Shoulder Resources

Clavicle pathology (R)(M) Clavicle pathology (R)(M)


Congenital pseudarthrosis of the clavicle

Aetiology
Usually an isolated entity, but may occur in conjunction with cleidocranial dysostosis. There is no association with neurofibromatosis .

Epidemiology
Usually unilateral, and in this case generally involves the right side, unless the patient has dextrocardia.
Can be bilateral in 10-15% of cases.

Pathology
Some feel the pseudarthrosis is caused by pressure from the subclavian artery on the developing clavicle. (The right supraclavicular artery is higher than the left).

Clinical
Patients usually present with a painless mass over the middle third of the right clavicle that may enlarge with skeletal growth. There may be pain on lifting or overhead activities.

Investigation
Radiographs show a pseudarthrosis which may be hypertrophic or atrophic.

Management
Surgery is indicated if there is significant pain or cosmetic defect, which is rare.
Spontaneous union does not occur.
In young children may try to excise the pseudarthrosis segment and reoppose the bone ends within the periosteal sleeve, using absorbable sutures.
In older children the pseudarthrosis is excised, bone graft put in the defect and compression plating performed.
Union is easier to achieve in clavicular pseudarthrosis than in tibial pseudarthrosis.

Condensing osteitis of the clavicle
This and the following two conditions are all uncommon affections of the clavicle.
Usually seen in women aged 20-40.
Thought to be an overuse reaction secondary to excessive lifting activities.
Presentation is with pain at the medial end of the clavicle, aggravated by arm abduction. The clavicle may be thickened and tender.
XR show sclerosis. Bone scan shows increased activity in the affected clavicle.
Treatment is with activity modification.

Sternoclavicular hyperostosis
This condition may be some form of seronegative spondyloarthritis.
Seen in slightly older people, affects men and women equally, usually bilateral.
Patients develop pain, swelling and tenderness over the sternoclavicular region. Can be associated with pustular lesions on the palms and soles (palmo-plantar pustulosis) and also with pustular psoriasis.
XR show hyperostosis of the medial ends of the clavicles, adjacent sternum, and anterior ribs. Vertebrae may also be affected.
ESR may be raised.
Biopsy has not demonstrated any organisms.

Subacute or chronic multifocal osteomyelitis
This usually occurs in children and adolescents.
Affects clavicle and lower limb metaphyses.
May present as a painful fusiform swelling of the clavicle. Like sternoclavicular hyperostosis, this condition may be associated with pustulosis.
XR show thickening and sclerosis of the medial third of the bone.
There is no effective treatment, and the lesions invariably heal slowly over months to years.

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