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Normal and abnormal clavicle: image review Poster No.: P-0085 Congress: ESSR 2015 Type: Educational Poster Authors: A. O' Brien , A. levai , T. Simelane , N. Ramesh ; Dublin/IE, 1 2 1 2 1 2 PORTLAOISE/IE Keywords: Anatomy, Bones, Musculoskeletal bone, Conventional radiography, CT, Education, Normal variants, Acute, Arthritides, Metastases DOI: 10.1594/essr2015/P-0085 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. 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Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.essr.org Page 1 of 20 Learning objectives The purpose of this poster is provide an illustrative guide to the changes seen in the clavicle and the uniqueness of this long bone Background The clavicle {collar bone} is an 'S' shape bone, the medial aspect is convex, and the lateral aspect concave. Divided into a sternal end, a shaft and an acromial end. Sternal (medial) End The sternal end articulates with the manubrium of the sternum at the sternoclavicular joint - an articular disc with a large facet; it is marked by a rough oval depression for the costoclavicular ligament Shaft The lateral one-third and medial two-third; The lateral one third is more flattened and thinner consisting of two borders, the anterior and posterior, two surfaces, the superior and inferior. The anterior border is concave forwards and deltoid muscle originates at this end. The posterior border is convex backwards and has the attachment of the trapezius muscle. The inferior border the conoid tubercle and the trapezoid ridge which gives attachment to the medial part of the coracoclavicular ligament{ the conoid ligament} and the lateral part of the coracoclavicular ligament{ the trapezoid ligament} The medial two thirds is circular and thicker consists of 4 surfaces. The anterior surface is convex forwards and has the origin of the pectoralis major; the posterior surface is concave backwards and has the origin of sternohyoid muscle; the superior surface; the inferior surface has the subclavian groove with attachment of the subclavius muscle. The shaft of the clavicle acts a point of origin and attachment for several muscles - deltoid, trapezuis, subclavius, pectoralis major, sternocleidomastoid and sternohyoid Acromial (lateral) End Page 2 of 20 The acromial end has a small facet for articulation {incomplete articular disc} with the acromion of the scapula at the acromioclaviclar joint, with attachment for two ligaments: Conoid tubercle - attachment point of the conoid ligament, the medial part of the coracoclavicular ligament Trapezoid ridge - attachment point of the trapezoid ligament, the lateral part of the coracoclavicular ligament. UNUSUAL FEATURES OF CLAVICLE 1. 2. 3. 4. 5. 6. 7. 8. 9. th First bone to ossify in foetus{5-6 week} Only long with 2 primary centres of ossification Only bone that ossifies in membrane{ not cartilage} Only long bone in the body that lies horizontally Has no medullary cavity Subcutaneous along its entire length Commonest bone amongst the 206 bones in the human body to fracture One of the only long bone that does not require routine two orthogonal views One of the easiest bones that can be assessed clinically. Imaging findings OR Procedure Details RADIOGRAPHY: OF THE CLAVICLE Radiograph of the clavicle it is desirable to perform a Postero- Anterio {PA},as the clavicle is close to the image reader to give optimum skeletal detail. It also reduces the radiation dose to the eyes and thyroid. The entire length of the clavicle should be included on the image, the lateral end of the clavicle clearly demonstrated with no foreshortening of the clavicle Alternate radiography include Anterio-Posterior view { AP} if patient immobile; Angulated {15-30 degrees} inferio-superior view may be useful in demonstrating certain fractures. Companion shadow is a term used to describe the appearance of a smooth, homogenous, density{ skin and subcutaneous fat } with a well-defined stripe that runs Page 3 of 20 parallel to the clavicle , not seen in every radiographs and can mimic periosteal reaction or other pathology Though non traumatic lesions are more common in lateral third of clavicle, some of the lesions like Freidrich`s disease, condensing osteitis, sternocostoclavicular hyper ostosis are quiet common at the medial end. Table: Congenital/developmental Birth Fracture Congenital Defects of Clavicle Congenital Pseudoarthrosis of Clavicle Cleidocranial dysplasia Short Clavicle syndrome Metabolic / Endocrine disorders Hyper Parathyroidism Hyper vitaminosis A, D Inflammatory Infantile Cortical Hyperostosis Infective-Bacterial Osteomyelitis Non suppurative Periostistis (CRMO, SAPHO, SCCH) Spondyloarthropathy-Rheumatoid arthritis, Recurrent Trauma / Overuse syndromes Anterior Subluxation of sterno clavicular joint Distal Osteolysis of the clavicle Osteitis Idiopathic Friedrich`s Disease Neoplastic: Primary: Ewing's tumour Secondary: Metastatic lesions: lung, breast, thyroid Fractures of the clavicle are common, up to 10% of all fractures. The mechanism of injury is usually medium to high energy falling on an outstrecthed arm, in direct impact sports. Fractures are commonest at the junction of the middle third and lateral third, the weakest point of the clavicle. Traditionally, these fractures are management conservatively. Occasionally, though internal fixation may be necessary { in malunion or non union, reduced function }.Birth fractures account for 0.5-0.9% of normal deliveries, Page 4 of 20 usually they are associated with difficult delivery, Some of the children may have brachial plexus injuries. They heal without any residual problems. Cleidocranial dysplasia, an autosomal dominant disorder,occurs in approximately 1 per million individuals worldwide. Individuals with cleidocranial dysplasia usually have underdeveloped or absent clavicles, only the medial part of the bone is absent, in 10% cases, they are totally absent. Caffey's Disease: {infantile cortical hyperostosis} an autosomal dominant disorder where in there is excessive new bone formation -hyperostosis is a bone disorder that most often occurs in babies. Changes are noted in the clavicle, including other bonesmandible, scapulae, mandible, long bones. Occurring in approximately 3/1000 infants, it is a self limiting disease, with changes not seen over the age of two months. EROSIONS LATERAL END OF THE CLAVICLE Bilateral: Hyperparathyroidism ; rheumatoid arthritis; scleroderma Unilateral: Trauma, metastatic, myeloma, osteomyelitis Images for this section: Page 5 of 20 Fig. 1 Page 6 of 20 Fig. 2: TABLE 1 Page 7 of 20 Fig. 3 Page 8 of 20 Fig. 4 Page 9 of 20 Fig. 5 Page 10 of 20 Fig. 6 Page 11 of 20 Fig. 7 Page 12 of 20 Fig. 8 Page 13 of 20 Fig. 9 Page 14 of 20 Fig. 10 Page 15 of 20 Fig. 12 Page 16 of 20 Fig. 11 Page 17 of 20 Fig. 13 Page 18 of 20 Conclusion A large number of pathologies involve the clavicles, often seen on Chest Radiographs. Pathological changes seen are either infective, benign {erosions secondary to systemic disorders} or primary or secondary malignant involvement. Some of these can often be subtle and missed on Chest radiographs, or changes seen in the clavicle may point to the underlying systemic disorders. References 1. Gray, Henry. Anatomy of the Human Body; Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout] 2. Clark's Positioning in Radiography 12Ed A. Stewart Whitley, Charles Sloane, Graham Hoadley, Adrian D. Moore CRC Press, 26 Aug 2005 3. E. Roos, M. Maas, S. J. M. Breugem, G. R. Schaap, and J. A. M. Bramer, "Nonbacterial Osteitis of the Clavicle: Longitudinal Imaging Series from Initial Diagnosis to Clinical Improvement," Case Reports in Rheumatology, vol. 2015, Article ID 182731, 4 pages, 2015. doi:10.1155/2015/182731 4. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. Feb 2009;91(2):447-60. [Medline]. Personal Information AMY O BRIEN ANDREA LEVAI THABISILE SIMELANE Page 19 of 20 NAGABATHULA RAMESH MIDLAND REGIONAL HOSPITAL, PORTLAOISE, IRELAND Page 20 of 20