Chest Wall: Clavicle


Chest Wall: Clavicle

Table 5.11 Clavicle: erosions and contour irregularities of the sternoclavicular and acromioclavicular joints





False appearance of midshaft fracture due to rotation or projection, especially in children.

A vascular channel in the bone may simulate a fracture.

Conoid tubercle

Bump on posteroinferior distal one-third of clavicle.

Attachment for the conoid portion of the coracoclavicular ligament. Ligament between conoid tubercle and coracoid process may undergo ossification, usually secondary to trauma.

Posttraumatic osteolysis

Fig. 5.10

Fig. 5.11a, b

Resorption of the distal or proximal ends of the clavicle. Acromioclavicular (AC) joint appears widened with erosions at the distal end.

May follow 6–8 wk after trauma at the AC joint.


Destruction and periosteal reaction.

Primary infection of bone (spread from trauma or blood) or secondary spread from sterno-clavicular or AC joints.


Generalized bone demineralization, erosion of the distal ends of the clavicles, and bone resorption along the inferior border of the distal clavicle at the attachment of the coracoclavicular ligament.

Brown tumor may be seen in primary hyper-parathyroidism (see Table 5.75 ). Pseudofractures (Looser zones).


Aseptic necrosis of the medial end of the clavicle (Friedrich disease).

Sclerosis of the medial end of the clavicle may persist.

Juvenile idiopathic arthritis (JIA)

Erosions at the ends of the clavicles with widening of AC joint.

Sternoclavicular joint involvement may be diff cult to appreciate on radiographs and may require cross-sectional imaging for detection of inflammatory changes.

Ankylosing spondylitis

Enthesopathy at the coracoclavicular and costoclavicular ligaments with bone proliferation and ligamentous calcification on radiographs and bone marrow edema on MRI.


Fig. 5.12

Langerhans cell histiocytosis, aneurismal bone cyst, hemangioma. Clavicle is rare site of involvement for fibrous dysplasia, metastasis, osteosarcoma, Ewing sarcoma, leukemia, and lymphoma.

Radiation necrosis

Spectrum of findings from localized bone demineralization to frank bone destruction.

An osteochondroma may arise at the medial end of the clavicle following irradiation of the bone during childhood. Pathologic fractures often fail to heal (pseudarthrosis). Secondary osteosarcoma may develop as a late complication.


Pressure erosions. Tapering of the clavicle (“pencil pointing,” distal > proximal).

Infantile cortical hyperostosis (Caffey disease)

Cortical hyperostosis. Clavicle appears thick and wide and is surrounded by exuberant periosteal reaction.

Infants less than 5 mo of age. Clavicles, ribs, and mandible are most common sites. DD: vitamin A toxicity.


Bone destruction, extensive sclerosis, and bone enlargement.

(see Table 5.1 )


Marked cortical thickening and characteristic dripping candle wax appearance.

Localized painful swelling and growth disturbances. Follows distribution of dermatomes.

Fig. 5.10 Posttraumatic osteolysis. Osteolysis of the sternoclavicular joint in a 17-year-old weightlifter, likely secondary to overuse.
Fig. 5.11a, b Posttraumatic osteolysis. Osteolysis of the AC joint from overuse in a football player (arrow in a). Bone marrow edema is seen on sagittal oblique MRI in the acromion with subchondral cysts and fluid in the AC joint (arrow in b) on axial imaging.
Fig. 5.12 Clavicle tumor. Aneurysmal bone cyst expanding the distal end of the clavicle (arrows).

Table 5.12 Clavicle: handlebar deformity or lateral clavicle hook—angulated clavicle or superior inclination of the clavicles (Fig. 5.13)




Brachial plexus injury

Handlebar deformity is acquired presumably from neuromuscular weakness.

VACTERL (vertebral defects, anal atresia, cardiac malformations, tracheoesophageal fistula with esophageal atresia, radial or renal dysplasia, and limb anomalies) association

(see Table 5.50 )

Radial ray defects (Holt-Oram syndrome, thrombocytopenia absent radius syndrome, Fanconi pancytopenia)

In addition to handlebar, clavicles may be hypoplastic with bulbous ends.

Pierre Robin syndrome

Radiohumeral synostosis, hypoplasia of the mandible, congenital amputations, syndactyly.

Overlap with other syndromes/anomalies: amniotic band syndrome, Beckwith-Wiedemann syndrome, CHARGE syndrome.

Campomelic dysplasia

Fig. 5.14a, b

Hypoplastic tibia, scapula, and vertebral bodies. Pear-shaped iliac bones, long femora that are anteriorly bowed, and deficient ossification of the pubis.

Lethal skeletal dysplasia. Pulmonary hypoplasia and laryngeal and tracheal stenosis. Ureteral stenosis. Thoracic platyspondyly and kyphosis. Multiple cutaneous dimples in the arms and legs.

Osteogenesis imperfecta

Handlebar deformity is acquired.

Cornelia de Lange syndrome

(see Table 5.50 )

Schneckenbecken dysplasia

Snail-shaped ilia, flat acetabular roofs, handle-bar clavicles, hypoplastic scapula, dumbbell-shaped very short long bones, wide fibula, and round vertebral bodies.

Hypoplastic vertebral bodies with relatively well-preserved posterior arches.

Fig. 5.13 Handlebar deformity of the clavicles.
Fig. 5.14a, b Campomelic dysplasia with hypoplastic scapulae and cervical vertebral bodies (a) and bowing of the extremities, dislocated hips, deficient ossification of the pubis, and hypoplastic fibulae and tibiae (b).

Table 5.13 Clavicle: pseudarthrosis




Posttraumatic pseudarthrosis

Continued lucency through the fracture with smooth fracture margins and adjacent sclerosis beyond when healing with union is expected. Exuberant callus formation without bridging.

Nonunion common in fractures that occur distal to the coracoclavicular ligament attachment.


Defect in the middle clavicle with no callus formation. Ends may be sclerotic and tapered.

Usually seen within 2 wk after birth. Right clavicle involved. Left clavicle if dextrocardia.

Cleidocranial dysplasia

Fig. 5.15a–d

Hypoplastic or absent clavicles: often central portion of the clavicle is absent with rudimentary medial and lateral portions remaining.

Clavicle findings may be confused with congenital pseudarthrosis.

Fig. 5.15a–d Cleidocranial dysplasia. (a) Hypoplastic clavicles and spinous processes. (b–d) Nonossification of the majority of the skull, pubic, and ischial bones.

Table 5.14 Clavicle: hypoplasia or absence




Posttraumatic osteolysis

Fig. 5.10, p. 499

Fig. 5.11, p. 499

(see Table 5.11 )

Postsurgical resection

Fig. 5.16

Destructive process

Tumor, infection.

Trisomy 13 and 18

Osteogenesis imperfecta

Slender, osteoporotic, and hypoplastic clavicles.

± Fracture with exuberant callus formation.

Cleidocranial dysplasia

Fig. 5.15a–d

(see Table 5.13 )

Cardiomelic syndrome (Holt-Oram syndrome)

Hypoplastic clavicles with bulbous ends (handlebar).

Otopalatodigital spectrum (e.g., Melnick-Needles syndrome)

(see Table 5.26 )

Scoliosis, joint subluxations, long fingers and toes.

Focal dermal hypoplasia (Goltz syndrome)

Syndactyly, polydactyly, camptodactyly, and skeletal absence deformities.


Generalized bone sclerosis and mild modeling deformity of the bones.

Short-limbed dwarfism with generalized increase in bone density. Acroosteolysis. Brittle bones.


Usually distal portion of clavicle affected.

Absent due to fibrosis. Rare: 1 in 8 million. Infant with an “old man appearance.” Generalized skeletal hypoplasia. Small mandible and face.

Fig. 5.16 Postsurgical resection. Postsurgical appearance of the medial right clavicle (arrow) after resection of Ewing sarcoma.

Table 5.15 Clavicle: congenital, genetic, and syndromic diseases that may alter the clavicle





Generalized osteopenia and coarse trabecular pattern in the intramedullary cavity.

Myeloid hyperplasia produces the radiographic findings that commonly involve the clavicle.

Turner syndrome

Short, premature fusion of manubriosternal junction or mesosternum, decreased ratio of sternal body to manubrium, two ossification centers, bowing, mild pectus excavatum.

(see Table 5.30 )

Poland syndrome

Absence of the pectoralis major muscle and syndactyly.

Other associated chest wall abnormalities: deformity of the sternum, absence or atrophy of the second to fifth ipsilateral ribs and other chest wall muscles, aplasia of the ipsilateral breast or nipple, and simian crease of the affected extremity.

Cleidocranial dysplasia

Fig. 5.15a–d, p. 502

Hypoplastic or absent clavicles: often central portion of the clavicle is absent with rudimentary medial and lateral portions remaining.

Delayed ossification of the pubic bones. Increased shoulder joint mobility. Delayed closure of the anterior fontanelle.

Primary hyperoxaluria (oxalosis)

Sclerosis and bulbous deformity of the me-dial ends (drumstick clavicles). Osteoporosis in the early phase and diffuse bone sclerosis in the advanced stage. Subchondral sclerosis in the long bones. Metaphyseal sclerosis, dense epiphyses.

Growing ends of bones show bulbous enlargement. Pathologic fractures are common. Growth disturbance and increased incidence of urinary calculi due to hyperoxaluria.

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Jul 12, 2020 | Posted by in PEDIATRIC IMAGING | Comments Off on Chest Wall: Clavicle

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