Ortho Dx: Severe Chest Pain Following IV Drug Use

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  • Figure. Computed tomography of the chest.

A 32-year-old man presents to the emergency department complaining of severe chest pain for the past week. He admits to a recent history of intravenous (IV) drug use but denies injury. Computed tomography of the chest is performed (Figure) and shows erosive destruction of the medial cortex of the head of the left clavicle and adjacent sternum. Additionally, soft tissue swelling surrounding the sternoclavicular (SC) joint is identified. These findings are consistent with osteomyelitis of the sternoclavicular joint.

Which of the following is the best treatment option?

SC joint infection is a relatively rare condition that can have devastating consequences if left untreated. Causes of infection include penetrating injury or a blood infection (septicemia) that seeds the SC joint. The most common presentation of an SC joint...

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SC joint infection is a relatively rare condition that can have devastating consequences if left untreated. Causes of infection include penetrating injury or a blood infection (septicemia) that seeds the SC joint. The most common presentation of an SC joint infection includes chest pain for an average of 14 days (78%), erythema of the SC joint, fever (65%), and bacteremia (62%).1 Staphylococcus aureus is the most common bacteria involved, particularly in IV drug users. Serious complications including retrosternal abscess and mediastinitis can arise from an SC joint infection. Symptomatic SC joint infections generally require surgery to prevent the development of complications.  The most common surgical procedure involves resection of the SC joint combined with pectoralis major muscle transposition to fill the void of the resected SC joint. The resection can be technically demanding due to limited soft tissue coverage over the major vascular structures underneath the SC joint. After SC joint resection, IV antibiotics are continued for at least 6 weeks.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

1. Ross JJ, Shamsuddin H.  Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004;83(3):139-148. 

2. Huang K, Zhang C. Sternoclavicular joint infection treated with debridement, vancomycin-loaded calcium sulfate, and partial pectoralis muscle flap: a case report. JBJS Case Connect. 2015;5(4):e86. 

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