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nontraumatic disorders occur in both children and adults; these include anterior subluxation of the sternoclavicular joint, Friedrich’s disease, hypertrophic osteitis, chronic multifocal

nontraumatic disorders occur in both children and adults; these include anterior subluxation of the sternoclavicular joint, Friedrich’s disease, hypertrophic osteitis, chronic multifocal periosteitis and arthropathy, and osteomyelitis Some nontraumatic clavicular disorders are found only in adults, such as distal

osteolysis Because the description and nomenclature of these disorders arise from several medical disciplines, they often are confusing Until clear, distinguishing features are described, it is advisable to combine some of the entities This is especially true of the nonsuppurative inflammatory disorders of the clavicle, which appear to fall under the heading of spondyloarthropathy Treatment varies by disorder and may include symptomatic and expectant management, drug therapy, and nonsurgical or surgical treatment

Nontraumatic disorders of the clavicle are uncommon, and frequently the diagnosis is not obvi-ous Some conditions occur only in infancy or early childhood, some only in adulthood; some occur in both childhood and adulthood, but with varied manifestations The no-menclature is confusing because several titles have been used to de-scribe the same disorder For many nontraumatic clavicular conditions, the cause is uncertain, the

patholo-gy is not specific, and the natural history is not completely known

Disorders of Infancy and Childhood

Birth Fracture of the Clavicle

The most common abnormality

of the clavicle in infancy is fracture

associated with delivery It occurs in between 0.5% and 0.9% of vaginal births and has equivalent sex and side distribution Risk factors in-clude large fetal size and shoulder dystocia.1 Nine percent of infants with a clavicle fracture also will have a brachial plexus palsy Birth fracture of the clavicle is suspected

by the presence of known risk fac-tors, lack of use of the upper extrem-ity, or deformity or tenderness of the clavicle The condition is confirmed

by radiographs, which demonstrate a fracture in the middle third (Figure 1)

An apparent fracture of the clavi-cle at birth does not always indicate birth trauma; syndromes involving chromosomes 11, 18, and 22 have been reported with congenital de-fects of the clavicle Congenital pseudarthrosis of the clavicle also

Dr Beals is Professor, Department of

Orthopaedics and Rehabilitation,

Oregon Health Sciences University,

Portland, OR Dr Sauser is Professor,

Department of Diagnostic Radiology,

Oregon Health Sciences University.

None of the following authors or the

departments with which they are

affiliated has received anything of value

from or owns stock in a commercial

company or institution related directly or

indirectly to the subject of this article:

Dr Beals and Dr Sauser.

Reprint requests: Dr Beals, Department

of Orthopaedics and Rehabilitation,

Oregon Health Sciences University,

3181 SW Sam Jackson Park Road, OP

31, Portland, OR 97239.

J Am Acad Orthop Surg

2006;14:205-214

Copyright 2006 by the American

Academy of Orthopaedic Surgeons.

may be present at birth Clavicle

fractures at birth are treated by

splinting the arm to the thorax, a

protection that may be discontinued

in 10 to 14 days, when abundant

cal-lus typically has developed Birth

fracture of the clavicle has no

per-manent sequelae

Infantile Cortical

Hyperostosis

Present at birth or occurring in the

first 6 months of life, infantile

corti-cal hyperostosis (Caffey’s disease) is

rare and characterized by painful

periosteal elevation involving one or

more bones The clavicle and

mandi-ble are the most commonly affected,

but the ulna, tibia, femur, scapula,

humerus, ribs, and other bones may

be involved.2The cause of infant

cor-tical hyperostosis is unknown but is

reported to be familial and inherited

It often is associated with fever,

ane-mia, elevated white blood cell (WBC)

count, elevated alkaline phosphatase

level, and elevated erythrocyte

sedi-mentation rate (ESR) Radiographs of

the involved bone demonstrate

peri-osteal new bone formation (Figure 2)

Patients suspected of having infantile

cortical hyperostosis should undergo

a skeletal survey that includes the

skull and extremities

The differential diagnosis

in-cludes conditions that cause

peri-osteal elevation, such as infection, trauma, neoplasia, hypervitaminosis

A and D, and syphilis The diagnosis

is made on the basis of clinical and radiographic findings; usually biopsy

is not needed

Treated by symptomatic manage-ment, infantile cortical hyperostosis has a natural history of spontaneous resolution of pain and swelling The radiographic abnormalities disap-pear over 1 to 2 years, rarely leaving residual abnormalities

Congenital Pseudarthrosis

of the Clavicle

Congenital pseudarthrosis of the clavicle is a rare condition, some-times associated with cervical or ab-normal ribs It typically occurs on the right side (95%), sometimes bilater-ally (10%), and more commonly in females.3Although the cause of con-genital pseudarthrosis is not known,

it is not the result of acute trauma

One hypothesis suggests that pseud-arthrosis is a result of pressure on the fetal clavicle from the underlying subclavian artery.3This hypothesis is supported by reports of the condition occurring on the left side in patients with dextrocardia

Although a number of familial oc-currences have been described, there

is no mendelian pattern of

inheri-tance It is present at birth but usu-ally is diagnosed in childhood be-cause of anterior prominence of the mid clavicle or asymmetry of the shoulder girdle with a mobile mid clavicle Congenital pseudarthrosis

of the clavicle is asymptomatic in early childhood but usually becomes symptomatic as the child under-takes the more strenuous activities

of throwing and lifting Radiographs show sclerotic smooth bone margins that are characteristic of pseudar-throsis (Figure 3)

The differential diagnosis in-cludes posttraumatic pseudarthro-sis, cleidocranial dysplasia, and neurofibromatosis Posttraumatic pseudarthrosis of the clavicle is very rare in childhood but has been re-ported Bilateral congenital pseudar-throsis of the clavicle has been

not-ed in association with trisomy 22 Either surgical or nonsurgical treatment is acceptable manage-ment The usual indications for sur-gery are a combination of cosmetic and symptomatic concerns that de-velop in mid childhood The most common surgical treatment in-volves open reduction, removal of prominent bone, iliac bone graft, and fixation by a contoured plate.4 Bra-chial plexus neuropraxia has been re-ported following resection and fixa-tion of the pseudarthrosis.5

Figure 1

Anteroposterior radiograph

demonstrating birth fracture of the

right mid clavicle in a newborn

Figure 2

Anteroposterior radiograph demonstrating periosteal new bone on the right clavicle in a patient with infantile cortical hyperostosis The scapula is also involved

Figure 3

Anteroposterior radiograph of deformity

of the right mid clavicle associated with congenital pseudarthrosis The bone margins adjacent to the pseudarthrosis are smooth and deformed

apparent because of increased

shoul-der mobility and abnormal facies

(Figure 4) The characteristic facies

include a broad and prominent

fore-head, delayed ossification of the

fon-tanelle, depression at the base of the

nose, and supernumerary teeth

Mild short stature, peripheral joint

laxity, mild kyphosis, and scoliosis

are common associated findings

Cleidocranial dysplasia is

transmit-ted by autosomal dominant

inheri-tance; the gene is on chromosome

21

Radiographs of the skull

demon-strate delayed closure of the

fonta-nelles, wormian bones, and a mild

increase in the size of the calvaria

Other radiographic features include

platybasia, hypoplasia of the

sphe-noid, hypoplasia of the maxilla, and

delayed union of the mandibular

symphysis There are

supernumer-ary teeth Spondylolysis and spina

bifida occulta have been noted in the

spine There is delayed ossification

and underdevelopment of the pubic

bones, with widening of the pubic

symphysis The proximal femurs

may exhibit developmental and

pro-gressive coxa vara.6

The differential diagnosis includes

a syndrome of cleidocranial dysplasia

associated with severe mental

retar-dation and absence of the thumbs,

unilateral complete absence of the

clavicle, and a rare autosomal

reces-sive form of cleidocranial dysplasia

Congenital absence of the clavicle is

treated symptomatically

Short Clavicle Syndrome

Short clavicle syndrome is

bilat-eral symmetric shortening of the

clavicle that allows the scapula to rotate forward, causing prominence

of the shoulders anteriorly and spreading and prominence of the scapula posteriorly (Figure 5) It is transmitted by autosomal dominant inheritance but is often sporadic

This condition is asymptomatic in childhood and usually presents as a postural concern.7

Radiographs are not diagnostic

The clavicle tends to be horizontal, and the scapulas appear wide-spaced

on a chest radiograph There is no in-crease in thoracic kyphosis

The differential diagnosis includes scapular winging from nerve palsy and muscle weakness or congenital muscle absence Salter and Kay8 de-scribed one family with a dominant short clavicle with forward fixation

of the scapula associated with a fi-brous band extending from the first rib to the coracoid process

Congenital short clavicle

normal-ly requires no treatment A single

se-vere case has been treated by a lengthening osteotomy.9

Dysplasias and Syndromes That Include Clavicle

Abnormality

Increased sclerosis, widening, or cortical irregularity of the clavicle in childhood, when associated with dysmorphism, abnormal facies, or delayed development, suggest the possibility of a syndrome or skeletal dysplasia Children with unusual ra-diographs of the clavicle should un-dergo a skeletal survey to search for other abnormalities

Disorders of Childhood and Adulthood

Anterior Subluxation of the Sternoclavicular Joint

Spontaneous anterior subluxation

of the sternoclavicular joint during overhead activities without a history

of trauma is an uncommon

condi-A patient with cleidocranial dysplasia

She is able to bring her shoulders together anteriorly because of the absence of segments of her right and left clavicles

A patient with short clavicle syndrome, resulting in forward rotation of the scapula with anterior prominence of the shoulders and posterior prominence of the scapula

tion This condition, sometimes

as-sociated with throwing or

gymnas-tics, typically appears between age 10

and 35 years and occurs equally in

males and females It also has been

described in middle-aged women.10It

is usually unilateral, occurring on the

dominant side, but is bilateral in

ap-proximately 10% of patients Laxity

of the costoclavicular ligaments

must exist for subluxation to occur,

and affected patients typically

dem-onstrate generalized joint laxity

The diagnosis usually is made on

clinical examination Radiographic

asymmetry in the size of the medial

clavicle suggests subluxation of one

clavicle A radiograph with 40º

ceph-alad tube angulation (serendipity

view) visualizes the sternoclavicular

relationship and may be helpful

Computed tomography (CT) will

best demonstrate the relationship of

the clavicle to the manubrium

(Fig-ure 6) The differential diagnosis

in-cludes rheumatoid arthritis,

infec-tion, and other disorders associated

with prominence of the medial

clav-icle and the sternoclavicular joint

Anterior subluxation of the

ster-noclavicular joint is mildly

symp-tomatic and does not preclude active

sports Therefore, treatment is

usu-ally not indicated An average 8-year follow-up of 29 patients treated without surgery revealed excellent results with no limitations in life-style, whereas surgically treated pa-tients had numerous problems.11 Persistent subluxation may lead to osteoarthritis

Distal Osteolysis of the Clavicle

Osteolysis of the distal clavicle, often bilateral and almost always oc-curring in young adult males, is gen-erally caused by overuse Cahill12 re-ported on 46 men with distal osteolysis associated with weight lifting in all but one A study of elite weight lifters revealed that 28%

had distal osteolysis, which is asso-ciated with pain, mild swelling, and tenderness at the acromioclavicular joint.13

Radiographs demonstrate os-teopenia, subchondral lysis, and cysts (Figure 7) There may be mi-crofractures in the subchondral bone, degenerative changes in the ar-ticular cartilage, chronic inflamma-tion, or fibrosis of the joint Radio-nucleotide studies demonstrate increased uptake at the distal clavi-cle

The differential diagnosis in-cludes conditions associated with osteolysis, such as

hyperparathy-roidism, rheumatoid arthritis, scle-roderma, infection, and neoplasia The treatment for painful distal osteolysis is modification of the weight-lifting program When this modification is not successful, the condition may be treated by resec-tion of the distal end of the clavicle, which usually provides pain relief and allows some patients to resume competitive weight lifting.14

Friedrich’s Disease

Occurring more often in young adults, Friedrich’s disease is a rare condition characterized by osteone-crosis of the end of the clavicle.15 The cause is unknown The usual clinical presentation is pain with swelling at the sternoclavicular joint Laboratory findings do not sug-gest infection, although the ESR may be elevated Radiographs dem-onstrate sclerotic irregularity of the medial or, less often, the lateral end

of the clavicle without enlargement

of the bone.16There also may be

flu-id in the adjacent joint (Figure 8) Metachronous involvement of both the medial and lateral clavicle has been described, with osteonecrosis and fibrosis present on microscopic examination

The differential diagnosis in-cludes painful conditions associated

Figure 6

Axial computed tomography scan of a

patient with anterior and superior

subluxation of the left clavicle The ribs

are seen symmetrically, whereas the

left clavicle is more anterior than the

right and is larger because of anterior

and cephalad subluxation

Figure 7

Anteroposterior photograph demonstrating loss of definition and osteolysis of the distal clavicular cortex (arrow)

Figure 8

Anteroposterior radiograph demonstrating increased bone density

in the proximal clavicle without periosteal new bone formations in a patient with Friedrich’s disease

with increased density of the end of

the clavicle, such as hypertrophic

os-teitis and chronic multifocal

peri-osteitis Osteonecrosis is

distin-guished radiographically by the lack

of periosteal elevation and by

in-volvement limited to the ends of the

bone Biopsy for diagnostic purposes

usually is not necessary The

treat-ment is expectant, or nonsurgical,

management, but excision may be

indicated for disabling pain

Hypertrophic Osteitis

(Condensing Osteitis)

The clinical and radiographic

findings and prognostic features of

hypertrophic osteitis and

condens-ing osteitis are similar, suggestcondens-ing

that these are the same condition

Until clear distinguishing features

are described, it is best to consider

them as a single entity

Hypertrophic osteitis is an

isolat-ed, usually unilateral, painful,

scle-rotic lesion with periosteal

enlarge-ment of the medial third of the

clavicle The sternoclavicular joint

is normal The condition is

de-scribed most often in adults, in

fe-males, and on the dominant side, but

it has been reported in childhood It

is not associated with acute trauma

The condition is not an infection or

neoplasm, but it may resemble

ei-ther.17,18 Some think that

hyper-trophic osteitis is an overuse syn-drome

Laboratory abnormalities may in-clude elevation of the ESR and vari-able elevation of the WBC count, and there is an increased uptake of radionuclide in the involved area

Radiographs of hypertrophic osteitis demonstrate enlargement and scle-rosis of the medial third of the clav-icle without involvement of the joint or ossification of adjacent liga-ments (Figure 9, A) Periosteal new bone may be notably prominent CT scans show increased bone density and bone formation (Figure 9, B), whereas magnetic resonance imag-ing (MRI) findimag-ings include loss of the marrow space Biopsy and culture may not be necessary when findings are typical, although biopsy demon-strates chronic inflammation of the bone and periosteum with thick tra-becula

The differential diagnosis in-cludes disorders with periosteal ele-vation and enlargement of bone, such as Paget’s disease, osteoid os-teoma, infectious disorders, chronic multifocal periosteitis, and neopla-sia

Hypertrophic osteitis responds variably to analgesics, anti-inflam-matory drugs, antibiotics, and mod-ification of activity Persistently painful lesions have been treated

successfully by resection of the me-dial clavicle19(Figure 9, C)

Chronic Multifocal Periosteitis and Arthropathy

Sternocostoclavicular hyperosto-sis (SCCH); synovitis, acne, pustules, hyperostosis, and osteitis (SAPHO); and chronic recurrent multifocal os-teomyelitis (CRMO) have been de-scribed as separate clinical entities, but they share many clinical fea-tures These conditions have in com-mon nonsuppurative periosteitis with hyperostosis; multifocal in-volvement of the extremities, spine, and pelvis; and a prolonged clinical course with exacerbation and remis-sion All three conditions may in-volve the clavicle These syndromes differ somewhat by age of presenta-tion and sites of major involvement CRMO is generally diagnosed in childhood and often involves the long bones SAPHO typically pre-sents in adults, has a high incidence

of pustular involvement of the palms and soles, and often involves the spine SCCH involves the anterior chest wall in adults, with less in-volvement of the spine and pelvis Until there are criteria that clearly separate these three conditions on the basis of etiology, clinical course,

or treatment, it is appropriate to

de-A,Anteroposterior radiograph of a patient with hypertrophic osteitis The medial one third of the clavicle is enlarged with

increased density B, Axial computed tomography scan of the clavicle shown in panel A demonstrating increased bone density

of the medial clavicle with periosteal thickening C, Medial third clavicle shown in panel A after removal for intractable pain

demonstrating dense cancellous bone

scribe them under the common term

chronic multifocal periosteitis and

arthropathy A further source of

diag-nostic confusion is that each of these

conditions has features that may

al-low a diagnosis of

spondyloarthrop-athy (ie, periosteitis, enthesopspondyloarthrop-athy,

sacroiliitis, uveitis, psoriasis,

urethri-tis, regional enteriurethri-tis, and

spondyli-tis) These three forms of chronic

multifocal periosteitis and

arthropa-thy—SCCH, SAPHO, SCCH,

CRMO—may be included within the

broad definition of

spondyloarthrop-athy20(Figure 10)

SCCH is a painful, chronic,

non-suppurative periosteitis involving

the sternum, ribs, and clavicle It is

multifocal, bilateral but often

asym-metric, and may sequentially affect

other joints It presents in adults

with pain, heat, tenderness, and

swelling over the medial clavicle and

adjacent ribs It causes hyperostosis

of the bones, synovitis of the

ster-noclavicular joint, and ossification of

ligaments around the clavicle The periosteitis may be sufficiently se-vere as to cause obstruction of the subclavian veins SCCH has been de-scribed more commonly in men (es-pecially Japanese) between ages 30 and 50 years In this setting, 60% of cases are associated with pustules of the palm or soles SCCH is also asso-ciated with ankylosing spondylitis (32%), vertebral hyperostosis (23%), sacroiliitis (22%), and arthritis of the peripheral joints.21,22 Radiographs demonstrate bone, joint, and soft-tissue abnormality (Figure 11, A)

Hyperostotic involvement of the clavicle is common Ossification of the costochondral and costoclavicu-lar ligaments and joint involvement

to include ankylosis of the sterno-clavicular joint may be present and are best demonstrated by CT (Figure

11, B)

SAPHO is a painful, chronic, non-suppurative periosteitis that usually presents in adults Many patients have only some of the descriptive features In a survey of 85 patients with SAPHO, 13 had severe acne, 44 had palmar or plantar pustules, and

28 had hyperostosis without skin change Approximately half of pa-tients with SAPHO have sacroiliitis, and some have inflammatory bowel

disease and/or psoriasis Many have polyostotic involvement; the

anteri-or chest wall is a common site.23,24In one study, 33% of patients with SAPHO were positive for HLA-B27 antigen.25Radiographs demonstrate areas of increased bone density, peri-osteal new bone, and arthritis

Thir-ty percent of these patients have metaphyseal involvement of the long bones, with osteosclerosis, os-teolysis, and periosteal new bone formation Ossification of the ante-rior vertebral ligaments may be present

CRMO is a painful,

inflammato-ry disease of children and young adults that especially affects the long bones but also may involve the spine and clavicle Girschick et al26

report-ed on 11 patients, 6 with CRMO that affected the clavicle Moore et

al27reported on 11 patients, 3 with CRMO that affected the clavicle In another study,28long-term follow-up

of 12 patients with a diagnosis of CRMO revealed that 11 had devel-oped hyperostosis of the vertebra, 7 had sacroiliitis, 4 had peripheral en-thesopathy, and 2 had unilateral ar-thritis of the hip Palmar or plantar pustulosis was present in about one third of patients, and 11 of the 12 pa-tients met the criteria for diagnosis

Figure 10

Spondyloarthropathy

SCCH SAPHO

CRMO

Clavicle

Clavicle involvement in chronic

multifocal periosteitis and arthropathy

The clavicle may be affected in

sternocostoclavicular hyperostosis

(SCCH); synovitis, acne, pustules,

hyperostosis, and osteitis (SAPHO);

and chronic recurrent multifocal

osteomyelitis (CRMO), which have

overlapping features They can

collectively be called chronic multifocal

periosteitis and arthropathy SCCH,

SAPHO, and CRMO each have

features that may allow a diagnosis of

spondyloarthropathy

Figure 11

A,Anteroposterior radiograph of a patient with chronic multifocal periosteitis and arthropathy demonstrating bilateral sclerotic enlarged clavicles and ossification

in soft tissues B, Axial computed tomography scan of the same patient

demonstrating juxta-articular ossification and new bone formation along the clavicle and sternum

ease and chronic inflammation late

in the disease Radiographs

demon-strate periosteitis of various bones,

synovitis of joints, and ossification of

ligamentous structures around joints

Evaluation of patients suspected

of these three diagnoses should

in-clude a search for other components

of spondyloarthropathy This search

should include a bone scan to

iden-tify areas of bone involvement that

are not clinically apparent as well as

the ESR, WBC count, and CRP level

The differential diagnosis includes

other causes of anterior chest wall

pain, including costochondritis and

fibromyalgia.30

There is no effective curative

treatment for these conditions The

clinical course can be protracted,

characterized by exacerbation and

remission; however, the condition

generally improves over time

Corti-costeroids, sulfasalazine,

nonsteroi-dal anti-inflammatory drugs, and

methotrexate have been used with

variable results Long-term

antibiot-ics generally are not effective except

in the presence of pustules

Tonsil-lectomy has been used with some

ported success Finally, surgical

re-moval of the clavicle has been

reported as a treatment of last resort

for intractable pain

Osteomyelitis

Acute osteomyelitis of the

clavi-cle in children and adults is usually

a result of Staphylococcus aureus

in-fection Because the clavicle is an

unusual site for osteomyelitis,

diag-nosis may be delayed This

condi-tion is a rare complicacondi-tion of

subcla-vian vein catherization, presenting

teomyelitis MRI will demonstrate bone destruction with edema in the bone and adjacent soft-tissue in-volvement Of 23 infections of the clavicle in children from South

Afri-ca, 11 were the result of pyogenic in-fection; 4, tuberculosis; and 8, con-genital syphilis.32 Suspected acute osteomyelitis is evaluated by WBC, ESR, and CRP laboratory studies and blood and bone cultures Treatment

is by antibiotics and surgical drain-age as clinically indicated

Primary subacute hematogenous osteomyelitis may involve the clav-icle It occurs in children and in en-vironments of increased host resis-tance and/or decreased bacterial virulence Appearing most often in the metaphysis of long bones, it is unifocal and presents with mild to moderate pain.33When the clavicle

is affected, there is prominent peri-osteal expansion of the medial or lat-eral clavicle with increased density and cystic changes The differential diagnosis of subacute osteomyelitis

of the clavicle includes hypertrophic osteitis, chronic multifocal peri-osteitis, and neoplasia Biopsy often

is indicated to clarify the diagnosis

Sternoclavicular Joint Infection

Sepsis of the sternoclavicular joint presents with local joint swell-ing, pain, and heat and is aggravated

by arm movement The WBC count and ESR are variably elevated This condition has been reported in im-munocompromised patients and is associated with drug use.34 Aspira-tion and culture may reveal unusual organisms Twenty percent of

chronic multifocal periosteitis, dis-tinguished by the unifocal site of in-volvement Treatment consists of antibiotics, serial aspiration or open drainage and débridement as clini-cally indicated

Acromioclavicular Joint Infection

Presenting with symptoms that include local swelling, heat, and pain with shoulder movement, sep-tic arthritis less commonly occurs in the acromioclavicular joint than in the sternoclavicular joint Infection

of the acromioclavicular joint may

be a complication of cortisone injec-tion Laboratory findings include el-evated ESR and WBC count Radio-graphs demonstrate soft-tissue swelling with destructive bone and joint changes MRI findings include marrow edema, joint fluid, increased vascularity, and soft-tissue edema (Figure 12) The condition is diag-nosed by joint aspiration or biopsy The differential diagnosis in-cludes inflammatory and osteolytic disorders such as rheumatoid arthri-tis, hyperparathyroidism, posttrau-matic osteolysis, and gout Treat-ment consists of antibiotics and serial aspiration of the joint, al-though open drainage and débride-ment may become indicated

Tumors of the Clavicle

Tumors of the clavicle are rare One benign condition occurs when the medial and lateral end of the clavicle, which are preformed in car-tilage, develop osteochondroma.35 Other reported benign conditions in the clavicle include osteoid

osteo-ma, aneurysmal bone cyst (Figure

13), neurofibromatosis,

hemangio-ma, eosinophilic granulohemangio-ma, rickets,

acromegaly, Paget’s disease, fibrous

dysplasia, and histiocytosis.36

Malignant tumors of childhood

that involve the clavicle include

os-teosarcoma, Hodgkin’s disease,

leukemia, and Ewing’s sarcoma The

clavicle is involved in 3% of

children with Ewing’s sarcoma, in

2% of children with osseous lesions

of Hodgkin’s disease, and in <1%

of patients with osteosarcoma

Radiation-induced tumors also

oc-cur because of the frequency in

which the clavicle is included in the

radiation field for malignant tumors

of the head and neck.37 Malignant

tumors of the clavicle reported in

adults include multiple myeloma,

lymphoma, angiosarcoma,

osteosar-coma, and chondrosarcoma

Meta-static disease may involve the

clav-icle (Figure 14)

Radiographs may demonstrate a

discrete tumor with the

characteris-tic features of a tumor, but the

changes often include sclerosis,

peri-osteal elevation, lysis, or

combina-tions of these Biopsy is

recommend-ed when the findings do not clearly

fit a known benign condition

Surgical Excision of the Clavicle

The clavicle or part of it may be excised as treatment for disease The degree of resection is determined by the nature and site of the pathology

The proximal clavicle medial to the costoclavicular ligaments and the distal clavicle and lateral to the cor-acoclavicular ligaments, can be re-sected without causing mechanical instability Excision of the distal end

of the clavicle for osteoarthritis is the most common surgical proce-dure and may also be indicated for infection, tumor, or osteolysis Re-section of <0.5 cm runs a risk of bone impingement with motion, whereas greater resection exacerbates the risk

of increased mobility and associated pain Care is indicated to restore the acromioclavicular ligaments when possible because they control antero-posterior movement of the clavicle.38 Excision of the medial end of the clavicle is less common but may be indicated for infection, hypertrophic osteitis, or tumor.39Excision is not the optimal treatment of chronic an-terior subluxation because the im-pairment may not warrant surgery, and the surgical results may be poor.11When possible, resection of the medial clavicle should include reconstruction of the costoclavicular ligaments by attaching the residual periosteum to the first rib

Larger resection of the medial or lateral clavicle, the mid clavicle, or the entire clavicle may result in good function but is not predict-able.40It may be indicated for infec-tion or tumor or to expose underly-ing pathology Excision of the entire clavicle has a venerable history, hav-ing been first performed in 1813 for tuberculosis.41 Function following removal may be surprisingly good and, when the periosteum is intact, may be associated with regrowth Reconstruction of the proximal hu-merus with the clavicle has been re-ported after tumor resection.42 For disability following claviculectomy, reconstruction of the middle or en-tire clavicle using a vascularized rib graft has been described.43

Summary

Nontraumatic conditions of the clavicle are challenging to diagnose and manage because of the varied presentation and manifestation, con-fusing terminology, lack of knowl-edge of the natural history, and diffi-culty in discerning cause Clavicle disorders that typically are found in infancy and early childhood include fracture of the clavicle, associated with delivery or the result of a syn-drome involving chromosomes 11,18, and 22; congenital pseudar-throsis of the clavicle, usually diag-nosed because of the anterior

prom-Figure 13

Anteroposterior radiograph demonstrating massive expansion of the cortex of the medial clavicle in a patient with aneurysmal bone cyst

Figure 14

Anteroposterior radiograph after biopsy demonstrating diffuse lytic involvement

of the distal clavicle in a patient with

a hemangioendothelioma

Figure 12

T1-weighted coronal MRI scan with fat

saturation postgadolinium

demonstrat-ing fluid in the acromioclavicular joint,

destruction of the adjacent clavicle and

acromion, and hyperemia in the marrow

and adjacent soft tissues in this patient

with septic arthritis

Nontraumatic disorders of the

clavicle in childhood and adulthood

include anterior subluxation of the

sternoclavicular joint, which is

uncommon and sometimes

associat-ed with throwing or gymnastics;

dis-tal osteolysis of the clavicle,

typical-ly a result of overuse; Friedrich’s

disease, with osteonecrosis at the

end of the clavicle; hypertrophic

os-teitis, which may be the same as

condensing osteitis; osteomyelitis, a

result of hematogenous

staphylococ-cus; chronic multifocal periosteitis

and arthropathy, which includes

SCCH, CRMO, and SAPHO; and

tu-mors of the clavicle

Management can be varied and

in-clude symptomatic and expectant

management; modification of

weight-bearing activities, such as weight

lift-ing; drug therapies, including

nonste-roidal anti-inflammatory drugs and

antibiotics; or surgical treatment,

in-cluding resection or excision

References

Evidence-based Medicine:The

refer-ences cited here include case reports

(level IV) and case series (level III)

but no level I or II randomized

clin-ical series

Citation numbers printed in bold

type indicate references published

within the past 5 years

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