Sports-related stress fracture of the clavicle: a case report
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Sports-related stress fracture of the clavicle: a case reportJ. Roset-Llobet, J.M. Sal-OrfilaDepartment of Orthopaedic Surgery and Traumatology, Hospital General de Manresa, Barcelona, Spain
&misc:Accepted: 30 November 1997
&p.1:Summary. Stress fracture of the clavicle is extremelyrare, even in sports medicine. The authors have treat-ed a young man who, for several years practised atraditional physical activity in which groups of peo-ple make human towers by standing on each othersshoulders. For the last three years the patient experi-enced pain in the medial aspect of the right claviclewhen he increased the intensity of his training. Bonescintigraphy revealed endosteal thickening which wasindicative of a stress reaction. The mechanism of in-jury, the diagnosis of stress fracture, and a review ofthe literature are presented.
&p.1:Rsum. Les fractures par stress de la claviculesont une pathologie extrmement rare, mme chez lessportifs. Les auteurs presentent un cas sur un junehomme qui a pratiqu un sport traditionnel pendantplusieurs annes, consistant, pour un groupe de gensde faire une tour humanine en sappuyant lun surlpaule de lautre. Pendant les trois derniers annsle patient a mal au tiers moyen de la clavicule droitelorsquil intensifie son entranement, et de douleursarrte a lissue de la sance athltique. Quand il at vu a lHpital, on a confirm une raction destress avec une scintigraphie positive et une con-densation endoste. Nous prcisons le mcanisme dutraumatisme, le diagnostic de fracture de fatique, etprsentons une rvision bibliographique.
Stress fracture and stress reaction are overuse prob-lems that, in athletes, usually occur in the lower
limbs. Although this type of lesion has been infre-quently described in other locations such as the ster-num , first rib [2, 12, 15, 19, 21], humerus [1,29], ulna [3, 23], tip of the olecranon [9, 22], acromi-
Resprint requests to: J. Roset-Llobet, Servei de COT, HospitalGeneral de Manresa, E-08240 Manresa, Barcelona, Spain &/fn-block:
International Orthopaedics (SICOT) (1998) 22:266268
Fig. 1. The human tower; a traditional Catalan physical activity&/fig.c:
J. Roset-Llobet and J.M. Sal-Orfila: Sports-related stress fracture of the clavicle 267
um  and the coracoid process of the scapula [4, 8,30], stress fracture of the clavicle has been reportedonly during surgery [7, 11, 25], in the absence ofstrenuous athletic activity [17, 26], or in poorly docu-mented cases .
A 26-year-old man with a history of three years of clavicularpain had been engaged in a traditional Catalan sport for theprevious six years. In this activity, teams of athletes make hu-man towers with up to nine levels, each standing on the shoul-ders of the level below them (Fig. 1).
The first symptoms appeared at the end of the 1993 athleticseason, during which he had rapidly increased his training in-sensity. He presented with a gradual onset of pain which hadprogressively worsened with activity. At that point physicalexamination and plain radiographs were absolutely normal(Fig. 2). The pain disappeared during the winter off-season,and slowly began to recur in a mild form when training com-menced. Thereafter, during a normal rotation movement of the
shoulder, he experienced acute clavicular pain which lasted fortwo weeks. He was seen in our hospital three months later, atthe end of the 1995 athletic season, when he reported signifi-cant pain that had forced him to decrease his level of activity.Physical examination revealed a small palpable mass andmarked localised tenderness at the middle third of the rightclavicle. There was no oedema or erythema, and no clinicalevidence of periosteal thickening. Anteroposterior radiographsof the right clavicle showed cortical hyperostosis and sclero-sis; the contralateral side was normal (Fig. 3). Conventionaltomography and computerised tomography demonstrated thesame hyperostosis but there was no visible fracture. Full bloodcount, ESR, and biochemical screening were normal. Bonescintigraphy revealed a distinct fracture line in the delayed im-age phase; the blood pool phase was slightly positive while theangiogram phase was negative (Fig. 4).
A stress fracture of the clavicle was suspected and ortho-paedic protection of the shoulder and clavicle was provided.The athlete is now asymptomatic and in full training.
Bone scintigraphy (bone scan) is 100% sensitive,with no false negatives, but it is not very specific forthe differentiation of a stress fracture or reaction fromother musculoskeletal abnormalities . For thisreason, many aetiologies must be considered in thedifferential diagnosis following a positive result;these include osteitis, chronic osteomyelitis, osteoma,osteoid osteoma and osteoblastoma . Other rareconditions such as syphilis, Pagets disease, or malig-nant neoplasms can be discounted as they are notconsistent with the evolution of the disorder and theresults of complementary investigations . A sim-ple periosteal reaction also warrants consideration,but the clinical findings, the acute increase of the painwithout previous trauma and the scintigraphic find-ings of diffuse non-focal periosteal uptake, mild inintensity, along the bone  were not seen in our pa-tient. His scintigraphic appearances are suggestive ofa stress fracture even if the process was in a subacuteor healing phase . A fracture was not detected byradiograph but it is known that up to 15% of patientswith a positive bone scan never show radiographicchanges . A true fracture occurs only when the re-moval of the cortex is accelerated beyond the capaci-ty of the periosteal reaction to offer adequate rein-forcement. For this reason, the radiological demon-stration of a fracture line is not necessary for the di-agnosis of a stress fracture. In our patient, however,the bone was in the resolution phase and it wasdoubtful whether the changes represented a moder-ately severe stress reaction (Grade 23) of Jones clas-sification  or the subacute-healing phase as de-scribed by Martine . We consider that the in-creased activity in the whole thickness of the clavicleand the distinct fracture line noted on delayed bonescan image were suggestive of a stress fracture in thehealing phase. Similar stress fractures of the ribs havebeen described by several authors [15, 19, 21].
In the sport of human tower construction, the feetare placed at each side of the neck with the heels onthe trapezius muscles and the tarsal bones on the
Fig. 2. Normal anteroposterior radiograph of the right clavicleat the onset of pain &/fig.c:Fig. 3. Anteroposterior radiograph of the right clavicle show-ing cortical hyperostosis and sclerosis &/fig.c:Fig. 4. Technetium-99m bone scan demonstrating a distinctfracture line on the delayed image
268 J. Roset-Llobet and J.M. Sal-Orfila: Sports-related stress fracture of the clavicle
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clavicles. The weight pushes the clavicle down whilethe sternocleidomastoid, trapezius, pectoralis major,and deltoid muscles, as well as the coraclavicular andacromioclavicular ligaments, are pulled upon, stress-ing the point wher