Findings: Image #1 is an axial CT image through the clavicles. This lesion demonstrates bony sclerosis at the sternal end of the clavicle.

Image #2 is an axial CT image of the clavicle formatted in the bone windows. This image again demonstrates bony sclerosis at the sternal end of the left clavicle without evidence for periostitis, cortical destruction, or soft tissue mass.

Diagnosis: Condensing osteitis of the clavicle.

Discussion: Condensing osteitis of the clavicle is a rare, benign often painful disorder of uncertain etiology. There are only sixteen histologically proven cases to date. The clinical features of condensing osteitis include pain and local swelling as well as tenderness confined to the medial aspect of the affected clavicle. The duration of symptoms prior to diagnosis is often extensive. The pain may present intermittently or steady, but is generally mild. The pain on occasion may radiate to the supraclavicular fossa or ipsilateral shoulder. Although a few cases have been associated with trauma, the majority of the patients recall no acute traumatic episode.

The radiologic findings consist of homogeneously dense sclerotic medial clavicle. The sternal end of the clavicle may be slightly expanded, but invariably, there is absence of periostitis, joint space abnormality, or cortical destruction. CT scanning will generally demonstrate obliteration of the marrow space with dense sclerosis. Radionuclide bone scan will demonstrate increased uptake in the region of the affected clavicle.

As was previously stated, the exact etiology of condensing osteitis is uncertain but it is felt to possibly represent a low-grade osteonecrosis, and may in fact, be related to Friedrich disease. The differential diagnosis would include Friedrich disease, bone island, osteoid osteoma, fibrous dysplasia, osteoarthritis, osteomyelitis, sclerotic metastasis, and osteosarcoma. All of the above-named lesions, however, have associated characteristic findings. For example, a bone island is invariably asymptomatic. In addition, the radiologic findings consist of bony streaks blending into the normal trabecula. Osteoid osteoma may be symptomatic, but the pain is more severe at night. In addition, radiologic examination will demonstrate a radiolucent nidus surrounded by sclerotic bone. Osteomyelitis is generally a diagnosis of patients secondary to IV drug abuse. In contradistinction to condensing osteitis, osteomyelitis will demonstrate bone destruction, periosteal reaction, and often joint space narrowing. For the same reasons, metastasis and osteosarcoma may be differentiated from condensing osteitis. Treatment consists of nonsteroidal anti-inflammatory medications. In the most severe cases, excision of the medial third of the clavicle is a last resort.

Reference:
Greenspan, A. Condensing Osteitis of the Clavicle: A Rare But
Frequently Misdiagnosed Condition. AJR 1991;156:1011-1015.

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