Manubriosternal Joint Injection

Indications and Clinical Considerations

The manubriosternal joint can serve as a source of pain that often may mimic pain of cardiac origin. It is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis ( Fig. 110.1 ). The joint is often traumatized during acceleration–deceleration injuries and blunt trauma to the chest. With severe trauma, the joint may sublux or dislocate ( Figs. 110.2 and 110.3 ). Overuse or misuse also can result in acute inflammation of the manubriosternal joint, which can be quite debilitating. The joint also is subject to invasion by tumor either from primary malignancies, including thymoma, or from metastatic disease. Rarely, the manubriosternal joint can become infected ( Fig. 110.4 ).

Physical examination reveals that the patient will vigorously attempt to splint the joint by keeping the shoulders stiffly in a neutral position. Pain is reproduced by active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder also may reproduce the pain. The manubriosternal joint may be tender to palpation and feel hot and swollen if acutely inflamed. The patient also may report a clicking sensation with movement of the joint.

Plain radiographs are indicated for all patients with pain thought to be emanating from the manubriosternal joint to rule out occult bony disease, including tumor and infection ( Fig. 110.5 ). On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the joint is indicated if joint instability is suspected and to clarify the diagnosis ( Fig. 110.6 ). The following injection technique serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The manubrium articulates with the body of the sternum via the manubriosternal joint. The joint articulates at an angle called the angle of Louis, which allows for easy identification. The joint is a fibrocartilaginous joint or synchondrosis, which lacks a true joint cavity. The manubriosternal joint allows protraction and retraction of the thorax ( Fig. 110.7 ). Above, the manubrium articulates with the sternal end of the clavicle and the cartilage of the first rib. Below, the body of the sternum articulates with the xiphoid process. Posterior to the manubriosternal 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, and pneumothorax may result.