Compared to other areas of inflammation, arthritis of the clavicular bone is relatively rare. For every 100 cases of registered joint pathologies, there are only 3 visits to the acromial clavicular ligament. However, clavicular arthritis (also known as acromioclavicular arthritis) cannot be ignored. If we talk only about damage to the clavicular bone, then we are talking about a specific form of the disease - a form of arthritis that is associated with age-related changes, osteoarthritis.
What parents need to pay attention to
Early symptoms:
Pain
The first significant symptom is increasing pain in the affected limb. After some time, the pain becomes unbearable, depriving sleep, it can appear both during exercise and at rest and is not relieved by conventional analgesics.
Swelling
The affected part of the bone increases in volume, the soft tissues above it become swollen, and phlebectasias (a network of small dilated veins) appear on the skin.
Impaired function of the affected limb. Restricted mobility in a nearby joint
When osteogenic sarcoma is localized in the bones of the lower extremities, movements in the joints become difficult, and lameness develops over time. A late symptom of this disease may include a pathological fracture in the area of the primary lesion.
The main problem of late diagnosis of osteogenic sarcoma is due to the fact that for a long time local pain is associated with a previous injury to the limb. But at the same time, the severity and duration of pain symptoms are not compared with the extent of the injury.
Unfortunately, pain in the extremities in children and adolescents often goes unnoticed or underestimated and is associated primarily with “growing pains,” as a result of which the child receives long-term analgesic therapy without effect.
The duration of the pain syndrome, its pronounced nature, not correlated with previous traumatic changes, is always a reason for an expanded diagnostic search.
Diagnostics
If osteogenic sarcoma is suspected, a diagnostic search is carried out by specialists such as a pediatric oncologist, a pediatric surgeon, a pathologist, and a radiologist. The final diagnosis is established based on the results of histological examination.
At the first meeting with a young patient, the doctor collects an anamnesis, clarifies information about the presence or absence of any chronic diseases of the musculoskeletal system, previous injuries, surgical interventions, hereditary syndromes, and family hereditary oncological pathology. A clinical examination of the patient includes an assessment of the focus of the affected limb, regional lymph nodes, and physical status (general condition of the patient).
The diagnostic search consists of the following studies:
- radiography of the affected area;
- computed tomography (CT) with contrast enhancement of the tumor-affected area and chest organs;
- osteoscintigraphy;
- Magnetic resonance imaging of the affected area.
The most common and simplest method for diagnosing osteogenic sarcoma, which can be performed on an outpatient basis, is an x-ray examination of the affected limb. Situations cannot be excluded when the formation is an accidental finding during radiography performed for a traumatic injury. In such situations, the patient is indicated for further examination.
Characteristic radiological signs of osteogenic sarcoma (Fig. 2):
- destruction and sclerosis of bone tissue in the affected area;
- Codman's periosteal visor, which is the periosteum exfoliated by the tumor;
- needle periostitis with multiple bone spicules;
- foci of pathological bone formation in soft tissues (fields of ossification) in the area of formation;
- pathological fracture of the affected limb.
Rice. 2. Radiological signs of osteosarcoma
For clearer visualization of the process, clarification of the size of the formation, spread, and exclusion of soft tissue damage, children are advised to perform computed tomography. In addition, this method allows you to evaluate the primary tumor and detect the presence of distant metastatic foci.
Skeletal scintigraphy has long been the standard method for diagnosing bone lesions, being more sensitive than x-ray methods. It allows you to study the entire human body in a short period of time. This study is based on an increase in the accumulation of phosphorus compounds in the lesion, which indicates the activity of a process characteristic of malignant neoplasms (Fig. 3).
Fig.3. Pathological accumulation of radiopharmaceutical (Technetium mTc)
Magnetic resonance imaging (MRI) of the primary tumor lesion involving the adjacent joint is the optimal method for local staging. MRI monitoring against the background of systemic therapy makes it possible to assess the dynamics of the process and, accordingly, plan the scope of surgical intervention in the future.
One of the key stages of diagnosis is a biopsy of the formation and subsequent histological and immunohistochemical examination of the obtained material.
There are two different approaches to obtaining material: using a trephine needle and an open type of biopsy. The manipulation is performed under CT or ultrasound navigation or using an electron-optical converter (Fig. 4).
Fig. 4: Biopsy using a trephine needle
WHEN SHOULD YOU BE CONCERNED?
Osteoarthritis or arthritis of the clavicular bone is a form of inflammation caused by wear and tear of the intra-articular cartilage. The latter is possible due to natural aging, autoimmune diseases, infections or injuries. The body signals about pathology more than clearly:
- “point” pain occurs associated with raising your arms up, trying to draw a circle with your hand from front to back;
- the person, without noticing, restrains the activity of the arm connected to the affected clavicular bone;
- often in patients with arthritis there is a feeling that the bone will disintegrate into small parts during movement;
- due to the specific location of the clavicle bone, its arthritis is often accompanied by prominent swelling, redness, weakness, fever and enlargement of nearby lymph nodes.
What is required to recognize pathology?
Such signs of arthritis cannot be left unattended. How to limit the treatment of clavicular pain with analgesics. Arthritis is one of the group of inflammatory reactions that not only do not go away without treatment, but also progress rapidly. Due to the proximity and small surface of the clavicular bone, there is a high risk of developing erosion, damage to the junction with the scapula, and bone wear (increasing its fragility). Additionally, abscesses may develop and purulent foci may appear. Against this background, toxicosis, inflammation of soft tissues, and infection of adjacent areas often develop. A positive factor is that the clavicular bone structure is clearly visible on x-rays. This method is the basis for recognizing pathology (although visual signs of arthritis affecting the clavicular bone are quite informative). To assess the affected area and verify the provoking disease (polyarthritis, arthritis of the humerus or scapula, spondyloarthritis, lordosis, kyphosis, spondylosis, osteophytes), it can Contrast x-rays (arthrography) will be required. MRI and ultrasound - to study the spread of the inflammatory process into soft tissues.
Classification
According to the WHO classification, there is a localized (locally advanced) version of osteosarcoma - 80% and a generalized (metastatic) - 20% of cases. Based on the examination of the material obtained through biopsy, the pathologist gives a histological assessment of the tumor. Tumors are divided into central (high and low grade of malignancy), superficial, intracortical, gnotic, extraskeletal and secondary - associated with Paget's disease, radio-induced, as a rule, this is a variant of high grade of malignancy.
In addition to histological classification, the TNM system is used, which evaluates the size of the tumor, the extent of damage to regional lymph nodes, the presence or absence of distant metastases, and the degree of differentiation of tumor tissue.
Based on the data from instrumental studies and histological findings, the disease is staged.
Symptoms and signs
The size and shape of a lump on the collarbone is one of the clinical signs for a preliminary conclusion.
To make a preliminary conclusion about the origin of the formation in the clavicle area, be sure to pay attention to the features of the clinical signs:
- Size and shape - large sizes usually indicate the development of various benign neoplasms.
- Painful sensations - pain always indicates an unfavorable course of the pathological process with inflammation or tissue destruction.
- Inflammatory changes in the skin - hyperemia, in which the tissues become red and swollen. Changes usually develop against the background of infection or tissue destruction.
- Violation of the integrity of the skin in the form of a long-term non-healing ulcer is an unfavorable sign that may indicate the development of an oncological process.
- A fistulous tract is the appearance of a channel through which pus comes out, which indicates a purulent process. Usually localized in the lymph nodes of the collarbone area, swelling of the skin develops around it.
- General intoxication - increased body temperature, weakness, aches in muscles and joints, loss of appetite indicate a severe course of the inflammatory process with purulent melting of tissues. Severe weight loss in a person, even to the point of exhaustion, is often the result of the development of a malignant neoplasm.
- Metabolic disorders and the functional state of the nervous system are a consequence of the pathology of the thyroid gland, which is located near the collarbone and can lead to the appearance of a lump.
Based on clinical symptoms, the nature and origin of changes in the clavicle area can be assumed. For a reliable diagnosis, an additional objective examination is prescribed.
Treatment of osteogenic sarcoma in children
Treatment methods for osteosarcoma have remained virtually unchanged over the past 20 years. To date, the main methods of treatment remain polychemotherapy and surgery.
There are two options for surgical intervention:
- organ-preserving,
- organ-carrying (crippling).
In the absence of contraindications, in most cases organ-preserving treatment is performed to help the child preserve not only the functional abilities of the limb, but also to minimize cosmetic defects. For this purpose, all the achievements of modern medicine in bone grafting and reconstructive surgery are used.
Endoprosthetics
Endoprosthesis replacement is an option for organ-preserving intervention. This is an operation to replace a joint with implants that have the anatomical shape of a healthy joint and allow full range of motion. Total endoprosthesis replacement is more often used due to the impossibility of preserving the joint (Fig. 5).
Rice. 5. Total knee replacement consists of three components: femoral, tibial and patella
Arthrodesis
Other options for organ-preserving intervention include arthrodesis. This is a surgical procedure that fixes the joint in a permanent position. The bones are rigidly connected for complete immobilization and fastened with metal clamps (special screws, knitting needles, pins). This joint provides support and motor function.
Rice. 6. Arthrodesis
Exoprosthetics
In cases of large spread of the tumor to surrounding tissues, involvement of the neurovascular bundle in the process, or growth of the tumor mass during treatment, amputation/disarticulation is performed, followed by prosthetics with an exoprosthesis (Fig. 7, 8, 9). Considering the quality of modern exoprostheses and the development of medical rehabilitation, it is possible to fully preserve functionality even with such organ-removing treatment. Rehabilitation aims not only to restore functional abilities, but also to help the child cope with the social and emotional consequences of limb loss.
Fig.7 Exoprosthesis of the upper limbs
Rice. 8 Exoprosthesis of the lower extremities
Fig.9 Exoprosthetics of the lower limb
Rotational plastic
Rotation plasty is a treatment method that is the method of choice in relation to mutilating amputation/disarticulation operations. The principle is resection of the affected part of the femur and rotation of the tibia by 180°. In this case, the ankle joint takes on the function of the “knee joint” (Fig. 10). The indication for this type of intervention is a tumor in the distal part of the femur with a pronounced soft tissue component, when the surrounding soft tissue is involved in the tumor process and organ-preserving surgery is impossible. In this case, a necessary condition for the operation is the preservation of the sciatic nerve.
Fig. 10 Rotational plastic
Chemotherapy
Chemotherapy is a treatment using drugs aimed at killing or inactivating tumor cells.
Drug therapy is carried out both before surgery (neoadjuvant) and after surgery (adjuvant) in order to reduce the volume of the tumor before surgery and destroy subclinical metastases after.
There are five main drugs (cisplatin, adriamycin, methotrexate, ifosfamide, etoposide), which are used in various combinations and doses.
Rehabilitation
Rehabilitation measures after the surgical stage of treatment depend on the volume and type of intervention. The principles, duration and outcomes of rehabilitation largely depend on the latter.
To achieve maximum functional results, it is necessary to follow the basic principles of rehabilitation
- Gradually increase the intensity of exercises on the surgical area.
- Maintain regular exercise.
- You should perform restorative exercises aimed at the entire body.
Rehabilitation activities are divided into several stages, including:
- The first (early) period begins immediately after surgery, after removal of the drainage system. As a rule, this is the second and third day after surgery. The main goal is to ensure that the exercises are aimed at minimizing the load in the area of surgical intervention, while maximizing the range of motion in the joint without stressing the muscle and bone structures.
- The second period involves a gradual increase in muscle activity.
- The third period is aimed at increasing muscle mass.
During surgical interventions on the lower extremities, all stages of rehabilitation should alternate with regular walking with a gradual increase in load. The first steps should be taken with the help of a walker, on crutches, with a stick and then without support.
Prevention
The development of the pathological process and the formation of a lump above the collarbone can only be prevented through regular medical examination. You also need to lead a healthy lifestyle, give up bad habits and engage in feasible physical activity. You need to take care of your health and prevent the possibility of injury. If all these preventive measures are carried out regularly, the risk of developing tumors will be minimized.
A lump above the collarbone is not a death sentence. Timely diagnosis and proper treatment gives a high chance of recovery.
Galina Polovnikova / author of the article
I write articles in various areas that, to one degree or another, affect such a disease as edema.
Forecast
In the past, osteosarcoma was one of the malignant tumors with the most unfavorable prognosis. Even though the treatment included severe mutilating operations, the five-year survival rate did not exceed 5–10%. Currently, due to the emergence of new treatment methods and the use of effective organ-preserving operations, patients' chances of a successful outcome have increased significantly even in the presence of metastases in the lungs. Today, the 5-year overall survival rate for localized osteosarcoma is more than 70%, while patients with the metastatic variant have much worse outcomes (5-year overall survival of about 35%).
Unfavorable prognostic factors continue to be early development of relapse, multiple foci and pleural involvement (in the presence of pulmonary metastases).
Bibliography:
- Federal clinical guidelines “Malignant neoplasms of bones and articular cartilage: osteosarcoma, Ewing’s sarcoma” (approved by the Ministry of Health of Russia).
- Scientific and clinical protocol EURAMOS-1.
- Aliev M.D. Malignant bone tumors. Sarcomas of bones, soft tissues and skin tumors 2010; 2:3–8.
- Pediatric oncology: Clinical guidelines for the treatment of patients with solid tumors. / edited by M. Yu. Rykov, V. G. Polyakov. - M.: GEOTAR-Media, 2021. -368 p.
- Pediatric oncology. National leadership / ed. M D Alieva [and others]. - M.: Publishing group RONC, Practical Medicine, 2012. - 684 p.: ill.
How to avoid a lump on your neck
It is not always possible to prevent the formation of a seal. The fact is that fibromas and lipomas have a genetic predisposition, while chemodectomas and cysts appear when leading an incorrect lifestyle. As for other types of formations, their appearance is avoided by adhering to the recommendations:
- treat skin diseases in a timely manner;
- It is advisable to be examined after injuries;
- lead a healthy lifestyle, since smoking, alcohol abuse and other bad habits significantly increase the risk of developing cancer;
- at the slightest suspicion and symptoms, consult a doctor to prevent the development of serious complications.