RadloGraphics index terms:

MUSCULOSKELETAL IMAGING
#{149}
Clavicle
Cumulative Index terms:
The clavicle:
Clavicle
Normal and abnormal

Rajendra Kumar, M.D. Marvin M. Lindell, M.D.t

John E. Madewell, M.D.t Ruppert David, M.D.

Leonard E. Swischuk, M.D.

Abstract: The clavicle

is an unusual long bone with many unique
embiyologic features.
It is often involved in congenital and acquired
disorders. Traumatic, inflammato,y, neoplastic, metabollc and many
other miscellaneous lesions may also affect the bone. Because of its
Ilgamentous attachments and the presence ofarticulations at both ends,
the clavicle can also be involved in arthrffic diseases. This article
Illustrates the radiographic manifestations ofmany ofthe disorders of
the clavicle that are commonly encountered in clinical practice.

THIS EXHIBIT WAS DISPLAYED AT Introduction

THE 74TH SCIENTIFIC ASSEMBLY
AND ANNUAL MEETING OF THE RA-
DIOLOGICAL SOCIETY OF NORTH
The clavicle (collar bone) is a long bone with a medullary cavity.
AMERICA. NOVEMBER 27-DECEM- Unlike other long bones, however, it has an lntnamembranous origin. It
BER 2, 1988, CHICAGO. ILLINOIS. IT is the first bone to ossify In the fetus. It is formed by two primary
WAS RECOMMENDED BY THE MUS- ossification centers for the body, one medial and one lateral, which
CULOSKELETAL IMAGING PANEL
appear during the 5th and #{243}th week of intrauterine life (Figure 1). The
AND WAS ACCEPTED FOR PUBLI-
CATION AFTER PEER REVIEW AND
third ossification center is secondary and represents the only
REVISION ON MARCH 13, 1989. epiphysis at the medial end of the bone. It is the last epiphysis to
ossify in the body at 18 to 20 years (Figure 2). It is also the last
epiphysis to fuse at age 25 to 26 years.
This article illustrates the radiographic featunes of many normal
variants and pathologic lesions of the clavicle.

,,. .. , . . ACROMIAL ARTICULAR FACET

From the Departments of JLAR FACET , :. : . . .. ,....

Radiology, The University of . . . - . DELTOID TUBERCIE . <.

Texas Medical Branch. Gal-

veston C). Penn State Univer-
sity School of Medicine, Milton
S. Hershey Medical Center,
Hershey, Pennsylvania (t).
TJ . TUBERCLE-’,
‘I

M.D. Anderson Hospital and

Cancer Institute (4:), and Bay-
.

. .
. . ,
,
I ‘ . primary
: ‘ ‘ :;‘c.
centers . .

Ion College of Medicine (s).

.;.
Houston, Texas.
Address reprint requests .. iry center ..

to R. Kuman, M.D., Depart- Figure 1 . ;

ment of Radiology, The Uni- (A) Normal clavicle (B) Ossification centers of the clavicle :
versity of Texas Medical
Branch, Galveston, TX 77550.

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The clavicle: Normal and abnormal Kumar et al.

Normal epiphysis at the medial end of the clavicle in

an 18 year old woman

The Normal Clavicle

The clavicle is a horizontally placed, “f” coclavicular ligament undergoes ossification,

shaped, tubular bone that connects the upper usually secondary to trauma (Figure 3C). An in-
extremity to the axial skeleton. Medially, it an- regular concavity may sometimes be present
ticulates with the manubnium to form the ster- near the medial end of the bone along its infe-
noclavicular (S-C) joint. Laterally it joins the ac- nor surface. It is the rhomboid fossa, the site at
nomion process of the scapula at the acromio- which the costoclavicular ligament is at-
clavicular (A-C) joint. A bony protuberance of tached (Figure 4). When prominent, the rhom-
varying size is often present along the postero- boid fossa may be mistaken for an osteolytic
inferior border of the distal third of the clavicle, lesion. The medial end of the clavicle may ap-
called the conoid tubencle (Figure 3A). The co- pear cupped and irregular before adoles-
noid tubencle provides attachment to the co- cence, simulating a destructive process. A
noid portion of the coracoclavicular ligament; small foramen may be present in the midpor-
the trapezoid portion of the ligament is at- tion of the bone, along its superior border (Fig-
tached to a bony ridge, the trapezoid line, ure 5). This foramen transmits the nutrient an-
that runs lateral to the conoid tubencle (Figure teny and, at times, the supraclavicular nerve.
3A). At times, an articulation may be present A normal clavicle may falsely appear to
between the conoid tubencle and the cora- be fractured in its midportion because of rota-
coid process (Figure 3B). Bony bridging may be tion or projection, especially in children (Fig-
seen between these two structures if the cora- ures #{243}A
and B).

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ifl _
3B 3C
Figure 3
(A) The conoid tubercle (arrow) and the trapezoid
line (arrowheads) (B) Articulation between the co-
noid tubercle and the coracoid process (C) This
coracoclaviculan ligament has ossified following
trauma.

Figure 4 Figure 5
A prominent rhomboid fossa is seen along the infeni- A nutrient foramen is present in the right clavicle (an-
on aspect of the medial portion of the night clavicle now).
(arrow).

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Figure 6
(A) Pseudofracture of the right
clavicle This appearance is
caused by rotation. (B) Bilateral
pseudofractures of the clavicles, a
misleading appearance caused by
projection

Th#{149}
Abnormal Clavicle

The clavicle is a common site of affliction branous and cartilaginous bones. Partial or to-
by many disorders. Congenital. traumatic, in- tal aplasia of one or both clavicles may occur
flammatony, metabolic, neoplastic, and other (Figure 7). The disorder usually affects the mid-
miscellaneous disorders may affect the bone. dIe and distal segments of the bone.
Some diseases produce diagnostic radio- 2. The clavicle, especially in its distal pon-
graphic features that are disease specific. Be- tion, may also be absent in progeria because
cause of the two articulations at the ends of of fibrosis.
the bone, many arthnitides may also involve 3. Congenital absence of the clavicle
the bone. must be differentiated from acquired causes
such as postsurgical resection of the clavicle
on a destructive process of bone (Figure 30).
I. CONGENITAL DISORDERS
A. Absence of the Clavicle

I . The clavicle may be absent in cleido- Figure 7

cranial dysostosis, an autosomal disorder asso- Cleidocranial dysostosis with total absence of the
ciated with abnormal development of mem- right clavicle Note the rudimentary left clavicle (an-
row).

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B. Congenital Pseudarthrosis

I Congenital
. pseudarthrosis is usually
seen within two weeks of birth.
2. Invariably, the right clavicle is involved.
Rarely, in the presence of dextnocardia, the
left clavicle may be involved.
3. A defect is seen in the midclavicle at
the site of pseudarthrosis (Figure 8).
4, Fibrous tissue bridges the defect in most
cases. No callus formation is seen about the
defect.
5. The bone ends at the defect appear
sclerotic and may be tapered.
Figure 8
o, The exact pathogenesis is unknown. It
Congenital pseudarthrosis of the night clavicle (an- may be caused by excessive pulsation of the
row) subjacent subclavian artery against the clavi-
cle.

C. Holt-Oram Syndrome

I Holt-Onam
. syndrome is an autosomal
dominant disorder that is manifested by con-
genital cardiac and limb anomalies.
2. The clavicles may be hypoplastic with
bulbous ends. Upward inclination of the clavi-
des imparts a characteristic “handle-ban”
configuration to the bones (Figure 9).

Figure 9
Holt-Onam syndrome with “handle-bar” clavicles

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D. Osteogenesis Imperfecta

I A congenital
. disorder, osteogenesis im-
penfecta is characterized by defective fonma-
tion of osteoid matrix and collagen.
2. The clavicles tend to be osteoponotic,
hypoplastic and slender (Figure 10).
3. A fracture associated with exuberant
callus formation may be present.

Osteogenesis imperfecta with hypoplastic, tapered

clavicles

E. Oxalosis

I Oxalosis is a rare, autosomal

. recessive
inborn error of metabolism in which excessive
amounts of oxalate salts are formed in the
body.
2. The disease is seen in childhood.
3. Growth disturbance and an increased
incidence of urinary calculi because of hypen-
oxalemia are noted.
4, Sclerosis of bone is seen on the radio-
graphs. The growing ends, especially, show
bulbous enlargement.
5. The medial ends of the clavicles are
most often affected, resulting in “drum stick” Figure 1 1
clavicles on radiognaphs (Figure 1 1). Oxalosis showing “drum-stick” clavicles with scle-
6. Pathologic fractures are commonly rosis and bulbous deformity of the medial ends of
present in oxalosis. the clavicles

II. TRAUMATIC DISORDERS

A. Fractures

I The clavicle
. is a commonly fractured 4. Elevation of the proximal fragment is
bone because of its superficial location. seen because of the upward pull of the sterno-
2. It is the most frequently fractured bone cleidomastoid muscle when a fracture occurs
in the newborn. at the junction of the middle and distal thirds.
3, Seventy-five to eighty percent of frac- The distal fracture fragment is depressed be-
tunes involve the midportion; 15-20%, the lat- cause of the downward pull of the conacocla-
enal portion; and approximately 5%, the medi- vicular ligament (Figure I2A).
al portion of the bone.

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5. Nonunion is common in fractures of the 12B). These fractures are most often seen with
clavicle that occur distal to the attachment of breech deliveries.
the coracoclavicular ligament. 7. Incomplete, plastic or bowed fractures
6. Fractures in the newborn usually occur may also occur in children (Figure 12C).
at the junction of the mid and distal thirds be- 8. Stress on “academic” claviculan fnac-
cause of pressure on the shoulder by the ma- tunes may be seen in students who carry heavy
tennal pubic symphysis during birth (Figure loads of books on their shoulders (Figure 12D).

12C

12D
Figure 12 vicular fracture in a newborn child (C) Nondisplaced
(A) Fracture of the left clavicle Note the superior plastic fracture of the left clavicle (arrow) (D) Bilat-
displacement of the medial fragment. (B) Right cIa- enal stress fractures of the clavicles (arrows)

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B. Dislocations

I Dislocation
. may occur at either end of 4. Sternoclaviculan joint dislocation is an-
the clavicle following direct trauma. tenor (anterosupenion) in 90%, and posterior
2. Acromioclavicular joint dislocation is (postenoinfenion) in the remaining 10%. It is diffi-
the most common (98%), and has been subdi- cult to diagnose stennoclaviculan joint disloca-
vided into six types (Figures 13A-D). tions on plain radiographs. Plain and comput-
3. Mild, grade I acromioclaviculanjoint in- ed tomography facilitate the diagnosis (Fig-
jury requires stress (weight bearing) views of ures I4A-C).
both shoulders for diagnosis. 5. Posterior dislocation of the sternoclavi-
cular joint may be associated with injury to the
trachea, esophagus, and major blood vessels.

l3A

l3B
Figures 1 3A & B
Acromioclavicular joint dislocation (A) Diagramatic
illustration of various acnomioclaviculan joint disloca-
tions (B) Grade II acromioclaviculan injury with
widening of the joint and slight superior displace-
ment of the distal clavicle

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Figures 1 3C & D
(C) Chronic grade IV acromioclaviculan dislocation
(D) CT shows that the distal end of the night clavicle
is displaced posteriorly with respect to the night ac-
romion process. The patient was a young woman
with a palpable tender mass along the posterior as-
pect of the night shoulder following trauma two
years previously. Note the normal acnomioclavicular
joint on the left. A = acromion; C distal end of
clavicle.

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l4A
: ..

. .‘-;...

, . ,..
..

- ..
.

i-H
R g ‘

14C
Figure 14
Left anterior stennoclavicular joint separation (A)
Plain AP radiograph shows the medial end of the left
clavicle to be displaced superiorly. (B) Plain tomo-
gram of the same separation (C) CT of the same
patient following reduction of the stennoclaviculan
separation Note the widening of the left sternoclavi-
cular joint persists. C = medial end of the clavicle;
M = manubnium.

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C. Posttraumatlc Osteolysis

I Osteolysis
. of the distal end of the clavi- 4. The distal 2 to 4 cm of the clavicle show
cle may occur following a sprain on overt tnau- bone erosions, and the acromioclavicular joint
ma at the acromioclaviculan joint. appears widened (Figure 15).
2. The exact pathogenesis is unknown. 5, The process of bone destruction is self
3, The osteolytic process usually begins 6 limiting, lasting for a few months.
to 8 weeks following the injury. 6. With the onset of the reparative phase,
the eroded distal end of the clavicle becomes
sclerotic and tapered.

Figure 15
Posttraumatic osteolysis of night clavicle secondary
to an old injury Note the tapering of the distal clavi-
cle, the widening of the acromioclavicular joint and
the presence of a bone fragment (arrow).

D. Posttraumallc Pseudarthrosis

I This entity represents

. nonunion of a cIa-
viculan fracture.
2. The fracture margins become well de-
fined, smooth and sclerotic.
3. Exuberant callus may be present at the
fracture site, but it does not bridge the frac-
tune line (Figure 16).

Figure 16
Posttraumatic pseudarthrosis of the left clavicle
Note the extensive callus formation at the fracture
site without union in this seven month old fracture.

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E. Osteitis Condensans
(Condensing Osteitis)

I Osteitis condensans
. is usually seen in 5. A similar appearance has been de-
middle aged women. scnibed in children and adolescents who have
2. It is believed to be secondary to chron- aseptic necrosis of the medial end of the clavi-
ic stress. cle (Friednich’s disease). The aseptic necrosis is
3. Clinically, localized pain and tender- believed to be due to an ischemic insult to the
ness are present, especially on abduction of epiphysis at the medial end of the clavicle.
the arm. The disorder is self limiting and responds well to
4. Radiographs show bone sclerosis of the conservative treatment with relief of symp-
medial end of the clavicle, which is slightly en- toms. Sclerosis of the medial end of the clavi-
larged (Figures 17A and B). cle may persist, however.

l7A

Figure 17
(A) Condensing osteitis of the left clavicle with scle-
rosis of its medial end (B) Radiograph of the ne-
sected surgical specimen

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F. Radiaion Effects

I Bone changes
. in the clavicle are usually 4. Bone sclerosis and aseptic necrosis also
seen following supervoltage irradiation of the may be seen.
bone. 5. An osteochondroma may occur at the
2. The severity and extent of the damage medial end of the clavicle following irradiation
depend upon the intensity and frequency of in- of the bone during childhood (Figure 19).
radiation. 6. Pathologic fractures may supervene.
3. The radiographic appearance may These fractures often progress to nonunion
vary from one of localized osteoporosis to one and pseudarthrosis.
of frank bone destruction (Figure 18). 7. Secondary osteosarcoma may develop
as a late complication.

Postinnadiation necrosis of the medial end of the left

clavicle, the adjacent sternum and nibs

Figure 19
Osteochondroma arising in the medial end of the
night clavicle 5 years after irradiation of the upper
chest

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III. INFLAMMATORY DISORDERS

A. Osteomyelitis

I Osteomyelitis
. often involves the clavi- 3, Osteomyelitis of the bone also may oc-
cle, producing destruction and peniosteal re- cur secondary to a septic sternoclavicular or
action. Sclerotic changes occur with healing acromioclavicular joint.
or when the process becomes chronic. 4. The stennoclavicular joint is a favorite
2. Infection may be the result of hematog- site for septic arthritis, and plain or computed
enous spread of organisms or of direct con- tomography facilitates the diagnosis (Figures
tamination of the bone as a result of trauma, 20A-C).
or diagnostic or therapeutic procedures. such 5. Although Staphylococcus aureus is the
as subclavian vein catheterization. most common causative organism, other
pathogens may be involved (Figure 21).

. : ‘.

R : #{149}‘“ I
20B

Figure 20
Septic arthritis of the left sternoclaviculan joint with
osteomyelitis (A) Bone destruction of the medial
end of the left clavicle caused by osteomyelitis (B)
A nadionuclide bone scan (anterior view) shows in-
creased radiotracen uptake at the left sternoclavicu-
Ian joint (arrow) in the same patient. (C) CT shows
bone destruction of the left sternoclavicular joint (an-
row). Note the associated soft tissue swelling. The
night sternoclaviculan joint is normal.

20C

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-.‘--.,-‘

Congenital syphilis Osteomyelitis with peniosteal

reaction is seen along the right clavicle in this baby
born to a syphilitic mother.

B. Chronic Symmetric Plasma Ceil

Osteomyeiltis
(Condensing osteitis of the clavicle in child-
hood, Chronic recurrent multifocal osteomyeli-
tis, Primary chronic osteomyelitis)

I Chronic
. plasma cell osteomyelitis is a in distribution, the condition often produces
chronic inflammatory condition of unknown bone destruction and extensive sclerosis of the
etiology. clavicle, resulting in enlargement of the bone
2. The disease is usually seen in children (Figure 22).
between 5 and 15 years of age. 5. Histological examination of this lesion
3. Clinically, it is first manifested as a local- shows the presence of chronic inflammatory
ized zone of painful soft tissue swelling. cells. Osteolytic foci within the lesion often re-
4. Usually multifocal and often symmetric veal the presence of plasma cells.

Plasma cell osteomyelitis of the left clavicle with

mdrked peniostitis, sclerosis and enlargement of the
bone.

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IV. NEOPLASTIC DISORDERS

Many benign and malignant neoplasms in-

volve the clavicle. Such lesions may come to
the attention of a physician because of a su-
penimposed pathologic fracture.

A. Benign Tumors

a. Enostosis (Bone island)

I The clavicle
. is an uncommon location
for a bone island.
2. On radiographs, the lesion is seen as a
round on oval, uniform opacity in the medullany
canal of the bone (Figure 23).
3. Histologically, the tumor consists of
compacted trabeculae of mature lamellar
bone.
4. An enostosis may grow slowly in size, al-
though most lesions are stable and rarely ex-
ceed I cm in diameter.

Figure 23
Bone island in the distal left clavicle (arrow)

b. Unicameral bone cyst (Simple bone cyst)

I The clavicle
. is an uncommon site (less
than 1%) for a simple bone cyst.
2. Eighty percent of these lesions occur
between 3 and 14 years of age.
3. Radiographically, the lesion is seen as a
well defined, well manginated, round to oval
radiolucency in the medullany portion of the
clavicle (Figure 24).

Figure 24
Unicameral bone cyst in the left clavicle, with local-
ized bone expansion

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c. Giant cell tumor

I The clavicle
. is rarely involved by giant
cell tumor.
2. Usually, this tumor occurs in patients be-
tween 20 and 40 years of age.
3. A giant cell tumor may be seen at ei-
then end of the clavicle.
4. On radiographs. a giant cell tumor ap-
pears as an osteolytic lesion that may be ex-
pansile and may erode the cortex (Figure 25).
5. Roughly 20% of these lesions are poten-
tially malignant.

Figure 25
Giant cell tumor arising in the medial end of the left
clavicle

d. Aneurysmal bone cyst

I Approximately
. 3% of aneunysmal bone trauma to the lesions of fibrous dysplasia, giant
cysts occur in the clavicle. cell tumor, simple bone cyst or chondroblas-
2. Seventy-five percent of these lesions toma.
are seen in patients under 20 years of age. 4, Radiognaphically, the tumor is a large
3. At least 50% of aneunysmal bone cysts expansile, multilocular lytic lesion with a thin
are secondary; they often occur following bony shell that may be disrupted (Figure 26).

Figure 26
4
Aneunysmal bone cyst causing marked bony expan-
sion of the distal left clavicle

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e. Fibrous dysplasia
I The clavicle
. is a rare site of involvement
by fibrous dysplasia.
2. Children and young adults are most of-
ten affected by this lesion.
3. The bone involvement may affect only
the clavicle (monostotic), on multiple bones
may be involved (polyostotic).
4. The lesion usually is seen as a well de-
fined osteolytic process with sclerotic bonders
and a tnabeculated on gnound glass appear-
ance on nadiognaphs (Figure 27).

f. Hemangloma
I The clavicle
. may be involved in up to
2% of cases of hemangioma of bone.
2. The lesion is usually seen in young
adults.
3. It may be monostotic on polyostotic.
4. Hemangioma is usually discovered mci-
dentally, as most cases are asymptomatic.
5. Hemangioma of bone is seen as a well
defined lytic lesion containing coarse trabecu- ,

lae that impart a “honeycomb” appearance

to the lesion on nadiognaphs (Figure 28).
Figure 28
Hemangioma arising in the distal right clavicle

g. Eoslnophiilc granuloma
I The clavicle
. is involved in about 4% of
cases of eosinophilic gnanuloma.
2. The lesion is most often seen in children
and young adults.
3. In addition to the clavicle, other bones
may be involved.
4. Usually it is seen as a well defined,
round on oval, osteolytic lesion on radiognaphs
(Figure 29). Periosteal reaction may be
present. At times, the lesion may appear ag-
gnessive.

Figure 29
Eosinophilic granuloma involving the left clavicle
with bone destruction The lesion may mimic an in-
fectious on neoplastic process. Note the presence of
solid peniosteal reaction, consistent with a benign
process.

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B. Malignant Disorders

a. Metastasis
I The clavicle
. is an un-
common site for metastatic
involvement.
2. Most metastases to
the clavicle are osteolytic
because of the lack of red
bone marrow.
3. Metastases are usually
seen in patients oven 40 years
of age.
4. The radiographic ap-
pearance depends upon
whether the lesion is osteoly-
tic or osteoblastic. In most
cases, a destructive lesion of
bone is seen that has ill-de-
fined margins (Figures 30A
and B). A permeating ostely-
tic lesion may also occur (Fig-
une 30C).

Figure 30
(A) Osteolytic metastasis to the
right clavicle from a high grade,
transitional cell carcinoma of the
urinary bladder Note the marked
destruction of the bone. (B) The
same patient, two years later, fol-
lowing radiotherapy The osteoly-
30B tic process has healed with necon-
stitution of the clavicle. (Courtesy
of Thomas S. Harle, M.D., Hous-
ton,TX) (C) A permeating osteo-
lytic metastasis to the right clavicle
from a breast carcinoma

j
30C

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b. Myeloma
I The clavicle
. is a common site of in-
volvement by myeloma.
2. This disease is seen in the elderly popu-
lation (oven 50 years).
3. Radiographically, myeloma appears to
be a purely lytic lesion with well to poorly de-
fined bonders. Endosteal erosion is often seen,
and a permeating destructive appearance is
not unusual. Bone expansion may occur (Fig-
ure 31).
4. The lesions tend to be multifocal and
one or both clavicles may be involved.
5. Pathologic fractures are commonly
seen.

L 31
Multiple myeloma involving the bones of the right
shoulder, including the clavicle

c. Osteogenic sarcoma
I Fewer than I % of osteosarcomas
. occur
in the clavicle.
2. Primary osteosancoma is usually seen in
patients who are between the ages of 10 and
25 years.
3. Secondary osteosarcoma may occur
following irradiation of the clavicle.
4, Radiographically, the tumor presents as
an aggressive osteolytic lesion with an osteoid
matrix; it often extends into the adjacent soft
tissues (Figures 32A and B).

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32A

Figure 32
(A) Osteogenic sarcoma arising in the night clavicle
Note the sclerosis and new bone production. (B)
CT reveals that the bone producing tumor is associ-
ated with bone destruction and soft tissue exten-
sion.

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d. Malignant fibrous histlocytoma 3. On nadiographs. the lesion appears as

I The clavicle
. is a rare site of involvement an ill-defined radiolucency which often breaks
by malignant fibrous histiocytoma. through the cortex (Figure 33).
2. Most cases are seen in the elderly, but 4. A soft tissue mass usually accompanies
no age is immune. the bone lesion.

Figure 33
Malignant fibrous histiocytoma arising in the left
clavicle This late phase of an arteniogram shows a
large hypervascular soft tissue mass associated
with the tumor causing bone destruction of the clavi-
cle.

e. Ewing’s sarcoma
I The clavicle
. is an uncommon site for moth-eaten osteolytic lesion with ill-defined
Ewing’s sarcoma. bonders and an intense peniosteal reaction,
2. This tumor may occur at any age, but which may be “laminated” on “sun-burst” in
most cases are seen in the first three decades appearance (Figure 34).
of life. 4. A large soft tissue mass usually accom-
3. Usually it is seen as a permeating on panies the lesion.

Ewing’s sarcoma arising in the left clavicle Note the

bone destruction with “sun-burst” and “laminated”
peniosteal reaction.

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f. Leukemia and Lymphoma 3. In leukemic children, peniosteal reaction

I The clavicle
. rarely is involved in leuke- may be seen along the clavicle on radio-
mia and lymphomas. graphs (Figure 35A). Osteolytic lesions are
2. These lesions may be seen at any age, more often seen in older children and adults
but they are more common in children and with leukemia (Figure 35B) and lymphoma (Fig-
young adults. une 35C).

35A

Figure 35
(A) Acute leukemia with peniosteal reaction along Note the extensive peniosteal new bone formation.
the clavicles in a child (B) Leukemia presenting as (C) Lymphoma of the left distal clavicle and adja-
an osteolytic process in the left clavicle of an adult cent scapula presenting as an osteolytic process.

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V. METABOLIC AND ENDOCRINE DISORDERS

A.

I The clavicle
. is a common site of in- also may be seen at the medial end of the
volvement both in the primary and secondary bone); (3) bone resorption along the inferior
forms of hyperpanathyroidism. border of the distal clavicle at the attachment
2. The disease may be seen at any age. of the conacoclaviculan ligament; (4) a brown
3. The radiographic findings in hyperpara- tumor, which may be seen in primary hypen-
thyroidism include: (1) generalized osteo- parathyroidism as an expansile, osteolytic le-
penia; (2) bone erosions at the distal end of sion with rather well defined margins; and (5)
the clavicle (Figure 36) (less severe erosions pseudofractures (Loosen’s zones) resulting from
osteomalacia (Figure 37).

Hyperparathynoidism Note the bone erosions at the

distal end of the clavicle and subpeniosteal nesonp-
tion in the region of the conoid tubencle.

Looser’s zone in the right clavicle in a patient with

hyperparathynoidism (arrow) Note the generalized
osteomalacia.

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VI. ARTHPITIDES
A. Rheumatoid Arthritis

I The acromioclaviculan
. joint is a com- 3. Synovial inflammation of these joints
mon site of arthritic involvement. Stennoclavi- leads to erosive changes at the ends of the
cular joint involvement is frequent, but the clavicle.
changes are difficult to appreciate on plain 4. Radlographs display bone erosions, es-
racliographs. pecially at the distal ends of the clavicles with
2. Most patients are middle aged and old- widening of the acromioclavicular joints (Fig-
en women, although children are affected in ure 38). The stennoclavicular joint may show
juvenile rheumatoid arthritis with predominant similar findings but requires plain on computed
involvement of the stennoclaviculan joint. tomography for proper evaluation.

Figure 38
Rheumatoid arthritis in a patient
with longstanding disease which
has caused bone erosions at the
left acromioclavicular joint

B. Ankyloslng Spondylitls and Diffuse 2. On nadiognaphs, bone proliferation on

idiopathic Skeletal Hyperostosis (DISH) “whiskening,” ligamentous calcification and
ossification, and panaarticulan osteophytes
I . Enthesopathy may occur at the attach- may be seen (Figure 39).
ment of the conacoclavicular and costoclavi-
cular ligaments in these disorders.

Figure 39
Ankylosing spondylitis with
marked bone proliferation of the
right clavicle Note the “whisker-
ing” in the region of the conoid tu-
bencle, representing enthesopathy.

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VII. MISCELLANEOUS DISORDERS 4, The child is febnile, irritable, and has 10-
A. Infantile Cortical Hyperostosis calized painful swelling oven the involved
bones.
(Caffey’s Disease) 5. Cortical hypenostosis is the hallmark of
I The clavicles,
. nibs and mandible are the the disease. The clavicle appears thick and
most common sites of involvement in infantile wide, surrounded by exuberant peniosteal ne-
cortical hyperostosis. One or both clavicles action on nadiographs (Figure 40).
may be affected. 6. Vitamin A toxicity may produce similar
2. The disease is seen in infants less than 5 changes, but it usually spares the mandible.
months of age. 7. Infantile cortical hyperostosis is a self
3. The etiology of this disease is unknown. limiting disease and subsides within a few
It may represent an infectious process. years.

Figure 40
Caffey’s disease in an infant with
extensive peniosteal reaction along
the right clavicle

B. Hypertrophic Osteoarthropathy 4. The exact pathogenesis of the process

is not known.
I . The clavicle is often involved, usually bi- 5. Radiographs show peniosteal reaction
laterally in hypertrophic osteoarthnopathy. of varying intensity along the clavicles (Figure
2. Most cases are seen in adults. 41).
3. It is seen with numerous systemic dis-
eases, but especially with bronchogenic carci-
noma.

Figure 41
Hypertnophic osteoarthropathy in a
patient with bronchogenic cancino-
ma Note the peniosteal new bone
formation along the distal right
clavicle (arrows).

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C. Paget’s Disease over 40 years of age.

(Osteitis Deformans) 3. The etiology of Paget’s disease is not
known.
I The clavicle
. is an uncommon site of in- 4. Radiographs show an enlarged clavicle
volvement in Paget’s disease. with marked cortical thickening and oblitena-
2. The disease is usually seen in patients tion of the medullany canal (Figure 42).

Figure 42
Paget’s disease of bone involving the night clavicle
which is markedly enlarged Note the loss of the
medullary cavity.

D. Neurofibromatosis 3. The radiognaphs may show “pencil

pointing,” with tapering of the clavicle, usually
I
Neurofibnomatosis
. is an autosomal dom- in its distal portion (Figure 43).
inant neunoectodenmal tissue disorder.
2. The clavicle may be eroded by neurofi-
bromas.

Figure 43
Neurofibromatosis Note bone erosion with tapering
of the distal left clavicle caused by neunofibnomas.
The sclerosis is artifactual due to technique.

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E. Thalassemia 3, It is a hereditary. hematologic disease

(Cooley’s Anemia) with defective globin synthesis.
4. The nadiognaphs of patients with thalas-
I The clavicle
. is commonly involved in semia show generalized osteopenia and a
Cooley’s anemia. coarse trabecular pattern in the medullany
2. This disease occurs in children of Medi- cavity owing to myeloid hyperplasia in bones,
tennanean descent. including the clavicles (Figure 44).

Figure 44
Thalassemia Note generalized os-
teopenia and increased trabecula-
tions in the bones, including the
right clavicle.

F. Sternoclavicular Hyperostosis men during the 5th and 6th decades of life.
4, Pustulan skin lesions of the hands and
I
. Stennoclaviculan hypenostosis is a painful soles of the feet may be present.
swelling about the sternoclavicular joints and 5. Subclavian vein occlusion may occur.
upper ribs. 6. The radiognaphs show osseous over-
2. The exact etiology of this lesion is not growth with bone expansion and sclerosis
known. It may represent an inflammatory pro- along the medial ends of the clavicles and up-
cess. per ribs(Figure 45).
3. Usually the condition occurs in older

Figure 45
Stennoclavicular hypenostosis There is thickening
and sclerosis of the bones about the manubnium.
The clavicles and first nibs are involved bilaterally.

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G. The Lateral Clavicle Hook is about 5 ± 2. In normal infants it is appnoxi-

mately 5.6 ± 3.4.
I This condition
. represents an excessive 5. A LCH index over 12 is considered ab-
upward convexity of the lateral portion of the normal.
clavicle.
2. The deformity has been described in
numerous congenital syndromes such as Holt-
Onam syndrome, TAR syndrome, etc., all of LCH Index =(b/a)x 100
which are associated with reduction deformi-
ties of the bones of the ipsilateral upper limb. It
can also be seen in newborns who sustain bra-
chial plexus injury during birth. Figure 46
3. The lateral clavicle hook (LCH) is ex- Lateral clavicle hook The diagram illustrates the
pressed as an index. This index is obtained as ii- measurement of the lateral clavicle hook (LCH) in-
lustrated in Figure 46. dex.
4. In normal children and adults, the index

H. Melorheostosis 4. On nadiographs, long bones including

the clavicle show marked cortical thickening
I A rare disorder of unknown
. etiology, and irregularity along the outer and inner sun-
melonheostosis begins in early childhood. The faces with narrowing of the medullany cavity
disease may be discovered at any age. resulting from extensive bone production (Fig-
2. Localized painful swelling may occur ure 47).
about the affected bones. 5. Ankylosis of the acromioclavicular and
3. Bone growth disturbance associated stennoclavicular joints may occur.
with melorheostosis may lead to significant de-
fonmity of the skeleton.

Figure 47
Melorheostosis of the right clavicle Note the exten-
sive bone proliferation along the midshaft.

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Sugg.st#{149}dReadings
I AIlman
. FL Jr. Fractures and ligamentous injuries of the 6. Neer CS II. Fracture of the distal clavicle with detach-
clavicle and Its articulation. J Bone Joint Surg (Am) ment of the coracoclavicular ligaments in adults. J
1967; 49:774-784. Trauma 1963; 3:99-110.
2. AppeIl RG. Oppermann HC. Becker W, Kratzat R, Bran- 7. Oestreich AE. The lateral clavicle hook: An acquired as
deis WE, Willich E. Condensing osteitis of the clavicle in well as a congenital anomaly. Pediatr Radiol 1981;
childhood: A rare sclerotic bone lesion-Review of lit- 11:147-150.
erature and report of seven patients. Pedlatr Radiol 8. Ozonoff MB. Pediatric orthopedic radiology. Philadel-
1983; 13:301-306. phia: Saunders, 1979.
3. Bragg DG. Shidnia H, Chu FC. et al. The clinical and ra- 9. Reeder MM, Felson B. Gamuts in radiology. Gamut D-
diographic aspects of radiation osteitis. Radiology 99, CIncinnati: Audiovisual Radiology of Cincinnati,
1970; 97:103-1 11. 1975.
4. Igual M, Giedion A. The lateral clavicle hook: Its objec- 10. Resnick D. Niwayama G. Diagnosis of bone and joint
tive measurement and its diagnostic value in Holt- disorders. 2d ed. Philadelphia: Saunders, 1987.
Oram syndrome, diastrophic dwarfism, thrombocyto- I I . Rockwood CA Jr. Green DP. Fractures in adults. Vol. I
penia-absent radius syndrome and trisomy 8. Ann Ra- Philadelphia: Llppincott. 1984.
diol 1979; 22:136-141. (French) 12. Wilner D. Radiology of bone tumors and allied disor-
5, March HC. Congenital pseudarthrosis of the clavicle. J ders. Philadelphia: Saunders, 1982.
CanAssocRadiol 1968; 19:167-169.

Figure 47 previously appeared in Diagnosis of Bone and Joint Disorders (10). Courtesy
of W. Pogue. M.D., San Diego, CA.

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