Condensing osteitis of the clavicle. Report of two new cases

Similarities and Differences between Clavicular Bacterial Osteomyelitis and Nonbacterial Osteitis: Comparisons of 327 Reported Cases

Background

Currently, both clavicular bacterial osteomyelitis (BO) and nonbacterial osteitis (NBO) remain not well understood owing to their much lower incidences. This study is aimed at summarizing similarities and differences between clavicular BO and NBO based on comparisons of literature-reported cases.

Methods

We searched the PubMed and Embase databases to identify English published literature between January 1^st, 1980, and December 31^st, 2018. Inclusion criteria were studies evaluating clinical features, diagnosis, and treatment of clavicular BO and NBO, with eligible data for synthesis analysis.

Results

Altogether, 129 studies with 327 patients were included. Compared with BO, clavicular NBO favored females (P < 0.001) and age below 20 years (P < 0.001) and mostly presented in a chronic phase (disease term exceeding 2 months) (P < 0.001). Although local pain and swelling were the top two symptoms for both disorders, fever, erythema, and a sinus tract were more frequently found in BO patients (P < 0.01). Although they both favored the medial side, lesions in the clavicular lateral side mostly occurred in BO patients (P = 0.002). However, no significant differences were identified regarding the serological levels of white blood cell count (P = 0.06), erythrocyte sedimentation rate (P = 0.27), or C-reactive protein (P = 0.33) between BO and NBO patients before therapy. Overall, the BO patients achieved a statistically higher cure rate than that of the NBO patients (P = 0.018).

Conclusions

Females, age below 20 years, and a long duration of clavicular pain and swelling may imply NBO. While the occurrence of a sinus tract and lesions in the lateral side may be clues of BO, inflammatory biomarkers revealed limited values for differential diagnosis. BO patients could achieve a better efficacy than the NBO patients based on current evidence.

Clinical characteristics and treatment of clavicular osteomyelitis: a systematic review with pooled analysis of 294 reported cases

BACKGROUND

It is usually difficult to diagnose clavicular osteomyelitis (OM), and treatment is delayed because of its rarity. This study aimed to summarize clinical characteristics and treatment of this disease.

METHODS

We searched the PubMed and Embase databases to identify English studies that reported on clavicular OM from January 1980 through December 2016. Effective data were pooled for analysis.

RESULTS

In total, 111 studies comprising 294 cases (bacterial OM, 146; nonbacterial OM, 148) were included, with a sex ratio of 1.89:1 indicating female predilection. Overall, the median age at diagnosis was 16 years. The acute to chronic phase ratio was 0.30, with a median symptom duration of 4 months. The most frequently reported symptom was pain (192 cases), followed by swelling (151 cases) and fever (52 cases). Altogether, 86.94% cases of single-site involvement were reported, with the medial side being the most common site (69.95%). The erythrocyte sedimentation rate achieved the highest positive rate (74.44%) before treatment. The total positive rate of culture for bacterial OM was 81.82%, with Staphylococcus aureus being the most frequently detected pathogen (44.70%). The average cure rate was 83.52%, with no significant difference between surgical (89.70%) and nonsurgical (79.63%) cases (P = .079).

CONCLUSIONS

Clavicular OM, predominant in female patients and young people, usually occurred at a chronic stage. Pain was the most frequent symptom, with the medial side being the most involved site. The erythrocyte sedimentation rate may be a helpful indicator for diagnosis. Regardless of surgery or nonsurgery, most patients achieved a favorable prognosis.

Unveiling the 'unique bone': a study of the distribution of focal clavicular lesions

AIM

Clavicle is a unique bone for many reasons. There is no study discussing the differential diagnosis of clavicular lesions based on the site of occurrence or age at presentation. This study aims to determine whether the distribution of lesions affecting the clavicle and age at presentation aid in the differential diagnosis of focal clavicular lesions.

MATERIALS AND METHODS

Clinical notes, imaging and histopathological reports of the clavicular lesions between Jan 1999 and Jan 2006 were reviewed. Virtually, all patients had been referred as suspected neoplasm.

RESULTS

Fifty-nine patients were identified. Patients <20 years (n = 27) had non-neoplastic or benign lesions. Patients between 20-50 years (n = 14) had predominantly non-neoplastic lesions. Patients >50 years (n = 18) had predominantly malignant lesions. The lesions most commonly affected the medial third (n = 35) and were predominantly non-neoplastic or benign. The middle third was affected in 15 patients and showed both benign and malignant lesions. The lateral third was least affected with predominance of malignant lesions.

CONCLUSIONS

The clavicle is not a primary common site for any particular tumour; hence, diagnosis of the lesions can be challenging. Our study has suggested that few factors like age and site of the lesions may be helpful in diagnosis.

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.

Noninflammatory sclerosis of the sternal end of the clavicle: a follow-up study and review of the literature

The cases of 14 adult females with swelling, tenderness, and sclerosis of the inferomedial part of the clavicle are presented. They were seen during a 16-year period, suggesting that the condition is rare. In ten patients strain at the sternoclavicular joint seemed to be an etiological factor. Eleven patients were followed for periods of 1-13 years (mean 5 years). The clavicular sclerosis regressed and they all developed signs of osteoarthrosis. Based upon available biopsy results and review of reported cases, it is hypothesized that the radiographic changes are due to osteonecrosis of the medial end of the clavicle with subsequent development of osteoarthrosis.

Radiographic findings of spontaneous subluxation of the sternoclavicular joint

Eight middle-aged women with spontaneous atraumatic subluxation of the sternoclavicular joint were evaluated with radiography and computed tomography. All patients were employed in occupations involving moderate to heavy physical labour, and no patients could recall a specific traumatic incident associated with onset of symptoms. In seven of the eight patients, the displacement of the medial clavicle was in a cranial direction; in four of the eight patients, there was an associated anterior subluxation, and in one patient, the subluxation was purely anterior. All five patients with an anterior component to the sternoclavicular subluxation had associated condensing osteitis of the clavicle. The sclerosis of the medial clavicle is possibly the result of chronic abrasion on the sternum and first costal cartilage in association with normal respiration and with upper extremity motion.

Case report 623. Osteitis condensans of the left clavicle (OCC)

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.

Inflammatory metachronous hyperostosis of the clavicle and femur in children. Report of two cases, one with long-term follow-up

Two preteenage girls developed painful swelling of the left clavicle. This was followed by painful swelling of the femur, 7 months later in one girl and 8 years later in the other. Radiographic studies showed a predominantly sclerotic process in one patient and destruction associated with cortical thickening in the other. The patients received analgesic medications only, followed by gradual healing with cortical and medullary sclerosis. Long-term follow-up suggests that the condition is self-limited and that, with or without treatment, the bones eventually return to normal. Although the etiology of the lesions remains unknown, the radiographic features suggest an inflammatory reaction.

Chronic sclerosing osteomyelitis of the clavicle. A manifestation of chronic recurrent multifocal osteomyelitis

The cases of five children/adolescents and two young adults with unilateral chronic osteomyelitis of the clavicle are reported. The clinical course was prolonged and characterized by intermittent periods of exacerbation followed by improvement. Extensive investigations revealed no causative organisms and the disease seemed resistant to antibiotic therapy. The only laboratory abnormality was elevated ESR, present in five cases. Osteomyelitis of other bones was detected in four cases and pustulosis palmoplantaris in two, suggesting that the disease is a manifestation of chronic recurrent multifocal osteomyelitis.

Inflammatory hyperostosis and sclerosis of the clavicle

Six cases with chronic inflammatory hyperostotic and sclerotic changes of the clavicle are reported. No causative organisms could be detected. Four patients had involvement of other bones including the thoracic spine, the femur, the tibia and the sternal end of the other clavicle. These may be classified as having "chronic recurrent multifocal osteomyelitis" (CRMO). The remaining two patients with similar clavicular changes might have an, as yet, unifocal CRMO.