Tophaceous gout in the sternoclavicular joint
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A 52-year-old fitness instructor, who was previously fit and well, presented with a painful bony mass in her sternal notch, which had increased in size over 3 years. She reported issues with swallowing and change in voice that worsened with forward flexion of the head.

Both magnetic resonance imaging (MRI) and computed tomography (CT) scanning demonstrated a lobulated calcified and necrotic mass of 3.9 cm by 4.3 cm on the left SCJ causing a mass effect on adjacent structures, Anteriorly the mass was bordered by the sternocleidomastoid muscle and dorsally by the sternohyoid muscle. There was compression of the left hemi-thyroid causing displacement of the trachea. There was no direct contact with the aorta or brachiocephalic vein. Differentials included synovial osteochondromatotis and malignancy. Biopsies of the lesion were non-diagnostic and therefore excision biopsy was carried out for diagnosis as well as symptomatic improvement.

Using a trans-cervical incision, the tumour was superficially shelled-out sparing the sternocleidomastoid on the right and partially preserving the left sternocleidomastoid insertion on the left. With a combination of sharp and blunt dissection, the tumour was dissected away from deep tissues and shaved off the manubrium and excised. The left clavicle head was then removed separately. The bony tumour with a casseous quality appeared to arise from the left clavicular head and did not involve the deeper vascular structures. The excised tumour was sent to histopathology.

Expert review was sought from the Orthopaedic Hospital, and the specimen was confirmed to be a benign cystic lesion with amorphous deposition. Under polarized light, the amorphous material contained needle-shaped refractile crystals suggestive of uric acid. Therefore, a diagnosis of tophaceous gout was made.