatol1993;32:403–7.
[Abstract/Free Full Text] - Taylor HG, Dawes PT. Sterno-costo-clavicular hyperostosis. Br J Clin Pathol1992;46:276–8.
- Ralston SH, Scott PDR, Sturrock RD. An unusual case of pustulotic arthro-osteitis affecting leg and erosive polyarthritis. Ann Rheum Dis1990;49:643–5.
[Abstract/Free Full Text] - Colhoun EN, Hayward C, Evans KT. Intersterno-costo-clavicular ossification. Clin Radiol1987;38:33–8.[Medline]
- Kato T, Kambara A, Hoshi E. A case with osteomyelitis of both clavicles associated with pustulosis palmaris and plantaris. Seiki Geka1968;19:590–3.
- Kohler H, Uelinger E, Kutzner J, West TB. Sternoclavicular hyperostosis: Painful swelling of the sternum, clavicle and the upper ribs. Ann Intern Med1977;87:192–4.[Medline]
- Sonozaki H, Azuma A, Okai K et al. Clinical features of 22 cases with ‘inter sterno-costo-clavicular ossification’, a new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13–22.[Medline]
- Sonozaki H, Kawashima M, Hongo O et al. Incidence of arthro-osteitis in patients with pustulosis palmaris et plantaris. Ann Rheum Dis1981;40:554–7.
[Abstract/Free Full Text] - Saghafi M, Henderson J, Buchanan WW. Sternoclavicular hyperostosis. Semin Arthritis Rheum1993;22:215–23.[Medline]
- Sonozaki H, Mitsui H, Miyanaga Y et al. Clinical features of 53 cases with pustulotic arthro-osteitis. Ann Rheum Dis1981;40:547–53.
[Abstract/Free Full Text] - Kotilainen P, Merilahti-Palo R, Lehtonen OP et al. Propionibacterium acnes isolated from sternal osteitis in a patient with SAPHO syndrome. J Rheumatol1996; 23:1302–4.[Web of Science][Medline]
- Resnick D, Niwayama G. Entheses and enthesopathy. Anatomical, pathological and radiological correlation. Radiology1983;146:1–9.
[Abstract/Free Full Text] - Chingira M, Maehera S, Nagase M et al. Sternoclavicular hyperostosis. A report of nineteen cases, with special reference to etiology and treatment. J Bone Joint Surg Am1986;68:103–12.
[Abstract/Free Full Text] - Misaki T, Doksh S, Mori E. Calcitonin treatment for intersternocostoclavicular ossification. Clinical experience in two cases. Ann Rheum Dis1991;50:813–6.
[Abstract/Free Full Text] - Van Holsbeck M, Martel W, Dequeker J et al. Soft tissue involvement, mediastinal pseudotumour and pseudothrombosis in a pustulotic arthro-osteitis. Skeletal Radiol1989;18:1–8.[Web of Science][Medline]
- Hayem G, Bouchaud-Chabot A, Benali K et al. Sapho syndrome: a long term follow up of 120 cases. Semin Arthritis Rheum1999;29:159–71.[Web of Science][Medline]
- Gillis S, Friedman B, Caraco Y, Blankstein A, Yellin A, Friedman G. Septic arthritis of sternoclavicular joint in healthy adults. J Intern Med1990;228:275–8.[Medline]
- Honda N, Machida K, Mamiya T et al. Scintigraphic and CT findings of Tietze's syndrome: report of a case and review of literature. Clin Nucl Med1989;14:606–9.[Medline]
- Aeschlimann A, Kahn MF. Tietze's syndrome: a critical review. Clin Exp Rheumatol1990;8:407–12.[Web of Science][Medline]
- Greenspan A, Gerscovich E, Szabo RM, Mathews JG. Condensing osteitis of the clavicle: a rare but frequently misdiagnosed condition. Am J Roentgenol1991;156: 1011–5.
[Abstract/Free Full Text] - Tait TJ, Chalmers AG, Bird HA. Condensing osteitis of the clavicle: Differentiation from sternoclavicular hyperostosis by magnetic resonance imaging. Br J Rheumatol1994;33:985–7.
[Free Full Text] - Chamot AM, Vion B, Grester JC. Acute pseudoseptic arthritis and palmoplantar pustulosis. Clin Rheumatol1986;5:118–23.[Medline]
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