What are the treatment options for a bony growth on the clavicle?

Treatment Options for Bony Growth on the Clavicle

Initial Diagnostic Approach

The first priority is to determine whether the bony growth represents a benign process (such as condensing osteitis, osteoarthritis, or chronic non-bacterial osteitis) versus a malignant bone tumor, as this fundamentally changes management from conservative treatment to urgent surgical referral. 1

Key Clinical Features to Assess

• Age at presentation and laterality: Congenital pseudarthrosis always occurs on the right side and presents in infancy without prior trauma 2. Chronic non-bacterial osteitis (CNO) typically presents with pain and swelling, often with multiple bone sites involved 1, 3

• Red flags for malignancy: Unexplained weight loss, solitary bone lesion with rapid growth, cortical destruction, or perpendicular periosteal new bone formation on imaging mandate urgent evaluation for malignant bone tumor 1

• Systemic symptoms: Fever, chills, significantly elevated CRP or ESR suggest infectious osteomyelitis rather than benign bone growth 1

• Pain characteristics: Asymptomatic medial clavicle enlargement is most commonly due to osteoarthritis of the sternoclavicular joint, condensing osteitis, or sternocostoclavicular hyperostosis 4

Essential Imaging Studies

• Plain radiographs first: Standard X-rays are the initial imaging modality and can demonstrate characteristic features such as ground-glass density (fibro-osseous lesions), osseous matrix (osteomas), or sclerotic changes (condensing osteitis) 1, 4, 3

• CT for bone detail: CT best depicts osseous changes and can distinguish bony remodeling typical of slow-growing benign masses from lytic destruction seen with aggressive malignancies 1

• MRI for soft tissue and activity: MRI without and with IV contrast is superior for characterizing soft-tissue components and detecting bone marrow edema, which indicates active disease in CNO 1. However, CT and MRI can be misleading in chronic recurrent osteomyelitis by suggesting malignancy 3

• Whole-body imaging consideration: For suspected CNO, whole-body MRI should be considered to map clinically silent but radiologically active lesions 1

Treatment Based on Diagnosis

Benign Asymptomatic Enlargement

Conservative management is appropriate for asymptomatic medial clavicle enlargement due to osteoarthritis, condensing osteitis, or sternocostoclavicular hyperostosis, as these conditions do not require surgical intervention. 4

• History, physical examination, and characteristic radiographic findings are sufficient for diagnosis without biopsy 4
• No specific treatment is required beyond observation 4

Chronic Non-Bacterial Osteitis (CNO)

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for CNO with clavicular involvement, providing rapid reduction in pain, swelling, and limitation of motion. 3

• NSAIDs are effective in most patients and should be initiated promptly 3
• Reconstructive surgery is not indicated for CNO 3
• Long-term outcome of growth and function is excellent with conservative management 3
• Follow-up imaging should be performed to monitor disease activity 1

Congenital Pseudarthrosis

Surgical treatment is recommended for congenital pseudarthrosis of the clavicle when there is significant deformity, symptoms, or parental request, consisting of excision of cartilaginous caps, iliac bone graft, and internal fixation with wire. 2

• Conservative management can provide good results in asymptomatic cases with acceptable cosmetic appearance 2
• Surgical indications include: symptomatic patients, major or increasing deformity, or parental preference for cosmetic correction 2
• Surgical technique should include excision of pseudarthrosis at both ends, bone grafting (critical to prevent nonunion), and internal fixation 2
• Healing is achieved in most cases with proper technique including bone graft 2

Suspected Malignancy

Any bony growth with red flag features (rapid growth, cortical destruction, unexplained weight loss) requires urgent referral to a specialized sarcoma center for biopsy before definitive treatment. 1

• Biopsy should be performed at the reference center by the surgeon who will perform definitive resection 1
• Core needle biopsy (multiple samples) is preferred over fine-needle aspiration 1
• Biopsy tract must be marked and removed with the resection specimen to prevent local recurrence 1
• Staging should include chest CT, bone scintigraphy, and MRI of the entire bone with adjacent joints before biopsy 1

Common Pitfalls to Avoid

• Do not perform excision biopsy for any lesion that could be aggressive-benign or malignant, as this contaminates tissue compartments unnecessarily 1
• Do not rely solely on CT or MRI in chronic recurrent osteomyelitis, as these can falsely suggest malignancy; combine with standard X-ray, bone scan, and open biopsy 3
• Do not assume growth has stopped in adolescents and young adults, as the clavicle continues growing until age 23-25 years with substantial growth potential even after age 18 5
• Do not perform internal fixation for pathological fractures in suspected malignancy, as this disseminates tumor and increases local recurrence risk; use external splintage instead 1