Sternoclavicular septic arthritis treatment,how to get rid of pink eye the natural way joomla,home remedies for bacterial pink eye symptoms,dog urinary tract infection symptoms and treatment methods - Reviews

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Anterior dislocations of the sternoclavicular joint result in less morbidity [pain, functional limitations, cosmetic issues] whereas a posterior dislocation has the potential for severe and even life-threatening complications like lung injury ( hemothroax, pneumothorax, tracheal injury, neurovascular injury and esophageal injury.
A traumatic dislocation of the sternoclavicular joint usually occurs only after tremendous forces, either direct or indirect, have been applied to the shoulder. A force act indirectly on the sternoclavicular joint from the anterolateral or posterolateral aspects of the shoulder. If the shoulder is compressed and rolled forward, an ipsilateral posterior dislocation results. Motor vehicle accidents are the most common mechanism producing sternoclavicular dislocation.
Fall on an outstretched abducted arm, driving the shoulder medially may also result in sternoclavicualr joint injury. Dislocations of the sternoclavicular joint also may result from congenital, degenerative, and inflammatory processes.
The most common cause of dislocation of the sternoclavicular joint is vehicular accidents folllowed by sports. Patients typically present with their head tilted toward the affected side and complain of chest and shoulder pain exacerbated by arm movement or in supine position.
The patient may complain of difficulty in swallowing or a tight feeling in the throat or may be in a state of complete shock or possibly have a pneumothorax. In patient with suspected sternoclavicular joint injury, tachypnea, stridor, hoarseness and other signs of respiratory distress should be carefully noted.
Radiological imaging is very important part of diagnosis making of sternoclavicular injuries. Anteroposterior x-rays of the chest or sternoclavicular joint may show sternoclavicular joint displaced as compared with the normal side.
Patient is in supine position, the x-ray tube is placed approximately 30 inches from the involved sternoclavicular joint and the central ray is directed tangential to the joint and parallel to the opposite clavicle. The patient is seated at the x-ray table,leaning forward in a way that the nape of his flexed neck is almost parallel to the table and lower anterior rib cage against the cassette  on the table.
The patient is positioned on his back and the tube is tilted at a 40-degree angle off the vertical centering over sternum with cassette under patient’s upper shoulders and neck. In children, the distance from the tube to the cassette is 45 inches and  in adults 60 inches. If the  sternoclavicular joint is dislocated anteriorly, the affected clavicle will appear to be displaced and riding higher.
Other imaging studies, such as angiography or esophagoscopy may be needed in posterior dislocations. For subluxation of the sternoclavicular joint, application of ice is recommended for the first 12 hours, followed by heat for the next 24 to 48 hours. For closed, under local or general anesthesia or sedation, the patient is placed supine on the table.
Posterior  sternoclavicular joint injury is more dangerous than anterior sternoclavicular injuries.
A general anesthesia is usually required for reduction of a posterior dislocation of the sternoclavicular joint because of pain and muscle spasms. Many different techniques have been described for closed reduction of a posterior dislocation of the sternoclavicular joint.
Lateral traction is applied to the abducted arm, which is then gradually brought back into extension. Occasionally, it may be necessary to grasp the medial clavicle with one’s fingers to dislodge it from behind the sternum. If this fails, a sterile towel clip is used to grasp the medial clavicle to apply lateral and anterior traction after skin preparation. The patient is placed supine on the table with a 3- to 4-inch bolster between the shoulders. Traction is then applied to the arm in adduction, while a downward pressure is exerted on the shoulder. Place the patient supine on the table with three or four folded towels between the two shoulders. Operative treatment of posterior strernoclavicular dislocation should be undertaken when the dislocation is not reducible because most adult patients cannot tolerate posterior displacement of the clavicle into the mediastinum. Loop of fascia lata, suture, internal fixation across the joint, subclavius tendon, osteotomy of the medial clavicle, and resection of the medial end of the clavicle have been described as treatment. About Dr Arun Pal SinghArun Pal Singh is an orthopedic and trauma surgeon, founder and chief editor of this website.
This website is an effort to educate and support people and medical personnel on orthopedic issues and musculoskeletal health. Joint Replacement Surgery – Present and FutureThis article is an introduction to total joint replacement. Quantitative Ultrasound or QUSQuantitative ultrasound is an ultrasound based modality to measure bone mineral density in osteoporosis.
Sternoclavicular joint septic arthritis (SSA) is rare and often difficult to manage condition.
Sternoclavicular joint septic arthritis (SSA) and its clinical presentation are infrequently seen and often difficult to manage. Vocal cord palsy is an important sign of thoracic and head and neck pathology that is caused by an extremely wide set of pathology. A 67-year-old gentleman presented to the emergency department with a 3-week history of worsening dysphagia and hoarse voice. With a working differential of parapharyngeal space infection and possible malignancy, the patient was referred for a computed tomography (CT) scan of the neck and thorax with contrast.
The antibiotic regimen for the patient was converted to intravenous benzylpenicillin (1.2 g four times per day) and flucloxacillin (1 g four times per day). Vocal cord palsy can be due to weakness in one or both vocal cords, and diagnosis is made when reduced mobility is evident by laryngoscope examination. Explanations for this unusual presentation of SSA seen in this case include tracking infection from the septic sternoclavicular joint, resulting in a vocal cord palsy due to reactive mediastinal lymphadenopathy. It has been shown that if radiological findings indicate a limited extent of disease, then medical therapy alone should be sufficient.
Interleukin 6 (IL-6) is a pro-inflammatory cytokine and one of the most important mediators of fever and of the acute phase response.
Caplan's syndrome describes lung nodules only in patients with both RA and pneumoconiosis related to mining dust (coal, asbestos, silica). Postglucocorticoid hypopigmentation of the skin can be avoided by the injection of air following the medication. Patients with primary SjA¶grena€™s syndrome and hypocomplementemia, particularly C4, are at increased risk for the development of lymphoma.
The shingles vaccine may be safe to give to SLE pts who have low disease activity and are on low doses of immunosuppressive meds. Those who develop Raynauda€™s phenomenon later in life (age >40) are more apt to have secondary Raynauda€™s phenomenon.
On a worldwide basis, the most common cause of Erythema nodosum is streptococcal infections (~20% of patients). In pregnant SLE patients who are flaring, starting azathioprine may not be all that effective. Melanonychia, or nail hyperpigmentation, is a well-described reversible adverse effect of cyclophosphamide. Limited joint mobility in a patient with diabetes mellitus indicates increased risk for microvascular disease, especially retinopathy.
An IgG1 autoantibody (NMO-IgG) that binds aquaporin 4 (AQP4) has been proposed as the primary autoimmune phenomenon in neuromyelitis optica.
Up to one-third of lupus patients have one or more additional autoimmune diseases such as Sjogren's or Hashimoto's thyroiditis. In patients with scleroderma and abnormal esophageal manometry, almost all will also have abnormal anorectal motility. Patients who undergo knee arthroplasty are at an increased risk of clinically important weight gain following surgery.
Excessive overgrowth of craniofacial bones in craniometaphyseal dysplasia may result from a loss of function in ANKH gene product.
The presence of HLA-B5 is associated with BehA§et's disease, ulcerative colitis, and polycystic kidney disease.
BLyS is a cytokine expressed on B cells and has been shown to play an important role in B cell proliferation and differentiation. Plaquenil can theoretically reduce the analgesic effect of both codeine and tramadol due to cytochrome P450 2D6 inhibition. Leflunomide is known to cause significant increases in systolic and diastolic blood pressures within 2a€“4 weeks of initiation.


A prolonged aPTT suggests the possibility of an lupus anticoagulant (LA), but only about half of all patients with LA have an abnormal aPTT. Hydroxyurea is the most commonly reported medication to induce drug-induced dermatomyositis (50-70% of case reports).
The development of mononeuritis multiplex in the absence of diabetes or compression injuries strongly suggests the presence of vasculitis. Posterior interosseous neuropathy is a cause of lateral elbow pain and hand weakness and can be a complication of rheumatoid arthritis.
Hand deformity in SLE (Jaccouda€™s arthropathy) results from ligamentous laxity rather than the destructive synovial pannus of RA.
A deficiency of either C1r or C1s is associated with SLE; these deficiencies generally have prominent renal and cutaneous manifestations. The incidence of chondrocalcinosis increases with age, and over 30% of persons over 75 have chondrocalcinosis on the knees. PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis & adenitis) is seen in children.
PMR occurs in about 50% of patients with GCA, while approximately 15 to 30% of patients with PMR eventually develop GCA. Dupuytren's contracture is progressive fibrosis of the palmar fascia resulting in contractures of one or more fingers at the MCP joints. A major side effect of IVIg is aseptic meningitis, especially in patients with a history of migraines.
The anti-synthetase syndrome is marked by myositis, Raynauda€™s, ILD, & mechanica€™s hands. IgG4-related disease is a fibroinflammatory condition characterized by formation IgG4+ plasma cells, fibrosis, a swift response to steroids. Wegener's granulomatosus is believed to be two or three times more common than MPA in western countries. Asians are more prone to Allopurinol hypersensitivity syndrome (aka DRESS) so consider starting at a lower initial dose.
Cellcept (MMF) inhibits inosine monophosphate dehydrogenase, which is a critical enzyme for the for the de-novo synthesis of guanosine. Rheumatoid arthritis can be seen in patients with T-cell large granular lymphocyte leukemia (T-LGL). Adult Henoch SchA¶nlein Purpura (HSP) patients generally have less abdominal pain and fever, and more joint symptoms and renal involvement. Chilblain lupus is a cold-induced microvascular injury, initially resembling chilblains but eventually assumes the form of discoid lupus.
Movement disorders seen in CNS lupus (tremors, chorea, and extrapyramidal syndromes) may improve with management of the underlying disease.
Young children with oligoarticular onset, ANA positive, JIA should be screened every three to four months for uveitis.
If a patient with PMR consistently requires > 20 mg of prednisone a day to control the disease symptoms, the diagnosis is probably wrong. Familial CPPD is associated with a gain of function of the ANKH gene product, leading to increased extracellular pyrophosphate. Mi-2 antibodies are seen in patients with a€?classica€? dermatomyositis, including Gottrona€™s papules, heliotrope rash, & a€?Va€? and a€?shawla€? sign. The vasculitis most commonly associated with hairy cell leukemia is polyarteritis nodosa (PAN).
Rheumatoid vasculitis in more common in patients who have had severe, destructive RA but whose joints are no longer active (burnt out). Synovial fluid crystals with a a€?Maltese crossa€? appearance on light microscopy indicate lipid drops & are suggestive of subchondral fracture.
Life expectancy is shorter in patients with RA, & survival rates are comparable to Hodgkin's, diabetes, & 3-vessel coronary artery disease.
Barefoot walking has been demonstrated to reduce the major force across the knee in patients with medial compartment knee OA. One of the most common sites for erosions in patients with rheumatoid arthritis is the lateral aspect of the head of the 5th MTP. In ankylosing spondylitis, inflammation has a predilection for fibrocartilaginous sites rich in aggrecans and type II collagen.
The ANCA-associated vasculitidies (Wegener's, Churg Strauss, & MPA) are all associated with a pauci-immune glomerular nephritis. Patients with HCV can have systemic vasculitis manifestations of polyarteritis nodosa type or mixed cryoglobulinemia type. Adhesive capsulitis (shoulder) is characterized by restricted range of motion (active AND passive) and nocturnal pain. Respiratory involvement (glottis or tracheobronchial tree) is a frequent finding in relapsing polychondritis and is the main cause of death. NOMID (neonatal onset multisystem inflammatory disease) can result from a mutation in the CIAS1 gene, which helps control inflammation.
The allopurinol hypersensitivity syndrome consists of rash, fever, hepatitis, eosinophilia, and renal failure. New unexplained pain located above the neck in a patient over 60 years old should suggest the possibility of giant cell arteritis. Osteopetrosis is caused by an osteoclast proton pump deficiency resulting in a failure of bone resorption while its formation persists.
Periodontal disease is associated with rheumatoid arthritis but its severity is not correlated with RA disease activity. The pericarditis of SLE is often painful whereas pericarditis in scleroderma and rheumatoid arthritis is generally painless. Cochicine-induced axonal neuromyopathy most commonly occurs when renal dysfunction is present, but it is reversible not permanent.
About 7% of patients with polyarteritis nodosa (PAN) have hepatitis B virus (HBV), but fewer than 1% of patients with HBV develop PAN. Epiphysitis, presenting as a step-like erosion of the anterosuperior angle of the vertebra, is one of the earlier findings in spondylitis. PML should be considered in lupus patients with progressive neurologic deficits especially if immunosuppression is ineffective. I patients with lupus, the presence of an anticardiolipin antibody can cause a false positive test for syphilis (RPR). Leflunomide (pregnancy category X) is detectable in plasma up to 3 years after discontinuation. Hypertrophic lupus erythematosus is a form of discoid lupus characterized by verrucous hyperkeratotic lesions. IV drug users are susceptible to septic arthritis with unusual organisms (gram negatives) and in atypical axial sites (sternoclavicular).
The most common types of soft tissue rheumatism are subacromial bursitis, epicondylitis, trochanteric bursitis, and fibromyalgia. The risk of lupus panniculitis is associated with discoid lupus, leg ulcers, serositis, and myositis, but not proteinuria. Serum IgA antiendomysial and anti-tissue transglutaminase antibodies are highly specific and sensitive for celiac disease.
Lupus nephritis occurs twice as frequently in African Americans with SLE than compared to Caucasians with SLE.
Feltya€™s syndrome is characterized by rheumatoid arthritis, splenomegaly and leukopenia with associated recurrent infections. Congenital heart block, due to anti-Ro and anti-La, is most often identified between 18 and 30 weeks gestation. Leflunomide (rheumatoid arthritis DMARD) works by inhibiting dihydroorotate dehydrogenase (enzyme involved in de novo pyrimidine synthesis). Superior migration of the humeral head detected by plain radiography indicates a significant rotator cuff tear.
Weber-Christian disease (relapsing febrile nodular panniculitis) is an inflammatory infiltration of subcutaneous adipose tissue.
Four forms of vasculitis which commonly cause bruits: Takayasua€™s arteritis, giant cell arteritis, Behceta€™s disease, and Cogana€™s syndrome.
Complex regional pain syndrome (CRPS) Type I, (formerly reflex sympathetic dystrophy (RSD)), does not have demonstrable nerve lesions.
Discoid lesions in children and adolescents are likely secondary to SLE, not to isolated discoid lupus. In most cases of primary angiitis of the CNS, abnormal CSF will be seen, including increased WBCs or an elevated total protein or both. Despite modern therapies, a lupus patient diagnosed at the age of 20 has a 1 in 6 chance of dying by the age of 35. All patients with rheumatoid arthritis needing pre-op clearance should have c-spine films because of the risk of atlantoaxial subluxation.


Patients with a€?rhupusa€? have an overlap syndrome with clinical and serologic signs of both SLE and RA, including radiographic erosions.
When evaluating a patient for SjA¶gren's, ask about dental health as poor dentition is associated with inadequate salivary production.
Hypercalcemia occurs in 10% of patients with sarcoidosis and is caused by endogenous production of 1,25 OH Vit D in the sarcoid granuloma.
Sternoclavicualr joint has little inherent stability but is supported by strong joint capsule ligaments. If the shoulder is compressed and rolled backward, an ipsilateral anterior dislocation results.
A player falls on the ground, landing on the lateral shoulder and several players pile on top of his opposite shoulder, which applies significant compressive force on the clavicle down toward the sternum.
There is mild to moderate amount of pain, particularly with movement of the upper extremity.
In addition to routine xray views,  special views have been developed to confirm the injury. The subluxed joint can be reduced by drawing the shoulders backward as done in reduction of fracture of clavicle. Non operative treatment can be successful but often when it fails, these dislocations are treated with operative procedures to repair or reconstruct the joint.
They should be carefully evaluated for severity before deciding in favor of nonoperative treatment. The damage to the structures posterior to the joint, like the trachea, esophagus, the brachial plexus, great vessels, the lungs must be carefully noticed.
CT scan of both medial clavicles allows the physician to compare the injured side with the normal side.
Intravenous narcotics and muscle relaxants may be considered for patient who have high threshold of pain. The sternoclavicular joint is an unusual site of septic arthritis in healthy persons, but may be commonly involved in intravenous drug users, primary or secondary immunosuppressive disorders, infections or the presence of infected central lines.
Presenting symptoms of SSA can vary, with chest and shoulder pain being the most common clinical features. His past medical history includes hypercholestrolaemia, osteoarthritis and hypertension only. The patient was also started empirically on intravenous co-amoxiclav as treatment for neck space collection. Response to antibiotic therapy was limited in the first few days of admission with little change in haematological inflammatory markers. Spreading infectious sequeale of SSA have been well documented and include empyema, osteomyelitis and mediastinitis [3]. It tends to occur in women with an average age of 40 and a history of stress in the region of the sternoclavicular joint (heavy lifting, sports, chronic repetitive trauma). Anterior dislocations of the sternoclavicular joint are much more common than are posterior ones.
Reduce the joint with direct gentle pressure over the anteriorly displaced clavicle while an assistant pushes both the shoulders back to table. After thorough literature search, no cases have yet been reported on SSA leading to vocal cord palsy. Other presenting complaints include neck pain and swelling over the sternoclavicular joint area.
CT imaging, performed 24 h after admission, revealed no evidence of malignancy or indeed any paraphayrngeal space collection.
Findings: left vocal cord palsy indicated by the para-median position of the left vocal cord in comparison with the right.
After discussion with the microbiologist, the flucloxacillin was increased to 2 g four times a day on the fourth day of admission. Significant contributing factors to these outcomes are the methicillin-resistant Staphylococcus aureus (MRSA) strains, which are becoming increasingly prevalent [4].
Plain films and CT usually reveal sclerosis confined to the medial, inferior aspect of the clavicle with osteophytes. Ligaments of the joint include the interclavicular, anterior and posterior sternoclavicular, and costoclavicular ligaments. The ratio of anterior dislocations to posterior dislocations of the sternoclavicular joint of approximately 20 to 1. Anterior or posterior subluxation may be obvious to when the injured joint is compared with the normal sternoclavicular joint. After reduction, the shoulders should be held back for 4 to 6 weeks with a figure-of-eight dressing.
It is best to protect the sternoclavicular joint with a figure-of-eight bandage for 2 to 6 weeks. The following case describes a male patient who presented to hospital with left vocal cord palsy and symptoms consistent with aero-digestive tract malignancy. Routine examination of the patient in the emergency department revealed that he was haemodynamically stable and apyrexial and exhibited tenderness in the left anterior neck. Few small lymph nodes were noted on the left side of the neck, but were deemed to be reactive in nature, and left vocal cord palsy was evident (Fig. 1). The patient made slow but positive improvements over the course of the next 8 days while on intravenous antibiotics, after which he was successfully discharged. A literature review of 180 cases shows mediastinitis as a clinical feature in up to 13% of patients with SSA [5]. The manubrium and joint space are typically normal.Differential diagnosis includes AVN of the medial clavicle epiphysis-Friedrich's disease, a rare entity seen in children and teens felt to be postraumatic or embolic. Radiological examination and subsequent response to treatment demonstrated the only causative pathology to be an ipsilateral septic sternoclavicular joint. Examination by the otolaryngology team demonstrated no evidence of cervical lymphadenopathy but tenderness of the lower left anterior triangle, as well as evident swelling, erythema and mild bruising of the anterior chest wall. The key finding was that of a left sternoclavicular joint collection and closely associated superficial anterior chest wall, soft tissue swelling and oedema (Fig. 2). He continued on oral antibiotics and on outpatient review 3 weeks after his admission, his external swelling, erythema and voice had returned to normal.
It is clear from the haematological and radiological findings, as well as the response to treatment, that all the presenting features of this patient were as a result of the septic focus in the sternoclavicular joint.
Sternoclavicular hyperostosis occurs in older patients, often men, and may be accompanied by pustular lesions of the palms and soles. On questioning the patient regarding this, he revealed that he burnt his chest using a hot water bottle ?3 weeks previously and he also admitted to having stiffness and pain in the left shoulder over this same period. This inflammatory process was also noted deep to the manubrium and sternum and extending somewhat into the mediastinum with evident enlarged mediastinal lymph nodes (Fig. 3). Findings: left sternoclavicular joint collection and closely associated superficial anterior chest wall, soft tissue swelling and oedema. Repeat CT performed 3 months following discharge demonstrated complete resolution of the deep and superficial inflammatory process as well as the mediastinal lymph nodes.
Reports of fibrosing mediastinitis and descending necrotizing mediastinitis leading to vocal cord palsy have been documented [6].
Septic arthritis and osteoarthritis should affect both sides of the joint with typical OA changes. The CT findings were in keeping with SSA with associated superficial and deep tissue inflammation and oedema.
The mild reactive mediastinal inflammation seen in the presented case has not been presented in the literature as a cause of vocal cord palsy. With no other cause found, the vocal cord palsy was attributed to the inflammation within the mediastinum, which in turn was caused by superficial burn from hot water bottle use. Therefore, as mentioned previously, it is most likely explained by mediastinal lymphadenopathy, which is a known cause of left vocal cord palsy in malignancy and atypical infections such as tuberculosis [7].
Findings: soft tissue oedema of the chest seen retrosternally (marker A) and superficially on the left anterior chest (marker B) as well as evidence of mediastinal lymph node enlargement. Hoarseness of the voice due to left recurrent laryngeal nerve palsy in tuberculous mediastinitis. Musculoskeletal infections in intravenous drug addicts: report of 34 cases with analysis of microbiological aspects and pathogenic mechanisms.



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