Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients

Chronic osteomyelitis of the clavicle in a pediatric patient: A case report

INTRODUCTION AND IMPORTANCE

Clavicular osteomyelitis, unlike the metaphysis of long bones, is a rare condition that poses a challenge for orthopedic surgeons in terms of diagnosis. The unique location of the clavicle makes it crucial to diagnose and effectively manage these non-traumatic clavicular lesions promptly. Localized pain and swelling are common symptoms experienced by patients with clavicular osteomyelitis.

CASE PRESENTATION

A 9-year-old boy presented with swelling and pain in the left clavicular area for 6 months. There was no fever or history of trauma. Physical examination revealed a tender, 2 cm by 3 cm swelling over the left clavicular area, with no abnormal findings in other body systems. This case was treated with surgical debridement and PO cloxacillin, and his condition improved.

CLINICAL DISCUSSION

To achieve an accurate diagnosis, a thorough analysis of the patient's clinical presentation, along with blood workups, radiologic studies, bacteriological studies, and histopathological studies, is essential. Treatment options for clavicular osteomyelitis may involve surgery, medical intervention, or a combination of both. Existing literature suggests that the cure rate does not significantly differ between patients who receive medical treatment and those who undergo surgery for clavicular osteomyelitis.

CONCLUSION

In evaluating non-traumatic clavicular lesions, considering chronic osteomyelitis as a potential diagnosis is important. The final diagnosis is determined through analysis of the clinical presentation, laboratory and radiographic tests, and confirmation with assistance from local culture and biopsy.

Salmonella Sternoclavicular Septic Arthritis in a Non-sickle Cell Disease Patient

Septic arthritis is one of the most common orthopedic emergencies. In most cases, the joints affected are large (e.g., knees, hips, and ankles). The presentation of septic arthritis in the sternoclavicular joint (SCJ) has a relatively low prevalence rate, most commonly found in intravenous drug users. Staphylococcus aureus is the most common pathogen identified. We report a case of a 57-year-old male with a known case of diabetes mellitus, hypertension, and ischemic heart disease who complained of chest pain and was later found to have right-side SCJ septic arthritis. The procedure involves aspiration of pus using ultrasound guidance as well as irrigation of the right SCJ. The result of a pus culture from the right SCJ (a rare joint to be affected) was Salmonella, which is an atypical infection, specifically in non-sickle cell disease patients. The patient was treated with a specific antibiotic covering this pathogen.

Anatomical distribution, the incidence of malignancy and diagnostic workup in the pathological lesions of the clavicle: a review of 410 cases

BACKGROUND

The clavicle poses a diagnostic dilemma of the pathological lesions due to the wide range of pathologies seen at this site. This study aimed to identify and stratify various pathologies seen in the clavicle and to guide ways of investigation for diagnosis based on age, site and investigation findings.

MATERIALS AND METHODS

Four hundred and ten cases with clavicle lesions were identified in our database. Data were collected about the patient's medical history, previous investigation, inflammatory markers radiological investigations and biopsy. All patients were worked up and managed after discussion in a multidisciplinary team meeting (MDT).

RESULTS

Non-malignant lesions accounted for 79% of cases. Infection was the most common diagnosis (39%) and the commonest diagnosis in those less than 20 years of age. 73% of the lesions were found at the medial end of the clavicle. Malignant tumours were 21%, while primary benign bone tumours accounted for only 14%. 50% of the malignant lesions were due to metastatic disease. The risk of malignancy increases with advancing age. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were not sensitive as a diagnostic tool in cases of osteomyelitis confirmed by histology. Magnetic resonance imaging (MRI) was noted to have high sensitivity and specificity for identifying the nature of a lesion and diagnosis.

CONCLUSION

We have identified age as a positive predictor of a malignant cause in pathological lesions of the clavicle. MRI should be considered in all these cases. CRP and ESR have poor predictive values in diagnosing infection in the clavicle. Patients presenting with clavicle lesions should be discussed in a specialist MDT and undergo a systemic diagnostic workup, still in some cases, diagnosis can be speculated based on the patient's age, location of the lesion within the clavicle and the features seen on the MRI scan.

LEVEL OF EVIDENCE

IV.

A Rare Presentation of Brodie Abscess in the Clavicle

A 12-year-old otherwise healthy boy presented with acute shoulder pain and remote history of trauma. Despite an unimpressive clinical examination, laboratory workup, and initial radiographic evaluation, the patient was ultimately diagnosed with a Brodie abscess of the distal clavicle. Complete resolution was achieved with débridement and tailored antibiotic therapy. These abscesses are rare, often presenting surreptitiously with nonspecific symptoms and without systemic signs of infection. Therefore, maintaining a broad differential and high clinical suspicion is crucial to mitigate the increased morbidity that can result from a delayed diagnosis.

Similarities and Differences between Clavicular Bacterial Osteomyelitis and Nonbacterial Osteitis: Comparisons of 327 Reported Cases

Background

Currently, both clavicular bacterial osteomyelitis (BO) and nonbacterial osteitis (NBO) remain not well understood owing to their much lower incidences. This study is aimed at summarizing similarities and differences between clavicular BO and NBO based on comparisons of literature-reported cases.

Methods

We searched the PubMed and Embase databases to identify English published literature between January 1^st, 1980, and December 31^st, 2018. Inclusion criteria were studies evaluating clinical features, diagnosis, and treatment of clavicular BO and NBO, with eligible data for synthesis analysis.

Results

Altogether, 129 studies with 327 patients were included. Compared with BO, clavicular NBO favored females (P < 0.001) and age below 20 years (P < 0.001) and mostly presented in a chronic phase (disease term exceeding 2 months) (P < 0.001). Although local pain and swelling were the top two symptoms for both disorders, fever, erythema, and a sinus tract were more frequently found in BO patients (P < 0.01). Although they both favored the medial side, lesions in the clavicular lateral side mostly occurred in BO patients (P = 0.002). However, no significant differences were identified regarding the serological levels of white blood cell count (P = 0.06), erythrocyte sedimentation rate (P = 0.27), or C-reactive protein (P = 0.33) between BO and NBO patients before therapy. Overall, the BO patients achieved a statistically higher cure rate than that of the NBO patients (P = 0.018).

Conclusions

Females, age below 20 years, and a long duration of clavicular pain and swelling may imply NBO. While the occurrence of a sinus tract and lesions in the lateral side may be clues of BO, inflammatory biomarkers revealed limited values for differential diagnosis. BO patients could achieve a better efficacy than the NBO patients based on current evidence.

Medical management of septic arthritis of sternoclavicular joint: A case report

RATIONALE

Sternoclavicular joint septic arthritis is an unusual disease in healthy adults, and Staphylococcus aureus is the most common causative pathogen. The current treatment of choice is surgery with sternoclavicular joint resection and pectoralis flap closure, especially when the disease is complicated by osteomyelitis and abscess.

PATIENT CONCERNS

Here, we report a 76-year-old woman without risk factors who visited our hospital for pain and redness, swelling on the left anterior chest wall.

DIAGNOSIS

Magnetic resonance imaging showed infectious arthritis in the left SCJ, with multiple abscess pockets at the subcutaneous layer of anterior chest wall communicating with the joint cavity. Streptococcus agalactiae was isolated from blood culture.

INTERVENTION

She was treated with 6 weeks of antibiotic therapy.

OUTCOMES

After antibiotic treatment, she was successfully treated without recurrence.

LESSONS

Besides surgery, medical treatment should also be considered for sternoclavicular joint septic arthritis, depending on patient status and the causative pathogen. Physicians should be aware of this rare disease to facilitate its prompt diagnosis and management.

Clinical characteristics and treatment of clavicular osteomyelitis: a systematic review with pooled analysis of 294 reported cases

BACKGROUND

It is usually difficult to diagnose clavicular osteomyelitis (OM), and treatment is delayed because of its rarity. This study aimed to summarize clinical characteristics and treatment of this disease.

METHODS

We searched the PubMed and Embase databases to identify English studies that reported on clavicular OM from January 1980 through December 2016. Effective data were pooled for analysis.

RESULTS

In total, 111 studies comprising 294 cases (bacterial OM, 146; nonbacterial OM, 148) were included, with a sex ratio of 1.89:1 indicating female predilection. Overall, the median age at diagnosis was 16 years. The acute to chronic phase ratio was 0.30, with a median symptom duration of 4 months. The most frequently reported symptom was pain (192 cases), followed by swelling (151 cases) and fever (52 cases). Altogether, 86.94% cases of single-site involvement were reported, with the medial side being the most common site (69.95%). The erythrocyte sedimentation rate achieved the highest positive rate (74.44%) before treatment. The total positive rate of culture for bacterial OM was 81.82%, with Staphylococcus aureus being the most frequently detected pathogen (44.70%). The average cure rate was 83.52%, with no significant difference between surgical (89.70%) and nonsurgical (79.63%) cases (P = .079).

CONCLUSIONS

Clavicular OM, predominant in female patients and young people, usually occurred at a chronic stage. Pain was the most frequent symptom, with the medial side being the most involved site. The erythrocyte sedimentation rate may be a helpful indicator for diagnosis. Regardless of surgery or nonsurgery, most patients achieved a favorable prognosis.

A diagnostic dilema in benign lytic lesions of clavicle - our experience of 37 patients

INTRODUCTION

The studies on benign lytic lesion of clavicle are sparse. Asymptomatic nature of lesions, rare occurrence, the difficulty in interpretation of the X-rays because of the surrounding structures and striking similarities in various lesions further make the diagnosis of such atraumatic lytic lesions difficult.

MATERIAL AND METHODS

Prompted by the rarity of lesion and scarcity of data regarding presentation and management, we performed a prospective study of benign lytic lesions of clavicle. The results of the lesions are categorised in infective, metabolic and neoplastic conditions.

RESULTS

Infective lesions were most common cause of symptomatic painful benign lytic lesions. Metabolic lesions, like rickets, were the most common cause of painless swelling in clavicle. Neoplastic conditions although rare were an important differential.

CONCLUSION

It is important to differentiate and diagnose lytic lesions of clavicle. Early MRI and Biopsy of the lesion helps in preventing an undue delay in diagnosis. Most lesions when diagnosed in time have excellent results.

Sternoclavicular Joint Infection Presenting as Nonspecific Chest Pain

BACKGROUND

Sternoclavicular joint infection (SJI), to include septic arthritis (SA), is a rare cause of chest pain and is often found in patients with significant risk factors and sources for SA. Most acute care laboratory results lack significant sensitivity to rule out SA. Radiographic findings in common acute care imaging often does not reveal findings of SA and osteomyelitis in the acute phase of the infection.

CASE REPORT

We present a patient without significant risk factors for SA, who initially presented with 3 days of pain to the left chest, left neck and shoulder. He had fever and was treated with a short course of antibiotics for possible pneumonia. His symptoms recurred along with fever 36 days after the initial onset of symptoms and was then diagnosed radiographically with left-sided SJI. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case reinforces the need to maintain a broad differential diagnosis in the evaluation for chest pain and pursue advanced imaging, such as magnetic resonance imaging, when the pretest probability of SJI is high, especially in the acute phase of the infection.

Spontaneous Bilateral Sternoclavicular Joint Septic Arthritis and Lumbar Discitis: An Unusual Case in a Healthy Adult

Introduction

Septic arthritis of the sternoclavicular (SC) joint is a rare condition. Typically, it presents in patients with risk of infection and is usually unilateral. In this report, we describe a case of spontaneous bilateral sternoclavicular joint infection of an otherwise healthy adult.

Case Presentation

A 67-year-old man presented in our hospital complaining of 2-week history of neck and chest pain which was radiating to his shoulders bilaterally. Clinical examination revealed erythema and swelling of the sternoclavicular area. Inflammatory markers were raised. Image investigation with CT and MRI was undertaken and verified the presence of bilateral sternoclavicular joint infection. The patient received prolonged course of intravenous antibiotics since his admission. The patient was discharged in a good condition and followed up in clinic.

Conclusion

High index of clinical suspicion of SC joint infection is important for early diagnosis to avoid further complications.

Sternoclavicular Septic Arthritis Caused by Streptococcus pyogenes in a Child

Septic arthritis can be a devastating condition that leads to further morbidity and potential mortality if not identified early in its course. Emergency providers must keep septic arthritis high on their differential of any joint-related pain in the pediatric population. We present a case of an eight-year-old female who initially presented with the chief complaint of chest pain and was subsequently diagnosed with septic arthritis of the left sternoclavicular joint in the emergency department.

A Rare Case of Clavicle Osteomyelitis in a Child and Literature Review

Acute clavicle osteomyelitis in children is rare representing <3% of osteomyelitis cases. We treated a 12-year-old boy who presented with acute pain in the right clavicle and high fever for 4 days. MRI showed abnormal signal in the right clavicle with periosteal reaction. Staphylococcus aureus isolated from blood was susceptible to methicillin, clindamycin, and macrolides. Clindamycin was given intravenously for 3 wks and orally for another 3 wks with no recurrence. We reviewed clavicle osteomyelitis cases in children searching PubMed English literature. From a total of 89 studies retrieved, only 6 fulfilled the criteria and were analyzed. Sixteen patients (56% female) were included with a median age of 9 yrs (range 2 wks–16 yrs). Osteomyelitis was hematogenous in most cases, with S. aureus being the most frequent cause, isolated from either blood or tissue. Symptoms included fever, swelling, and localized bone tenderness. Antimicrobial therapy lasted for 4–12 weeks (median 7.5). Three patients required drainage or curettage. Recurrence occurred in 1/16 cases (6.2%) and persistence of symptoms occurred to 2/16 cases (12.5%) reported before 90s with unknown antimicrobial susceptibility of the pathogen. Acute clavicle osteomyelitis mainly affects older children and has generally good prognosis. Staphylococcus aureus is most commonly implicated and surgery may be needed.

Acute bacterial sternoclavicular osteomyelitis in a long-term renal transplant recipient

Kidney transplantation is the treatment of choice for a significant number of patients with end-stage renal disease. Although immunosuppression therapy improves graft and patient’s survival, it is a major risk factor for infection following kidney transplantation altering clinical manifestations of the infectious diseases and complicating both the diagnosis and management of renal transplant recipients (RTRs). Existing literature is very limited regarding osteomyelitis in RTRs. Sternoclavicular osteomyelitis is rare and has been mainly reported after contiguous spread of infection or direct traumatic seeding of the bacteria. We present an interesting case of acute, bacterial sternoclavicular osteomyelitis in a long-term RTR. Blood cultures were positive for Streptococcus mitis, while the portal entry site was not identified. Magnetic resonance imaging of the sternoclavicluar region and a three-phase bone scan were positive for sternoclavicular osteomyelitis. Eventually, the patient was successfully treated with Daptomycin as monotherapy. In the presence of immunosuppression, the transplant physician should always remain alert for opportunistic pathogens or unusual location of osteomyelitis.

Complicated acute haematogenous osteomyelitis with fatal outcome following a closed clavicle fracture-a case report and literature review

Among adults, post-traumatic osteomyelitis following a closed fracture is a rarely described entity in the literature, with the involvement of the clavicle bone being particularly uncommon. Early diagnosis and treatment of clavicular osteomyelitis is crucial to prevent serious consequences such as sepsis, mediastinitis and haemorrhage from the great vessels. A 54-year-old male patient presented to the emergency department complaining of fatigue and limited mobility after having fallen and hit his head and right shoulder 10 days previously. No major injury was found during the diagnostic procedure, and the patient was discharged. 2 weeks later, the patient returned with clinical signs of right upper arm cellulitis and probable sepsis. Diagnostic ultrasound imaging and MRI of the right upper arm, as well as re-examination of the X-ray image, confirmed acute complex osteomyelitis of the right clavicle following an overlooked clavicle fracture. Microbiological analysis confirmed clavicular osteomyelitis caused by Escherichia coli septicaemia. Despite prompt treatment with i.v. antibiotics and surgery, the patient's condition rapidly deteriorated and he passed away. Our case demonstrates the critical importance of early diagnosis and appropriate treatment of a closed fracture. Late diagnosis may lead to severe complications, such as complicated osteomyelitis and sepsis, and even a fatal outcome. Furthermore, a brief literature review is presented of previously reported acute osteomyelitis following a closed fracture, including evidence of affected bone and isolated pathogens. Although uncommon, osteomyelitis should be considered a possible cause of a deteriorating clinical condition in patients with a history of recent trauma.

Whole clavicle sequestration from chronic osteomyelitis in a 10 year old boy: A case report and review of the literature

Chronic osteomyelitis is a childhood disease and so it is not uncommon to diagnose it in a 10 year old boy who is suffering from pains and discharging sinuses from the left shoulder girdle. What is not common is the involvement of the clavicle in this infective process and even more uncommon is for the whole length of the clavicle to sequester. This case report describes a rare case of chronic osteomyelitis of the left clavicle in which the entire length was removed as a sequestrum during surgery. And despite the removal of an entire length of the clavicle in the patient, there was no functional deficit and there was also no shoulder asymmetry.

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Chronic osteomyelitis is common in childhood and clavicular involvement is less common than femur, tibia or humerus.

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In this clavicular osteomyelitis, the entire bone was sequestered.

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It is not absolutely important to have huge involucrum before sequestrectomy since it is not a weight bearing bone.

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The whole sequestered clavicle was necessarily removed despite the thin involurcum.

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Regardless, the removal of the entire bone was not associated with functional deficit or shoulder asymmetry.

[Infectious arthritis of sternoclavicular joint: surgical approach to the issue]

AIM

To study the features of occurrence, diagnosis, clinical course of infectious arthritis of sternoclavicular joint, as well as to develop differentiated therapeutic tactics depending on the clinical form and stage of disease.

MATERIAL AND METHODS

It was analyzed treatment of 18 patients with infectious arthritis of sternoclavicular joint aged 27 to 88 years who were hospitalized for the period 2008-2014. Acute or chronic forms were determined depending on clinical course and serous arthritis, para-articular phlegmon and osteoarthritis--according to nature of tissue damage. Hypothermia and blunt trauma were often preceded to onset of disease. Diabetes and drug addiction were present as comorbidities. Also disease as the variant of purulent metastasis in case of sepsis was noted. Bone scintigraphy, CT and magnetic resonance imaging are the most informative.

RESULTS

Infectious arthritis of sternoclavicular joint often had hematogenous origin, and Staphylococcus aureus was the most common cause. At the stage of serous arthritis antibacterial therapy was effective. Incision and drainage were performed urgently in case of para-articular phlegmon. Sternoclavicular joint resection was performed usually in 2-3 months after subsidence of inflammation.

Appearances are Deceptive: Staphylococcus Superinfection of Clavicular Tuberculous Osteomyelitis

A man, aged 25 years, presented with pain, swelling, and drainage from the right clavicular area. He had a past history of abscess at the sternoclavicular joint. The cultures from the drainage site grew methicillin-sensitive Staphylococcus aureus, and he was placed on appropriate antibiotics. As S. aureus infection of the clavicle is often secondary in nature, particularly in adults, a thorough workup was done to identify the underlying cause. Quantiferon gold, done as a part of the workup, came back positive, while the bone cultures grew S. aureus and Mycobacterium tuberculosis. He was placed on 9 months of combination therapy for tuberculosis osteomyelitis with a good clinical outcome.

Streptococcus pyogenes sternoclavicular septic arthritis in a healthy adult

Sternoclavicular septic arthritis is a rare infection, accounting for approximately 1% of septic arthritis in the general population. Staphylococcus aureus is the predominant etiologic agent, and it usually occurs in relatively young adults with some type of predisposition to infection. We report, to the best of our knowledge, the first case of group A streptococcal, sternoclavicular arthritis in a previously healthy 62-year-old male patient. We present a detailed history and physical examination, with laboratory findings, imaging studies, cultures, and therapy.

Bilateral clavicle osteomyelitis: A case report

INTRODUCTION

Osteomyelitis of the clavicle is rare. Infection occurs from hematogenous spread or trauma. In adults infection is usually secondary due to an exogenous cause such as open fractures, surgery (iatrogenic) or spread from local tissue with infection.

PRESENTATION OF CASE

The case is presented here of a 50-year old female with bilateral clavicular fractures, who was operated on with open reduction and internal fixation. At the 6-month follow-up, she had complaints of bilateral osteomyelitis which was successfully treated with resection of the infected segment of the bone, and antibiotic impregnated collagen.

DISCUSSION

Predisposing factors include diabetes, intravenous drug abuse, tuberculosis or immune suppression. Management involves the removal of bone fixation, debridement of the bone and if there is a defect, coverage with a muscle flap is applied.

CONCLUSION

In cases of clavicular osteomyelitis where infection continues despite debridement and antibiotic therapy, excision of the sequestered clavicular section is a successful treatment approach and has been seen to improve quality of life without any functional loss.

[Acute osteomyelitis of the clavicle in the newborn infant: a case report]

Acute osteomyelitis of the clavicle accounts for less than 3% of osteomyelitis cases, with its usual location in the middle third. It may be hematogenous, due to contiguity, or secondary to catheterization of the subclavian vein or neck surgery. The diagnosis is often delayed, and clinical symptoms may simulate obstetric brachial plexus palsy in young children. We report a new case of osteomyelitis of the clavicle in a 30-day-old newborn.

Sternoclavicular osteomyelitis: a new complication of misplaced tracheostomy tube

We report a patient who presented with erythema and swelling over the chest and neck several days after the placement of a tracheostomy tube. Sternoclavicular osteomyelitis and anterior mediastinal abscess occurred, as complications of inadvertent pretracheal tracheostomy tube placement, which were treated with right sternoclavicular resection and mediastinal drainage.

Bone tumors of the clavicle: risk of malignancy in the elderly and safe needle biopsy

The clavicle is a rare site for bone tumors and little is known from the limited literature about the prognostic factors and management techniques, including biopsy. The method of biopsy is controversial in the clavicle because of the risk of injury to the neighboring neurovascular structures. Twenty patients with clavicular lesions were retrospectively reviewed with clinical, radiological, and histopathological reports. A needle biopsy was planned in the presence of an osteolytic lesion providing nonforceful entry of the needle, detailed knowledge obtained about the local anatomy, and known availability of an oblique angle for the needle entry away from vascular structures. A needle or tru-cut biopsy was performed for preoperative histopathological diagnosis in 6 selected patients with no complications. Considering the histological diagnosis and prevalence of clavicular bone tumors, benign and malignant lesions had a similar prevalence rate; however, malignant tumors occurred in an older (>50 years) population (P=005). Statistical analysis revealed that the best cutoff point for age for discriminating malignant lesions was 50 years with high sensitivity. The main concern for these patients is primary lesion site treatment and symptom palliation. Every clavicular lesion in patients older than 50 years should be considered as malignant unless proven otherwise. This article demonstrates that needle biopsy can be performed safely in selected lesions with particular attention to cross-sectional local anatomy during needle insertion.

Clavicular tuberculosis following trivial trauma

Tuberculosis of the clavicular bone is a very rare clinical entity, with limited cases reported in the United States. Furthermore, sparing of the sternoclavicular joint is exceedingly unusual. A literature review of the prevalence of clavicular tuberculosis identified fewer than 80 cases reported since the discovery of the tubercular bacillus, over a century ago. To our knowledge, there have been no cases reported over the last decade in the United States. A rare case of tuberculous osteomyelitis of the clavicle in an immunocompetent patient who presented with swelling of the upper chest is reported.

Tubercular osteomyelitis of the clavicle: a report of four cases

We report the clinicoradiological features of tuberculosis in the clavicle in 4 patients. The patients' ages ranged from 9 months to 29 years. All patients were managed with antitubercular drug therapy for one year and one underwent surgical debridement and curettage as well. Clinicians should be aware of the varied presentation (pain, non-healing ulcer, abscess, multifocal osteoarticular tuberculosis) of this condition. With the worldwide resurgence of tuberculosis, clinicians should maintain a high index of suspicion. The diagnosis of osteoarticular tuberculosis is usually made on clinico-radiological features.

Bilateral sternoclavicular joint septic arthritis secondary to indwelling central venous catheter: a case report

Introduction

Septic arthritis of the sternoclavicular joint is rare, comprising approximately 0.5% to 1% of all joint infections. Predisposing causes include immunocompromising diseases such as diabetes, HIV infection, renal failure and intravenous drug abuse.

Case presentation

We report a rare case of bilateral sternoclavicular joint septic arthritis in an elderly patient secondary to an indwelling right subclavian vein catheter. The insidious nature of the presentation is highlighted. We also review the literature regarding the epidemiology, investigation and methods of treatment of the condition.

Conclusion

SCJ infections are rare, and require a high degree of clinical suspicion. Vague symptoms of neck and shoulder pain may cloud the initial diagnosis, as was the case in our patient. Surgical intervention is often required; however, our patient avoided major intervention and settled with parenteral antibiotics and washout of the joint.

Post-traumatic osteomyelitis of the clavicle: A case report and review of literature

Osteomyelitis of the clavicle is a rare form of infection occurring from hematogenous spread or trauma. This has been reported following head and neck surgery, and subclavian catheter placement. In traumatic cases, the management involves removal of bone fixation, debridement of the bone and coverage with a muscle flap.

Infection and musculoskeletal conditions: Osteomyelitis

Osteomyelitis can result from hematogenous or contiguous microbial seeding of the bone. Staphylococcus aureus is the most common infecting microorganism. Although any bone can potentially develop osteomyelitis, long-bone, vertebral, and foot osteomyelitis account for the majority of cases. Confirmatory diagnosis of osteomyelitis often depends on the results of a bone biopsy and bone cultures. Radiologic and laboratory studies are often helpful in leading to the diagnosis, determining the extent of the disease, and following up selected patients with osteomyelitis. Optimal therapy for osteomyelitis requires the collaboration of a multidisciplinary team of physicians. Debridement is often needed in contiguous osteomyelitis, whereas acute hematogenous and vertebral osteomyelitis can often be treated with a prolonged course of antimicrobial therapy.

Clavicular osteomyelitis: a rare complication after surgery for head and neck cancer

Clavicular osteomyelitis (COM) is a rarely described disease entity, occurring especially after head and neck surgery. We herein report the ninth case according to the English language literature and describe the pertinent diagnostic and therapeutic measures to treat this complication. A 63-year-old Caucasian male underwent total laryngectomy and partial pharyngectomy for a post-radiotherapy recurrence of a T2 hypopharyngeal cancer. He presented multiple systemic (cardiovascular problems, previous pneumonectomy, malnutrition) and local-regional (previous radiotherapy, neck dissection, tracheostomy) factors favoring postoperative complications. Sixteen days after surgery, he developed a painful swelling with overlying erythematous skin at the level of the medial portion of the left clavicle. A purulent discharge from the adjacent stomal dehiscence was also noted. COM, suspected on the base of patient's history and clavicular inspection, was confirmed by CT scan. Surgical debridement allowed for definitive diagnosis, ruling out any possible suspicion of stomal recurrence or secondary localization to the clavicle. Cultures from the debrided bone sequestra grew Streptococcus pyogenes Group A and allowed for proper targeting of antibiotic therapy, which was carried out for 4 weeks after surgery. Four years after surgery the patient is tumor-free and does not show any sequela related to the COM or its treatment. COM is a rarely encountered complication after major head and neck surgery. Nevertheless, prompt diagnosis and treatment are mandatory due to the potential life-threatening evolution of this condition.

Sternoclavicular infectious arthritis in previously healthy adults

OBJECTIVE

To define characteristics of sternoclavicular infection (SCI) in previously healthy patients.

METHODS

SCI in a previously healthy man is reported along with 4 similar cases found by surveying the hospital's database; 22 previously reported cases were culled from the literature and summarized.

RESULTS

The frequency of SCI in healthy adults was 0.5% of all bone and joint infections admitted to the hospital. The clinical and bacteriologic features were similar to previous reports in nonselected SCI patients. Computerized tomography (CT) scan, arthrocenthesis, and biopsy were required for diagnosis. Complications included abscess formation, mediastinitis, and sepsis. The majority of patients were treated by surgical drainage and antibiotics. The final outcome was good, without mortality or long-term morbidity.

CONCLUSIONS

Although SCI is a rare infection in healthy adults, it should be considered in the differential diagnosis of a painful sternoclavicular joint. Prompt diagnosis and appropriate treatment of SCI results in excellent outcome in most cases.

Chronic recurrent multifocal osteomyelitis in children: diagnostic value of histopathology and microbial testing

Chronic recurrent, unifocal or multifocal osteomyelitis (CRMO), an inflammatory disorder of unknown origin, involves different osseous sites and may be associated with palmoplantar pustulosis. Bacterial cultures of affected tissue were reported negative in nearly all cases. Radiological and magnetic resonance imaging features of CRMO have been described, but differential diagnosis remains difficult, including rheumatic diseases, bacterial osteomyelitis, and malignancy. Although definite diagnosis relies on histopathologic confirmation by biopsy, histopathologic criteria have not been defined. Because CRMO may be treated with nonsteroidal antiinflammatory drugs, but not antibiotics, distinguishing CRMO from bacterial osteomyelitis is of major importance. Histopathologic analysis of 12 patients with CRMO indicated a wide variation of reparative changes of bone, but chronic inflammation could not be found at all sites in the same biopsy. The inflammatory infiltrate was mostly scattered, consisting mainly of lymphocytes, plasma cells, histiocytes, and also few neutrophil granulocytes. Immunohistochemistry showed a predominance of CD3(+), CD45RO(+) T-cells, which were mainly CD8(+). In addition, CD20(+) B cells and CD68(+) macrophages were abundant in each biopsy specimen. Mild lymphocytic and granulocytic infiltrates were also detected in three synovial biopsy specimens obtained from adjacent joints. All bacterial and fungal cultures from native biopsy tissues were negative. Amplification of partial-length 16S ribosomal DNA by polymerase chain reaction (PCR) using broad-range eubacterial primers was below the detection limit in all patients. Because histopathologic features alone may not provide conclusive evidence, CRMO should be included in the differential diagnosis of chronic inflammatory bone lesions in children, and the definite diagnosis should be made by the clinical picture, x-ray studies, bone scan, bacterial culture, and histopathologic analysis in a multidisciplinary approach.

Aggressive surgical management of sternoclavicular joint infections

BACKGROUND

Although the sternoclavicular joint is an unusual site for infection, thoracic surgeons may preferentially be called on to coordinate management of cases refractory to antibiotic therapy because of the anatomic relationship of this joint to major vascular structures.

METHODS

Since 1994 we have surgically managed nine sternoclavicular joint infections in eight patients. Associated medical problems were frequent and included diabetes mellitus (n = 2), end-stage renal disease (n = 2), hematologic disorders (n = 2), and multiple joints affected by sepsis (n = 4). Open joint exploration with drainage and débridement with the use of general anesthesia was performed in four patients. The remaining four patients (one with bilateral sternoclavicular joint infections) had computed tomographic evidence of diffuse joint and surrounding bone destruction with infection extending into mediastinal soft tissues. Surgical therapy for these five joint infections involved en bloc resection of the sternoclavicular joint with an ipsilateral pectoralis major muscle covering the bony defect.

RESULTS

There were two deaths unrelated to the surgical procedure. After a mean follow-up of 20 months, the remaining six survivors (seven joints) have complete healing with no apparent limitation in the range of motion even after en bloc resection.

CONCLUSIONS

Most cases of early sternoclavicular joint infections will respond to conservative measures. However, when radiographic evidence of infection beyond the sternoclavicular joint is present, en bloc resection, although seemingly aggressive, results in immediate eradication of all infection with negligible functional morbidity. Prolonged antibiotic therapy or continued local drainage procedures appear to have little value in these cases, adding only to patient care costs and the potential sequelae of chronic infections.

Osseous manifestations of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome

The SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome includes a complex group of disorders characterized by peculiar bone lesions, most commonly involving the anterior chest wall, and sometimes accompanied by dermatologic manifestations. The clinical and radiographic features of this syndrome are well described, but few studies have examined the histologic features of the bone lesions. We describe the clinical, radiographic, and histologic features of the osseous lesions encountered in eight patients with a clinical diagnosis of SAPHO syndrome. The patients included five female and three male patients ranging in age from 5 to 63 years (mean, 35.3 years). The most common clinical presentation was pain related to the sites of osseous involvement. Two patients also had some form of pustular dermatosis. The radiographic features of the osseous lesions varied but often suggested the possibility of a neoplasm. Nine pathologic specimens were available for review, five from the clavicle, two from the first rib, one from the calcaneus/cuboid, and one from the tibia. The histologic features varied but seemed related to the duration of the patients' musculoskeletal symptoms. Early lesions contained acute inflammation, edema, and prominent periosteal bone formation, histologically indistinguishable from ordinary bacterial osteomyelitis, whereas late lesions demonstrated markedly sclerotic bone trabeculae with prominent marrow fibrosis and only mild chronic inflammation; one of these biopsies appeared virtually identical to Paget's disease. One biopsy was performed after an intermediate duration of symptoms and contained prominent chronic inflammation only. The histologic findings in SAPHO are variable and nonspecific and may depend on the duration of disease, but it is important to recognize the spectrum of histologic changes possible in the syndrome and to realize that clinicopathologic correlation is necessary to avoid misdiagnosis and unnecessary long-term antibiotic therapy.