CASE REPORTS Condensing Osteitis of the Clavicle GCOoi FRCR(UK) WCGPeh FRCR(UK) Department of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Abstract Condensing osteitis of the clavicle is a rare benign condition of unknown aetiology which afflicts women of child-bearing age. It is characterised radiologically by sclerosis of the infero-medial aspect of the clavicle, with preservation of the sternoclavicular joint in the early stages of the disease. The clinico-radiological features of this condition are discussed in this review, together with other conditions which resemble this entity. Introduction Condensing osteitis of the clavicle is a rare benign but painful disorder of unknown aetiology:It is characterised radiographically by sclerosis of the medial end of the clavi- cle, without involvement of the sternoclavicular joint. This term is actually a misnomer, as inflammation is not recog- nised to be a component of this disorder. I Jurick (1994) in a recent comprehensive review of the literature, found 62 reported cases of what she termed "noninflammatory sclerosis of the clavicle", in addition to 14 of her own cases/ Besides "condensing osteitis", other descriptive terms used include "Friedrich's disease"," "post-traumatic reactive and resorptive le- sions of the medial end of the clavicle"," "non-inflammatory sclerosis? and simply, "sclerotic changes" of the sternal end of the clavicle.This paper aims to review the clini- cal and imaging features of patients with condensing osteitis of the clavicle and other similar entities. Corrclerrsirig osteitis Condensing osteitis of the clavicle was first identified as a distinct entity by Brower et al (1974),7 Their original description of the clinical, radiographic and histological fea- tures of this lesion, with symptomatic re- lieffollowing surgical excision in two young women, has subsequently been recognised by several other workers. To date, about 30 cases of condensing osteitis, mainly in the 25 SA JOURNAL OF RADIOLOGY. May 1996 form of case reports, have been docu- mentedinfnglishliterature'<-" Nearly all affected patients were adult women (96%) aged between 26 to 69 years (mean age of 4 5 years). The majority complained of pain and! or swelling of the medial end of the clavicle. In some cases, the pain radiated to the supraclavicular fossa and ipsilateral shoulder; aggravated by abduction or for- ward movement of the shoulder. The pain was usually mild but could be severe, with duration of symptoms varying from 4 weeks to 5 years. In about half of the re- ported cases,there was an assedation with minor stress or repetitive physical activity, such as lifting of heavy weights or sports- relatedactivity.,,2,7'22 Van Holsbeek (1992) postulated that the clavicular sclerosis may be secondary to chronic abrasion of a spon- taneously subluxing sternoclavicular joint20 The radiographic features are character- istic, comprising dense sclerosis at the infe- rior aspect of the medial clavicle, often as- sociated with mild bony expansion. A hook-like osteophyte arising from the infero-medial aspect of the clavicle has also been recognised as a feature of this condi- tion (Figure 1). The sternoclavicular joint space is not narrowed, at least in the early Figure 1: 70-year old woman with dense sclerosis of the right medial clavicle. Note associated inferior osteophyte (arrowed). The left clavicle is normal. stages of the disease, with preservation of the articular surfaces. Periosteal reaction and bony destruction are absent. Jurick (1994) in a follow-up study of Il patients with condensing osteitis, demonstrated topage26 Condensing Osteitis of the Clavicle regression of bony sclerosis and develop- ment of adjacent osteoarthritis with time. 2 Computed tomography (Cf) depicts accu- rately the extent and nature of bone in- volvement. It demonstrates the preserva- tion of the sternoclavicular joint, the scle- rotic involvement of the sternal end of the clavicle and excludes a destructive or aggressiveprocess. The bone marrow cavity is typically obliterated, with soft tissue swelling occasionallyreported (Figures2 and 3).1,11,12,14-20These lesions also produce Figure 2: 63-year old woman with condensing osteitis. (c) preservation of Ihe adjacenl sternoclavicular joint. Figure 3. Reformatted oblique coronal CT Image demon- slrates typical site of clavicular sclerosis (arrowheads), as well as degeneralive changes at its articulation with the calcified right first costal carlilage (arrowed). The sternoclavicular joint is relatively unaffected. markedly increased focal tracer uptake on isotope bone scans, corresponding to the site ofbony sclerosis (Figure 4).1,8-17,19,21Mag- netic resonance imaging is useful in Figure 4: Isotope bone scan (Tc-99m methylene dlphosphonate, 2 hour delay) in a 67-year old woman with condensing osteitis. Right anterior oblique projection of the chest shows an intense area of increased uptake at the medial end of the right clavicle (arrow- head). The sternum is arrowed. confirming the benign nature of the cla- vicular sclerosis, demonstrating areas of hypointense signal intensities on both spin- echo Tl andT2 weightedimages21,23which represent the regions of sclerotic bone. The histological features of condensing osteitis are an increased amount of normal bone with marrow obliteration, thickened cancellous bone and trabecular reinforce- ment.1,7,11,14-17,19,23Someauthorshavealso~ ported marrow fibrosis and osteonecrosis, suggesting a low-grade ischaemie 26 SA JOURNAL OF RADIOLOGY. May 1996 process.I,14,17,23Thetrue cause of condensing osteitis is unknown, although it is generally accepted as representing a response to mechanical stress which particularly af- fects women of child-bearing age. Symptomatic patients should be man- aged with nonsteroidal anti-inflammatory drugs and limitation of physical activities. If the diagnosis is in doubt or ifthe patient is refractory to conservative treatment, excision of the medial end of the clavi- deisrecommended.v'é-" Friedrich's disease Friedrich's disease is ischaemie necrosis of the medial clavicular epiphysis. Itis a rare disorder, with only 28 cases having been reported to date.2-4 Clinically, the present- ing signs and symptoms are similar to that of condensing osteitis. There is painful swelling over the sternoclavicular joint, which may be aggravated by movement. Unlike condensing osteitis, however, Friedrich's disease is not confined to the adult population, and in fact typically af- flicts children and adolescents. The radio- logical appearances may resemble those of condensing osteitis but careful examination of plain radiographs will demonstrate that the entire medial end of the clavicle is scle- rotic, with fragmentation and a notch-like defect at the articular surface.These lesions appear hot on isotope bone scans,hence are scintigraphically indistinguishable from condensing osteitis.The disease is often self limiting with eventual normalisation of ra- diographic appearance after conservative treatment. Necrosis, with fibrosis of the marrow cavity and empty lacunae, is the main histological feature of Friedrich' s dis- ease. Trauma or an embolic event at the medial clavicular epiphysis is believed to cause the ischaemie necrosis that isthe hall- mark of this condition/" topage27 Condensing Osteitis of the Clavicle Other lesions which may resemble condensing osteitis Chronic recurrent osteomyelitis is an unusual condition usually affecting chil- dren. With clavicular involvement, devel- opment of hyperostosis and bony en- largement may mimic condensing osteitis." Appell et al (1983) used the term condensing osteitis to describe marked sclerotic enlargement of the me- dial two-thirds of the clavicle associated with periosteal reaction in seven girls (aged 7 to 15), three of whom had multifocal bone involvement. All cases had raised erythrocyte sedimentation rates,two had high white cell count while four responded to antibiotics." Jones et al (1990) described radiographic findings of marked expansion and sclerosis of the medial two-thirds of the clavicle, with thick dense periosteal reaction, in 3 chil- dren. Bone biopsies confirmed chronic osteomyelitis in one patient and non-spe- cific inflammatory changes in the other two. The patients responded to antibiot- ics leading to the authors to suggest that condensing osteitis could be a form of low grade osteomyelitis. 25 The consensus in subsequent reviews was that these authors reported cases of chronic recur- rent multifocal osteomyelitis, which dif- fered clinically and radiologically from condensing osteitis,': 17,23,26 Apter et al (1992) described post- traumatic reactive and resorptive lesions of the medial end of the clavicle in 3 young soldiers, biopsy of which showed new bone formation and chronic inflam- mation. These changes were thought to be stress-related.' Stemocostoclavicular hyperostosis is another condition which typically affects the medial end of the clavicle, as well as other juxtasternal 8. Teates CD, Brower AC, Williamson BRJ et al. Bone scans in condensing osteitis of the clavicle. Southem Medical Jouma/1978; 71: 736-738. 9. Simpson AI. Positive bone scintigraphy in cond ns- ing osteitis of the clavicle. Clinical Nuclear Medicine 1978;3:204. 10. Duro K, Estrada P, Ribas Detal. Condensing osteitis of the clavicle. Anhritis and Rheumatism 1981 ;24: 1454- 1455. structures. Unlike condensing osteitis, it afflicts older male patients who present with bilateral painful anterior chest wall swellings and pustular lesions of the palms and soles. About 200 cases have been reported to date." Other differen- tial diagnoses of medial clavicular lesions which may be considered include sternoclavicular joint pyoarthrosis, septic arthritis and osteoarthritis, and miscella- neous conditions like osteoid osteoma and fibrous dysplasia.V' Summary Despite some similarity in presenting signs and symptoms, with careful radio- logical assessment one should be able to differentiate condensing osteitis from Friedrich's disease and the other condi- tions that resemble this entity. The selec- tive sclerotic involvement of the infero- medial aspect of the claviclein women of child-bearing age,in the absence of consti- tutional symptoms, should lead one to the correct diagnosis.Recognition of this con- dition should spare the patient from fur- ther unnecessary and potentially inva- sive investigations. References 1. Greenspan A, Gerscovich E, Szabo RM et al. Condens- ing osteitis of the clavicle: a rare but frequently misdiagnosed condition. 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