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Condensing osteitis of the clavicle:magnetic resonance imaging as an adjunct methodfor differential diagnosis

Marianne A C Vierboom, Julia D J Steinberg, Eduard L Mooyaart, Martin H van Rijswijk

Department ofRheumatology,University Hospital,Groningen,The NetherlandsM A C VierboomM H van RijswijkDepartment ofRadiology,University Hospital,Groningen,The NetherlandsJ D J SteinbergE L MooyaartCorrespondence to:Dr Marianne A C Vierboom,University HospitalGroningen,Department ofRheumatology,Oostersingel 59,PO Box 30.001,Groningen 9700 RB,The Netherlands.Accepted for publication30 July 1991

AbstractCondensing osteitis of the clavicle is a benigndisorder leading to osteosclerosis of themedial end of the clavicle. The differentialdiagnosis between condensing osteitis of theclavicle and ischaemic necrosis of the medialclavicular epiphysis (Friedrich's disease),osteoid osteoma, and low grade osteomyelitiscan be difficult. In the case history reportedhere, magnetic resonance imaging was auseful non-invasive procedure for the diagnosisof condensing osteitis of the clavicle.

Condensing osteitis of the clavicle is a rare andbenign disorder, manifested by a painfulswelling at the medial end of the clavicle. It wasfirst described by Brower et al in 1974.1Clinically and radiologically the differentialdiagnosis- between condensing osteitis of theclavicle and ischaemic necrosis of the medialclavicular epiphysis (Friedrich's disease), osteoidosteoma, and low grade osteomyelitis can bedifficult. As magnetic resonance imaging isreported to be an excellent diagnostic modalityfor the imaging of bone abnormalities, westudied a patient with possible condensingosteitis of the clavicle using magnetic resonanceimaging.

Case historyA 37 year old woman with three young children

was referred to the department of rheumatologywith a 10 month history of a painful swelling ofthe medial end of the left clavicle. Raising theleft arm above shoulder level aggravated thepain. There was no history of infection ortrauma. She had no systemic complaints.

Examination showed slight tenderness andswelling over the medial end of the left clavicle.Abduction intensified the pain. No otherabnormalities were found. The results ofroutine biochemical tests were within normallimits.

Plain radiography and polytomography (fig 1)of the left sternoclavicular joint showed bonysclerosis of the caudal half of the medial end ofthe left clavicle without joint narrowing ordestruction of the articular surface. A tech-netium-99m total body bone scan (fig 2) showeda unifocal, intense uptake at the medial end ofthe left clavicle.The clinical and radiographic features sug-

gested the diagnosis of condensing osteitis of theleft clavicle. Non-steroidal anti-inflammatorydrugs (NSAIDs) and limitation of physicalactivities were advised. During the followingyear the symptoms did not subside and theradiographic features remained constant. Toexclude other causes of sclerotic bony lesions,such as ischaemic necrosis of the medial clavi-cular epiphysis (Friedrich's disease), osteoidosteoma, and low grade osteomyelitis, weadvised an incisional biopsy of the clavicle. This

Figure I Tomography ofthe sternoclavicular region showing amorphous sclerosis ofthecaudal part oJ'the media end ofthe left clavicle. There is no narrowing oJ'thejoint ordestruction oJ'the articular surface.

Figure 2 Technetium-99m bone scan. There is a region ofhigh uptake at the medial end of the lefi clavicle.

Annals ofthe Rheumatic Diseases 1992; 51: 539-541

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Vierboom, Steinberg, Mooyaart, van Rijswpik

was refused by the patient. Therefore weperformed a magnetic resonance imagingexamination. TI (TR 650 ms, TE 20 ms) andT2 (TR 2000 ms, TE 100 ms) weighted spinecho images of the sternoclavicular region wereperformed in the coronal plane on a 1*5 Tmagnet system using a surface coil and a 180mm field of view. The TI weighted images (fig3A) showed an area of low signal intensity andan area with a complete lack of signal at themedial end of the left clavicle. There is a slightlythickened cortex. The T2 weighted images (fig3B) showed low signal intensities in this region.Within these areas no nidus or double lines wereseen. The soft tissue and joints were notaffected.The diagnosis of condensing osteitis of the

clavicle could thus be confirmed. After con-tinuation of treatment with NSAIDs andlimitation of physical activities, the symptomssubsided over the next follow up period of sixmonths.

Figure 3 (A) Ti weighted image (TR 650 ms, TE 20 ms) ofthe sternoclavicular regionshowing an area oflow signal intensity and an area with no signal. There is a slightlythickened cortex. (B) T2 weighted images (TR 2000 ms, TE 100 ms) showing low signalintensities at the medial end ofthe left clavicle.

DiscussionSince the first description by Brower et al in1974,' approximately 25 cases of condensingosteitis of the clavicle have been reported. Mostof the patients are women of late childbearingage who have a painful swelling over the medialpart of one clavicle. The pain is often referred tothe ipsilateral shoulder and is aggravated byabduction of the arm. Usually there is a historyof repeated mechanical stress. 1-3 Systemiccomplaints are absent. Routine laboratory testsare within normal limits. Plain radiographs andtomograms reveal bony sclerosis and mildenlargement of the inferomedial aspect of theclavicle. In all cases described, the sterno-clavicular joint and the adjacent soft tissuesappear to be normal; however, technetium-99mbone scintigraphy shows an increased accumu-lation of the isotope in this region.As the radiological features of condensing

osteitis of the clavicle are usually distinctive,several workers recommend that an excisionalor preferably an incisional biopsy should onlybe performed in patients with a doubtful clinicalor radiological presentation.4 5 As the symptomsof our patient did not subside, we questionedour diagnosis of condensing osteitis of theclavicle, but the patient refused the proposedbiopsy. As an alternative, we performed amagnetic resonance imaging examination. Inour opinion, the most difficult entities to beexcluded in this patient were ischaemic necrosisof the medial clavicular epiphysis (Friedrich'sdisease), osteoid osteoma, and low grade osteo-myelitis.There is a clinical similarity in Friedrich's

disease and the radiographic features can mimicthose of condensing osteitis of the clavicle,particularly in the first phase of the disease.6However, we expect the magnetic resonanceimaging findings of Friedrich's disease to besimilar to aseptic bony necrosis in the otherparts of the body-that is, a high signalintensity of the inner border parallel with a lowsignal intensity of the periphery, also known asthe double line sign.7 8 In our patient no doubleline sign was seen.

Osteoid osteoma is a benign tumour of thebone that consists of a nidus of osteoid tissuewith a highly vascular stroma, surrounded byreactive sclerosis. Radiological demonstration ofthe nidus may be difficult, even with tomo-graphy. Magneticresonanceimaging is extremelysensitive in showing the central nidus of highsignal intensity in the surrounding low signalintensity of sclerotic bone.7 9 A nidus was notfound in the clavicle of our patient.The clinical resemblance of low grade osteo-

myelitis with condensing osteitis of the claviclehas been discussed by several workers.' 2 4Radiographic features include a periostalreaction which was not present in our patient.Furthermore, there were no signs of soft tissuedisease or inflammation in the marrow onmagnetic resonance imaging examination,normally seen as areas of high signal intensityon T2 weighted images.' 'o

Our diagnosis of condensing osteitis of theclavicle could therefore be confirmed. Weconclude that if there is doubt about the clinical

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Condensing osteitis ofthe clavicle: magnetic resonance imaging as an adjunct methodfor differential diagnosis

presentation and radiographic features ofcondensing osteitis of the clavicle, magneticresonance imaging examination of the claviclecan be a discriminating non-invasive diagnosticprocedure. This is the first time diagnosis ofcondensing osteitis of the clavicle by magneticresonance imaging has been described.

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2 Duro J C, Estrada P, Ribas D, Bartons S, Rotes-Querol.Condensing osteitis of the clavicle [letter]. Arthritis Rheum1981; 24: 1454-5.

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Haghighi P. Condensing osteitis of the clavicle. AmRoenigenol 1983; 141: 387-8.

4 Kruger G D, Rock M G, Munro T G. Condensing osteitis ofthe clavicle: a review of the literature and report of threecases. Bone Joint Surg [Am] 1987; 69: 550-7.

5 Abdelwahab I F, Hermann G, Ramos R, Klein M J, KenanS, Lewis M M. Case report 623. Osteitis condensans of theleft clavicle. Skeletal Radiol 1990; 19: 387-9.

6 Linng G, Heinemeier G. Morbus Friedrich-AseptischeKnochennekrose des sternalen Klaviculaendes. FortschrRontgenstr 1981; 134: 74-5.

7 Holland B R, Freyschmidt J. KernspintomographischeErgebnisse bei Knochenveranderugen mit Skierose. FortschrRontgenstr 1988; 149: 513-21.

8 Ensign M F. Magnetic resonance imaging of hip disorders.Semin Ultrasound CTMR 1990; 11: 288-306.

9 Glass R B J, Poznanski A K, Fisher M R, Shkolnik A, DiasL. MR imaging of osteoid osteoma. . Comput Assist Tomogr1986; 10: 1065-7.

10 Cohen M D, Cory D A, Kleiman M, Smith J A, BroderickN J. Magnetic resonance differentiation of acute andchronic osteomyelitis in children. Clin Radiol 1990; 41:53-6.

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