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An unusual cause of shoulder pain in an elderly woman: a case report
© Akasbi et al.; licensee BioMed Central Ltd. 2013
Received: 18 March 2013
Accepted: 26 September 2013
Published: 13 December 2013
Stress fracture of the clavicle is a rare entity. It can manifest itself with an atypical shoulder pain. The clavicle is vulnerable to pathological fractures from several causes such as neoplasm, infection and rarely metabolic bone disease.
We report a case of a bone insufficiency fracture of the clavicle, in a 67-year-old Moroccan woman patient with several risk factors of bone insufficiency including osteoporosis, osteomalacia and primary hyperparathyroidism.
The diagnosis of bone insufficiency-related fracture of the clavicle can be challenging. It should be considered in the differential diagnosis of shoulder or clavicle pain.
Stress fractures are common lesions that occur without high energy trauma or focal abnormality. They include fatigue fractures which are caused by the application of abnormal stress to a bone with normal resistance, and insufficiency fractures which occur when normal activity stresses a bone that is deficient in resistance .
Insufficiency fractures of the clavicle are particularly rare. Only a few cases have been reported. Also, medial clavicle fractures are uncommon and are normally caused by high-energy trauma. A low impact mechanism of injury should lead one to suspect a pathological fracture . Many reports about insufficiency fractures of the clavicle indicate several predisposing activities in which the clavicle is subject to repetitive shearing forces, especially in sporting activities .
We report the case of a patient with a stress insufficiency fracture of the clavicle, in which the diagnosis was delayed because of the pain’s localization to the shoulder and multiple predisposing risk factors including osteoporosis, osteomalacia and primary hyperparathyroidism.
Osteoporosis and hyperparathyroidism associated with osteomalacia were considered as the potential culprits of the spontaneous clavicle’s fracture in our patient. The fracture was dressed with a figure-of-eight dressing. The patient was treated with vitamin D for the osteomalacia and zoledronic acid for the osteoporosis. Surgical treatment for parathyroid hyperplasia was indicated but our patient refused it. The patient died some time after her diagnosis of unrelated issues.
Stress clavicle fractures are not frequent, but more common in the sporting population . Other etiologies of non traumatic clavicle fractures are skeletal metastases, lymphomatous or myelomatous proliferation and infections. Clavicular metastases comprise of 6-18% of all bone metastases, particularly from renal cell carcinoma . The nonspecific pain of a clavicular stress fracture referring to the upper extremity, can misdirect the clinician to more common causes of shoulder pain, such as rotator cuff and cervical disc diseases .
A conventional X-ray is usually normal when symptoms first present themselves. Later, a pseudotumor appears in the clavicle which corresponds to the fracture callus, that can be misdiagnosed as a tumour or infectious processes . Further imaging of the clavicle such as computed tomography scan or magnetic resonance imaging is needed to adequately define the fracture and appreciate the quality of the surrounding bone. Bone scintigraphy remains an early method for detection of this injury .
Medial clavicular fractures are uncommon. They are the least frequent of clavicular fractures, comprising between 2% to 10% [8, 9]. They are normally caused by a high-energy trauma, and are associated with other multisystem injuries, especially in men. A low impact mechanism of injury should raise suspicion of a pathological fracture of the clavicle .
In most of the cases reviewed, stress fractures of the clavicle, especially a medial fracture, were due to a neoplasm or infection. Benign causes like metabolic bone disease are very rare. In our patient, there were several benign factors that may have contributed to the development of this injury, notably osteoporosis, primary hyperparathyroidism and osteomalacia. Other benign predisposing risk factors of bone insufficiency could be rheumatoid arthritis, renal failure, fibrous dysplasia and algodystrophy . This present case report demonstrates the difficulty in diagnosing pathological fractures of the clavicle especially an insufficiency medial fracture, which is not routinely suspected to be pathological. We have shown that a stress fracture of the clavicle can manifest itself with unusual and atypical localization of shoulder pain. In our patient, the association of several additional risk factors contributed to weaken the clavicle, to decrease the bone resistance and to predispose it to the development of a stress fracture.
Stress fractures of the clavicle must be kept in mind in the differential diagnosis of shoulder and clavicle pain. Medial fractures are a rare entity, usually caused by a high energy trauma or tumor proliferation in most cases. In our patient, it was due to many additional benign risk factors.
Written informed consent was obtained from the patient's next of kin (her son) for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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