Sclerosis of the clavicle––A challenging diagnosis

Condensing osteitis of the clavicle is a rare benign disease described as an increase in bone density at the medial end of the clavicle. Its clinical and radiographic presentation can frequently be equivocal and tissue sampling is necessary for diagnostic confirmation. Here we present the case of a 29-year-old female with condensing osteitis of the right medical clavicle, who remained undiagnosed for many years despite obtaining imaging studies and undergoing an initial biopsy. This disease presents oftentimes a challenging diagnosis due to its imaging features overlapping with many benign and malignant bone lesions. A qualified multidisciplinary team with expertise in rare bone conditions becomes oftentimes essential to arrive at an accurate diagnosis.     

Radionuclide and radiographic demonstration of condensing osteitis of the clavicle

Radionuclide and radiographic images of a case of condensing osteitis of the clavicle are presented. The clinical and radiographic features are discussed along with a differential diagnosis of sclerotic lesions of the clavicle.     

Painful sclerosis of the medial end of the clavicle

Pain and swelling of the medial end of the clavicle may be associated with radiographic sclerosis. The commonest causes are osteoarthritis, infection and condensing osteitis of the clavicle. Distinguishing between these clinically and radiologically can be difficult but computed tomography (CT) and magnetic resonance imaging (MRI) are often useful for their differentiation. In this review, the typical imaging features of these conditions are presented with an emphasis on the CT and MRI appearances. These are correlated with clinical features, which together should enable a confident diagnosis to be made.     

Condensing osteitis of the clavicle

Two cases of condensing osteitis of the clavicle are reported in which plain films, computed tomography, scanning, and histologic findings established the diagnosis of this rare entity.     

Case report 623

A case of OCC in a 35-year-old woman is presented. Proof was obtained by open biopsy. This rare entity is benign and its etiology is still obscure. No definite association with osteitis pubis or osteitis condensans ilii has been reported. The involvement of the clavicle is invariably unilateral. The clinical and radiographic characteristics of this benign condition have been discussed and the differential diagnosis has been considered. Consideration should be given to the concept that if the imaging features are characteristic, as in this case, biopsy may not be necessary.     

Condensing osteitis of the clavicle: case report and review of the literature

Osteitis condensans of the clavicle is a benign, often painful disorder of unknown etiology manifested by bony sclerosis of the clavicular head with an uninvolved sternoclavicular joint. The case presented demonstrates the characteristic scintigraphic findings of osteitis condensans of the clavicle. A review of the published pathologically proven cases reveals this disorder to have distinctive clinical and radiological features that allow differentiation from infection, neoplasia, and arthritides in most instances. The frequent observation, as in this case, of devitalized bone and marrow fibrosis with remodeling of cancellous bone suggests that osteonecrosis may play an important role in the pathogenesis of this disorder.     

The painful swollen sterno-clavicular joint

Thirteen patients with isolated pain and swelling of a sterno-clavicular clavicular joint have been reviewed. Three groups were identified. Group 1 comprised four patients, all of whom had a short history of less than six weeks and suffered a pyarthrosis or malignant disease; group 2, four patients who were shown to have features of condensing osteitis of the clavicle (Cone et al, 1983); and group 3, five patients, had degenerative arthritis of a sterno-clavicular joint. The only difference between groups 2 and 3 were that patients in group 3 had a rather longer history, both articular surfaces were involved and showed a possible increase in the incidence of degenerative joint disease elsewhere. It is suggested that condensing osteitis is but a part of a spectrum of degenerative disease of the sterno-clavicular joints, akin to discogenic vertebral body sclerosis (McCarthy & Dorfman, 1982).     

Degenerative sternoclavicular arthritis and hyperostosis

Symptomatic arthritic involvement of the sternoclavicular joint is relatively uncommon and can be a result of distant trauma, infection, and sternocostoclavicular hyperostosis, post-menopausal arthritis, condensing osteitis of the proximal clavicle, or secondary to an underlying arthropathy. Patients with degenerative osteoarthritis due to trauma most commonly have had either an anterior or posterior dislocation, subluxation, or periarticular fracture. Medical claviculectomy with or without ligamentous stabilization is indicated only in situations of painful primary and secondary rheumatoid arthritis, or in patients with neoplastic lesions. Numerous authors have recommended surgical reconstruction but few have reported series larger than two or three cases. This article reviews a few specific arthropathy conditions about the sternoclavicular joint and discusses their nonoperative and operative management.     

Primary tumors and tumor-like lesions of the clavicle

Fifty eight patients seen at Memorial Sloan-Kettering Cancer Center over a 50-year period were reviewed for lesions of the clavicle. A variety of malignant neoplasms, benign neoplasms, and tumor-like lesions were seen. There were 30 malignant neoplasms, the commonest of which were plasmacytomas, osteosarcomas, and Ewing sarcomas. There were five postradiation sarcomas. An unusual granulocytic sarcoma with dense sclerosis was described. Among the benign lesions were two osteochrondromas, two hemangiomas, and a giant cell tùmor secondary to Paget disease. The tumor-like lesions included six aneurysmal bone cysts and five eosinophilic granulomas. There were two patients with chronic sclerosing osteomyelitis and one each with sternocostoclavicular hyperostosis (Sonozaki syndrome) and condensing osteitis. An unusually large lesion of pseudogout and a large brown tumor were also included in the series.     

获得性骨肥大综合征的影像表现

目的 分析获得性骨肥大(SAPHO)综合征的影像表现.方法 回顾性分析11例SAPHO综合征的影像资料,男6例、女5例,年龄28～68岁,平均51岁,X线平片检查9例、CT检查10例、MR检查3例、核索扫描检查3例.结果 9例胸前壁X线平片表现为胸骨上部、第一前肋及锁骨增生、硬化并肥大,相互之间骨桥形成或骨性融合;10例胸前壁CT检查,9例表现为胸、肋、锁骨区骨质增生硬化伴有骨质破坏,胸锁关节和胸肋之间骨性融合,1例仅表现为胸骨柄体关节骨质硬化,2例在轴面像上胸骨柄上缘似"海鸥翅"样改变.11例患者中除1例胸骨病变仪累及胸骨柄体关节外,其余10例胸前壁均多骨受累,其中8例呈对称性,2例为偏侧性(均为右侧).除胸前壁骨病变外,伴有骶髂关节炎、髂骨骨髓炎1例,胸椎骨髓炎2例,腰椎致密骨炎1例和双手掌指关节骨关节炎1例.MR检查3例,分别是胸锁关节、胸椎和骶髂关节,MRI显示锁骨头周围软组织肥厚,胸椎病变表现为椎体内T1WI呈低信号,T2WI呈混杂信号,抑脂像以高信号为主,骶髂关节见软骨下长T1WI短T2WI信号.核素扫描3例,显示胸骨上部及锁骨区呈"T"形异常高浓聚.结论 胸前壁多骨受累是SAPHO综合征主要影像特点,可并发骶髂关节炎、脊椎及髂骨骨髓炎、腰椎致密骨炎和双手骨关节炎.     

获得性骨肥大综合征的影像表现

目的 分析获得性骨肥大(SAPHO)综合征的影像表现.方法 回顾性分析11例SAPHO综合征的影像资料,男6例、女5例,年龄28～68岁,平均51岁,X线平片检查9例、CT检查10例、MR检查3例、核索扫描检查3例.结果 9例胸前壁X线平片表现为胸骨上部、第一前肋及锁骨增生、硬化并肥大,相互之间骨桥形成或骨性融合;10例胸前壁CT检查,9例表现为胸、肋、锁骨区骨质增生硬化伴有骨质破坏,胸锁关节和胸肋之间骨性融合,1例仅表现为胸骨柄体关节骨质硬化,2例在轴面像上胸骨柄上缘似"海鸥翅"样改变.11例患者中除1例胸骨病变仪累及胸骨柄体关节外,其余10例胸前壁均多骨受累,其中8例呈对称性,2例为偏侧性(均为右侧).除胸前壁骨病变外,伴有骶髂关节炎、髂骨骨髓炎1例,胸椎骨髓炎2例,腰椎致密骨炎1例和双手掌指关节骨关节炎1例.MR检查3例,分别是胸锁关节、胸椎和骶髂关节,MRI显示锁骨头周围软组织肥厚,胸椎病变表现为椎体内T1WI呈低信号,T2WI呈混杂信号,抑脂像以高信号为主,骶髂关节见软骨下长T1WI短T2WI信号.核素扫描3例,显示胸骨上部及锁骨区呈"T"形异常高浓聚.结论 胸前壁多骨受累是SAPHO综合征主要影像特点,可并发骶髂关节炎、脊椎及髂骨骨髓炎、腰椎致密骨炎和双手骨关节炎.     

获得性骨肥大综合征的影像表现

目的 分析获得性骨肥大(SAPHO)综合征的影像表现.方法 回顾性分析11例SAPHO综合征的影像资料,男6例、女5例,年龄28～68岁,平均51岁,X线平片检查9例、CT检查10例、MR检查3例、核索扫描检查3例.结果 9例胸前壁X线平片表现为胸骨上部、第一前肋及锁骨增生、硬化并肥大,相互之间骨桥形成或骨性融合;10例胸前壁CT检查,9例表现为胸、肋、锁骨区骨质增生硬化伴有骨质破坏,胸锁关节和胸肋之间骨性融合,1例仅表现为胸骨柄体关节骨质硬化,2例在轴面像上胸骨柄上缘似"海鸥翅"样改变.11例患者中除1例胸骨病变仪累及胸骨柄体关节外,其余10例胸前壁均多骨受累,其中8例呈对称性,2例为偏侧性(均为右侧).除胸前壁骨病变外,伴有骶髂关节炎、髂骨骨髓炎1例,胸椎骨髓炎2例,腰椎致密骨炎1例和双手掌指关节骨关节炎1例.MR检查3例,分别是胸锁关节、胸椎和骶髂关节,MRI显示锁骨头周围软组织肥厚,胸椎病变表现为椎体内T1WI呈低信号,T2WI呈混杂信号,抑脂像以高信号为主,骶髂关节见软骨下长T1WI短T2WI信号.核素扫描3例,显示胸骨上部及锁骨区呈"T"形异常高浓聚.结论 胸前壁多骨受累是SAPHO综合征主要影像特点,可并发骶髂关节炎、脊椎及髂骨骨髓炎、腰椎致密骨炎和双手骨关节炎.

Abstract：

Objective To explore the imaging characteristics of SAPHO syndrome in 11 cases.Methods Clinical features and imaging findings from 11 patients (6 male,5 female, 28 to 68 years old)with SAPHO syndrome were analyzed retrospectively Including DR in 9 cases, CT in 10 cases, MRI and radioisotope scanning in 3 cases. Results Multi-bones of anterior chest wall disorders were shown in 9cases on DR images including superior sternum , anterior first rib and clavicle hyperostosis. Bony fusion and bony bridge were also seen in these cases. Hyperostosis osteosclerosis, bone destruction and bony fusion of sternoclavicular articulation and first rib were shown on CT images in 9 cases. Osteosclerosis of the joint between manubrium and midsternum was seen in 1 case on CT image. Thc sign of flying sea gull was seen in 2 cases on axial anterior chest wall CT images. The disorders of anterior chest wall were bilateral in 8 cases and unilateral in 2 cases. Sacroiliitis and osteomyelitis of ilium were found accompanied in 1 case.Osteomyelitis of thoracic vertebrae were found in 2 cases, while sclerosing osteitis of lumbar vertebrae and ostearthritis of bilateral hands were observed respectively in 1 case. The thicken soft tissue surround clavicle head, thoracic vertebra disease with long T1 ,jumbly T2 and high fat suppression signal ,long T1 and short T2signal under sacroiliac joint were shown on MRI. Radioisotope scanning displayed higher radioactive uptake of radionuclides, with T shape in sternoclavicular area in 3 cases. Conclusions Multi-bones of anterior chest wall involvement was the common imaging characteristics in 11 patients. Sacroiliitis, osteomyelitis of vertebrae and ilium, sclerosing osteitis, ostearthritis of hand could be seen in some cases.     

Athletic osteitis pubis

Athletic osteitis pubis is a painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis. The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction. The differential diagnosis for osteitis pubis is extensive and includes many other syndromes resulting in groin pain. Imaging, particularly in the form of MRI, may be helpful in making the diagnosis. Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. Prolotherapy injections of dextrose, anti-inflammatory corticosteroids and a variety of surgical procedures have been reported in the literature with varying efficacies. Future studies of athletic osteitis pubis should attempt to define specific and reliable criteria to make the diagnosis of athletic osteitis pubis, empirically define standards of care and reduce the variability of proposed treatment regimens.     

Arthroscopic distal clavicle resection

The acromioclavicular joint is a potential source of pain in the shoulder. There are a variety of disorders that can affect this joint, including distal clavicle osteolysis, posttraumatic arthritis, osteoarthritis, and rheumatoid arthritis. Nonoperative treatment for this condition with nonsteroidal medication and activity modification can alleviate the pain. When conservative treatment is exhausted, surgical resection of the distal clavicle is often necessary. Arthroscopic resection of the distal clavicle preserves the acromioclavicular ligaments to prevent postoperative distal clavicle instability. The procedure is performed in either the beach chair or lateral position and requires the use of a shaver, electrocautery, and a burr for soft tissue and debridement and bone resection.     

The unilateral wavy clavicle

14 patients are recorded in whom one clavicle has a wavy shape not related to trauma or to a known congenital anomaly. Since the affected clavicle is more often the right, it is suggested that this alteration may be related to the effect of subclavian artery pulsations, such as cause congenital pseudarthrosis of the clavicle.     

锁骨骨折内固定术三种麻醉方法的临床经济学评价

目的 采用成本效果分析方法对锁骨骨折内固定手术患者三种麻醉方法作出临床经济学评价。方法随机将144例患者分为3组,Ⅰ组臂丛加颈浅丛神经联合阻滞,Ⅱ组臂丛神经阻滞,Ⅲ组颈浅丛神经阻滞。分别计算出三种麻醉方法的成本和效果,作出成本效果比较。结果单病例成本而言,单纯颈浅丛神经阻滞成本最低,锁骨骨折位于锁骨外2／3时单纯臂丛神经阻滞平均成本最低,锁骨骨折位于锁骨内1／3时单纯颈浅丛神经阻滞平均最低。结论从临床经济学角度来看,锁骨骨折位于锁骨外2／3时首选单纯臂丛神经阻滞,锁骨骨折位于锁骨内1／3时首选单纯颈浅丛神经阻滞。     

Management of clavicle fractures

Fractures of the clavicle are relatively common injuries that can occur in patients of all ages. The history and physical examination remain the primary means of diagnosing this injury. Plain radiographs are helpful to confirm the diagnosis and to provide information regarding fracture classification, prognosis, and treatment options. The emphasis of this article is on the management of these injuries. Historically, only unstable distal clavicle fractures were treated operatively. However, recent well-conducted studies demonstrate that plate fixation of displaced midshaft clavicle fractures may result in improved functional outcome and a lower rate of malunion and non-union, compared with non-operative treatment. For clavicle fractures managed non-operatively, the sling-and-swathe or figure-of-eight splints remain appropriate options. Multiple factors should be considered when counseling an athlete on the appropriate time to return to sports participation after a clavicle fracture.     

Synovitis,Acne, Pustulosis,Hyperostosis and Osteitis (SAPHO) and chronic recurrent multifocal osteomyelitis (CRMO): Role of imaging in diagnosis

There is a spectrum of musculoskeletal disorders which can be associated with dermatologic findings, the fundamental component of which is a nonbacterial osteitis. CRMO (Chronic recurrent multifocal osteomyelitis) and SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis) describe paediatric and adult conditions, respectively, of inflammatory osteitis that can be associated with palmoplantar pustulosis and acne. Imaging findings are similar and a key component to the diagnosis in both conditions. This report describes two patients with strikingly similar radiologic presentations of clavicular osteitis in whom the diagnosis was made predominantly on the basis of imaging findings. The typical imaging features and radiographic hallmarks of both conditions will also be discussed.     

Unique distal clavicular fracture in an active-duty military population

We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.