The sternoclavicular ganglion cyst, a rare pediatric diagnosis.

We briefly describe the case of a 4-year-old girl, referred for imaging of a small, firm, round, skin-colored, subcutaneous nodule that suddenly appeared at her right sternoclavicular junction. A plain radiograph was non-contributory, but ultrasonography revealed a small cystic structure, leading to the diagnosis of a sternoclavicular ganglion cyst. Sternoclavicular ganglion cysts are a rare diagnosis, with only seven reported pediatric cases. A watchful waiting approach can be adopted so long as they remain asymptomatic.

Utility of 3D reformatted images in the diagnosis of sternoclavicular joint injury.

INTRODUCTION: The purpose of this study is to evaluate the ability of musculoskeletal radiologists to diagnose sternoclavicular joint injuries in the standard CT imaging planes compared to 3D volume rendered images to define the most accurate plane to improve prospective diagnosis. MATERIALS AND METHODS: A retrospective query of our institutional database was performed. Twenty-six patients with a diagnosis of sternoclavicular joint injury, who had been evaluated with CT and treated by orthopedic surgery, and 30 control patients who did not have a sternoclavicular joint injury were included for analysis. Two blinded radiologists with specialty training in musculoskeletal radiology independently reviewed axial, coronal, sagittal, and 3D reformatted CT images and documented whether injury was present or not present. RESULTS: Accuracy was good for both radiologists on all views. It was lowest on the sagittal view for both readers. Accuracy was highest for the 3D view. When comparing the accuracy of the four views for each radiologist, there was a significant difference for Radiologist A, whose 3D images were more accurate compared to the axial and sagittal views. There was no significant difference for Radiologist B. There was good inter-reader agreement, which was highest on the 3D images. CONCLUSION: 3D volume renderings of the sternoclavicular joints have the potential to improve radiologist accuracy for detection of sternoclavicular joint injury/dislocation in the setting of chest well trauma, which could decrease instances of missed or delayed diagnosis.

Increasing Incidence of Sternoclavicular Joint Infections in Intravenous Drug Users.

Sternoclavicular joint septic arthritis is rarely seen in the general population. The majority of cases are seen in intravenous drug users. Given the lack of reported cases in the literature, there is no standardized treatment algorithm for this disease. Described treatment methods range from medical management to wide local debridement. The incidence of sternoclavicular joint septic arthritis will likely continue to increase with rising usage of intravenous drugs in the United States. Within the past year, our institution treated four cases.

Physeal injuries of the clavicle: pediatric counterparts to adult acromioclavicular and sternoclavicular joint separations.

The epiphyses at the medial and lateral ends of the clavicle are small, ossify relatively late, and may not fuse until early adulthood. Because of this unique anatomy, pediatric and young adult injuries that involve the clavicle often differ from the patterns typically seen in older adults. Clavicular trauma that affects the acromioclavicular joint laterally or sternoclavicular joint medially often results in a physeal fracture and as such, can go unrecognized or be mistaken for a joint dislocation. Radiographic assessment is challenging, particularly when the epiphysis is not yet ossified. However, MR imaging allows for visualization of the cartilage, periosteum and perichondrium, and ligaments of the affected joints. Lateral clavicle physeal injuries can be categorized by the Dameron and Rockwood system, the pediatric correlate to the Rockwood classification of adult acromioclavicular joint injuries. Medial clavicle physeal fractures, similar to adult sternoclavicular joint dislocations, may result in anterior or posterior displacement. Because of their great ability to heal and remodel, clavicular physeal fractures respond better to conservative management than true acromioclavicular or sternoclavicular joint dislocations. Therefore, it is essential to recognize the true nature of these injuries, as there are implications for successful treatment and appropriate prognosis.

Operative treatment outcomes of anterior sternoclavicular joint dislocation using two experimental methods - an acromioclavicular joint hook plate versus a locking plate: a retrospective study.

BACKGROUND: We aimed to compare the intraoperative and early postoperative clinical outcomes of using an acromioclavicular joint hook plate (AJHP) versus a locking plate (LP) in the treatment of anterior sternoclavicular joint dislocation. METHODS: Seventeen patients with anterior sternoclavicular joint dislocation were retrospectively analyzed from May 2014 to September 2019. Six patients were surgically treated with an AJHP, and 11 were surgically treated with an LP. Five male and one female patients composed the AJHP group, and nine male and two female patients composed the LP group. The mean age of all patients was 49.5 years. RESULTS: Reduction and fixation were performed with AJHP or LP in all 17 patients. The mean operative blood loss, operative time, and length of incision in the AJHP group were significantly better than those in the LP group. Shoulder girdle movement of the AJHP group was significantly better than that of the LP group. CONCLUSIONS: This study revealed that AJHP facilitated glenohumeral joint motion, reduced the risk of rupture of mediastinal structures, required a shorter incision, and had lesser blood loss and a shorter duration of operation compared with LP. However, some deficiencies require further improvement.

Successful Nonsurgical Management of a Posteriorly Displaced Medial Clavicular Physeal Fracture in an Adolescent Athlete: A Case Report.

ABSTRACT: Traumatic and sport-related sternoclavicular (SCJ) injuries in adolescent athletes are more commonly physeal fractures rather than true SCJ dislocations. Although rare, posterior displacement of the medial clavicular metaphysis after a physeal fracture necessitates prompt evaluation and treatment. Despite the inherent healing ability of physeal separations, delayed or failed diagnosis has the capacity to cause serious complications or fatality secondary to injury of retrosternal structures. Even with the potential severity, a lack of consensus exists in the literature regarding the most appropriate treatment modality. We report an adolescent football player with a medial clavicular physeal fracture with posterior metaphyseal displacement abutting the left brachiocephalic vein. After nonsurgical management and progression to play, the patient returned to play football. This case not only highlights the diagnostic principles of medial clavicular physeal fractures with posterior metaphyseal displacement but also discusses how these challenging injuries can be managed successfully with conservative treatment.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department.

BACKGROUND: Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries. OBJECTIVE: This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician. DISCUSSION: SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification. CONCLUSIONS: SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

Diffuse large B-cell lymphoma involving the left sternoclavicular joint mimicking rheumatoid arthritis flare: a case-based review.

Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting primarily joints and an increased risk of developing malignant lymphomas in RA has been well reported. However, primary lymphoma in a joint in RA patient is rare. We report the case of a 65-year-old man with RA suffering from pain and swelling of left sternoclavicular (SC) joint, which was not relieved by adding low-dose glucocorticoid. Magnetic resonance imaging (MRI) showed a para-osseous soft tissue swelling around the SC joint and a fracture of proximal clavicle. Histology of the soft tissue demonstrated diffuse large B-cell lymphoma and the patient subsequently underwent R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. He was successfully treated with six cycles of R-CHOP chemotherapy, with discontinuation of MTX, resulting in a complete response. We performed a literature review and identified nine cases of lymphoma which involved joints in patients with rheumatoid arthritis. This is the first described case of a primary large B-cell lymphoma involving the unilateral SC joint in a patient with RA, which was initially confused with aggravation of RA. Therefore, malignant lymphoma should be considered in the differential diagnosis when a RA patient develops monoarthritis with spontaneous fracture, even without B symptoms.

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients.

PURPOSE: to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment. METHODS: We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization. RESULTS: Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again. CONCLUSIONS: The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment. LEVEL OF EVIDENCE: Level IV case series.

Sternoclavicular tuberculosis: an atypical imitator of refractory shoulder pain.

INTRODUCTION: Sternoclavicular joint tuberculosis is rare and has been presented in literature with few sporadic case reports or small case series. Rarity of the condition, nonspecific symptoms, difficulty to visualise the area on X-rays, and minimal clinical signs make diagnosis of sternoclavicular tuberculosis extremely difficult. Delay in diagnosis is therefore the common feature of all presented reports in literature. We here present our experience of treating 19 cases of sternoclavicular tuberculosis at our centre. MATERIALS AND METHOD: This is an observational study from 2010 to 2017 in a tertiary care referral hospital. All patients with clinical tenderness of sternoclavicular joint and shoulder joint pain of over three week duration were subjected to MRI. Patients who showed radiological lesions (radiography/MRI) were subjected to core biopsy under image guidance. A total of 26 patients had biopsy confirmed sternoclavicular tuberculosis (TB) during this period. RESULTS: All patients had improvement in shoulder function after treatment completion. Mean CSS pre-treatment was 29 which improved to mean of 8 after 18 months of ATT. Eight patients had excellent results, seven good, three fair, and one patient poor result. High initial ESR, late commencement of ATT from initial symptoms, and surgery of the involved joint were considered poor prognostic factors. DISCUSSION: Sternoclavicular tuberculosis is a rare disease with controversial etiology. Both haematogenous spread through suprascapular artery and contiguous spread through latent disease in apical lungs has been postulated. Delay in diagnosis is common to most reports in literature. Early MRI is useful in diagnosis of the lesion. The treatment for sternoclavicular joint in literature is controversial with proponents of both surgery and conservative management. CONCLUSION: Primary sternoclavicular tuberculosis is rare condition and requires a high index of suspicion for an early diagnosis. A focused sternoclavicular MRI and early biopsy may help in timely diagnosis. Early commencement of ATT has overall good clinical and functional results.

[Injuries of the sternoclavicular joint]. / Verletzungen des Sternoklavikulargelenks.

Injuries of the sternoclavicular joint (SCJ) are rare accounting for 3% of all injuries to the shoulder girdle and are often overlooked. The SCJ is surrounded by tight ligamentous structures, thus substantial energy with corresponding force vectors is needed to cause dislocation. Causative are mostly high-energy traumas. Anterior dislocation is most common but in rare cases potentially life-threatening posterior dislocation occurs, which requires immediate reduction. The established gold standard is 3D reconstruction in contrast-enhanced computed tomography (CT) for depiction of neurovascular structures. Low-grade instability can initially be treated conservatively. For unsuccessful attempts at reduction, high-grade instability and chronic instability various surgical techniques are established. Next to retentive augmentation with suture materials, in acute cases with chronic instability biological tendon augmentation is preferred. In cases of posttraumatic instability arthritis SCJ resection with or without additive biological augmentation can be carried out. Various study groups have shown good to very good midterm outcome.

Anatomic shape variants of extremitas sternalis claviculae as collected from sternoclavicular thin-slice CT-studies of 2820 male borderline-adults.

Within medical age assessment practice, the indicator "medial clavicular ossification" constitutes crucial evidence capable of excluding age minority "beyond reasonable doubt" concerning age-disputed individuals doubtfully claiming children's rights during legal procedures. Yet, one of its characteristics affects the morphological variability including a fair amount of downright peculiar appearances. As a result, inexperienced examiners are tempted to classify actually not-assessable formations according to the two established developmental typologies of Schmeling et al. and Kellinghaus et al. being at the same time the most frequent systemic error of age-related clavicular taxation. Since a respective overview appears missing, the study extracts not-assessable shape variants of the medial collar bone from a large sample of 2820 male borderline-adults as seen from thin-slice, sternoclavicular computed tomography. The two already highlighted configurations "more than one, medial, secondary ossification centres" and "medial metaphyseal concavity" are found as the most commonly encountered features impeding reliable delineation of staging criteria. In accordance with previous literature, it is emphasized that "qualified" rating of extremitas sternalis claviculae within age assessment practice presupposes "knowledge about the diversity of [its] anatomic shape variants."

Total Endovascular Repair of Post-Trauma Ascending Aortic Pseudoaneurysm and Secondary Superior Vena Cava Syndrome.

BACKGROUND: Clavicular fracture or sternoclavicular luxation is observed in 10% of all polytrauma patients and is frequently associated with concomitant intrathoracic life-threatening injuries. Posterior sternoclavicular luxation is well known to induce underlying great vessels damage. The gold standard treatment usually is a combined orthopedic and cardiovascular surgical procedure associating vascular repair, clavicular open reduction, and internal fixation. METHODS: A 59-year-old wheelchair ridden, institutionalized woman, known for psychiatric disorder, severe scoliosis, malnutrition, and chronic obstructive pulmonary disease was admitted in our hospital for chronic chest pain 3 months after a stairway wheelchair downfall. A thoracic computed tomography (CT) scan revealed a voluminous ascending aortic pseudoaneurysm (63 × 58 mm, orifice 5 mm) consecutive to perforation following posterior sternoclavicular luxation. The patient refused all therapies and was lost to follow-up. Six months later, she was readmitted for a symptomatic superior vena cava syndrome. Thoracic CT scan revealed pseudoaneurysm growth with innominate vein thrombosis and superior vena cava subocclusion. Pseudoaneurysm orifice was stable. In the presence of symptoms with massive facial edema and inability to open her eyelids, the patient accepted an endovascular treatment. RESULTS: The procedure was performed under general anesthesia using both fluoroscopic and transesophageal echocardiographic guidance. Through a femoral arterial access, a 10-mm atrial septal defect occluder device was used to seal successfully the pseudoaneurysm orifice. The superior vena cava was then opened with a 26-mm nitinol high radial force stent through a femoral venous access. Postoperative course was uneventful. At 3-month follow-up, the patient remains symptom free and a CT scan confirmed pseudoaneurysm thrombosis and superior vena cava permeability. CONCLUSION: Post-traumatic sternoclavicular posterior luxation is a cause of great vessels and ascending aorta injuries. Minimally invasive endovascular approaches can be considered to treat vascular injuries and their consequences, especially in elderly patients and those at high risk for surgery.

MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis.

OBJECTIVES: To analyze and identify magnetic resonance imaging (MRI) and clinical findings for the differentiation between infectious arthritis and spondyloarthritis in patients with unilateral sternoclavicular arthritis. MATERIALS AND METHODS: We retrospectively collected and evaluated the magnetic resonance (MR) images of 21 patients diagnosed with unilateral sternoclavicular arthritis, including 12 with infection and nine with spondyloarthritis, between 2004 and 2017. Capsular distension, extracapsular fluid collection, periarticular muscle edema, the prevalence and distribution of bone marrow edema, and the prevalence and size of bone erosions were assessed on the MR images. Clinical data were also reviewed. RESULTS: Capsular distension was more prominent in patients with infectious arthritis than those with spondyloarthritis (p = 0.002); extracapsular fluid collection and periarticular muscle edema were also more common in infectious arthritis than spondyloarthritis (p < 0.001, respectively); moreover, bone erosions were larger in infectious arthritis than spondyloarthritis (p = 0.023). Other findings significantly associated with infectious arthritis included advanced age (p = 0.007), an elevated C-reactive protein (CRP) level (p = 0.001), and erythrocyte sedimentation rate (ESR) (p < 0.001). The prevalence and distribution of bone marrow edema and the prevalence of bone erosions on MRI, the white blood cell count, and sex showed no significant differences between the two groups. CONCLUSIONS: Capsular distension, extracapsular fluid collection, periarticular muscle edema, and the size of bone erosions on MRI, as well as the age, CRP level, and ESR of patients, could be helpful for differentiating infectious arthritis from spondyloarthritis involving the sternoclavicular joint.

Anterior buttress plate is successful for treating posterior sterno-clavicular dislocation.

PURPOSE: Traumatic posterior instability of the sternoclavicular joint is a potentially life-threatening injury. In contrast to the low incidence there is a plethora of different strategies to treat this lesion. It was the objective of this retrospective analysis to evaluate and further develop current strategies. METHODS: In this retrospective analysis all posterior dislocations that were diagnosed and treated between 2011 and 2018 were included. In this 7 year period, eight male patients (median age 32 years) were operated. RESULTS: Three patients were not diagnosed at the primary institution and were referred later. Five patients were treated with an anterior buttress plate with clavicular stabilisation only. One patient was stabilized with a temporary sternoclavicular arthrodesis. Two patients were operated using an autologous tendon graft. All of the patients underwent an immediate postoperative CT-scan that documented the anatomical articulation. All patients treated with a plate underwent implant removal. A final CT examination after removal documented the maintenance of the anatomic alignment. CONCLUSIONS: The buttress plate technique with clavicular screw fixation is a sufficient treatment to restore and preserve a normal sternoclavicular alignment. The technique finds its indication in unidirectional posterior instability. LEVEL OF EVIDENCE: IV.

Chronic anterior sternoclavicular instability: technique and results of corrective clavicular osteotomy.

BACKGROUND: Chronic anterior sternoclavicular (SC) instability is a rare but potentially disabling condition. It can arise in conjunction with trauma or hyperlaxity, or both. Numerous surgical techniques have been described, but no gold standard exists. SC instability is often position-dependent and can be reduced with the arm in a specific position. METHODS: To directly address this issue, we used a technique of corrective osteotomy of the clavicle with the goal to reorient the articular portion of the medial end of the clavicle so that it remains stable in all functional positions of the arm. To illustrate the technique and the correction in space, we performed postoperative 3-dimensional computed tomography analyses of the shoulder girdle of 4 patients. Clinical scores were obtained at the final follow-up and compared with preoperative scores. RESULTS: Mean follow-up was 64 months (range, 19-191 months). The mean Constant score improved from 58 (range, 45-68) preoperatively to 73 (range, 69-84) postoperatively and the Subjective Shoulder Value from 42 (range, 15-80) to 79 (range, 50-100). All patients reported good or very good stability of the SC joint at the last follow-up. We recorded no intraoperative or direct postoperative complications. During follow-up, 3 patients underwent removal of the plate, 1 of them for plate breakage. The mean postoperative correction for combined rotations is given as a 3-dimensional angle and averaged 28.0° (range, 8.6°-39.7°). CONCLUSION: In this pilot study, medial corrective clavicular osteotomy using the described technique treated anterior SC instability with improvement of clinical shoulder function scores and good patient satisfaction. The technique appears simple and safe and deserves further evaluation.

Redefining the morphometry of subclavian vessels for clavicle fracture treatments.

PURPOSE: Clavicle fractures are common injuries in adults and children. Although neurovascular damage is rarely seen, acute subclavian artery pseudoaneurysms and injuries to subclavian vessels were reported for closed fractures of the clavicle. The aim of this study was to identify the morphological details of the subclavian vessels and their relation to the sternoclavicular joint and body of the clavicle. METHODS: 127 patients (66 females and 61 males) were evaluated using reconstructed three-dimensional computed tomographic angiographies. The point at which the subclavian artery crossed posterior to the clavicle was detected as a landmark. The medio-lateral distance between the sternal end of the clavicle, landmark, antero-posterior distance between the clavicle and the subclavian artery, diameter of the artery and vein, angle between the subclavian artery and vein, distance of the subclavian vein to the subclavian artery and the clavicle at the landmark were measured. Measurements were compared according to gender and right and left sides, and age correlation was determined. RESULTS: Morphometric relationship between the subclavian vessels and clavicle presented differences between genders. We measured the antero-posterior distance between the subclavian artery and the clavicle to be less than 1 cm (0.91 cm). CONCLUSION: The subclavian artery travelled longer distances in men than women to reach the point that it crossed the clavicle. Our results demonstrated that the subclavian artery does not pass from the inferior margin of the clavicle, thus, superior plate osteosynthesis does not have any risk to injury against the subclavian vessels during the management of the clavicle fractures.

Digital tomography is an effective investigation for sternoclavicular joint pathology.

OBJECTIVE: Plain radiographs of the sternoclavicular joint (SCJ) are difficult to interpret, and a CT or MRI scan is the usual investigation of choice. At our hospital, we use digital SCJ tomograms as our first-line investigation for all SCJ pathologies. We wanted to ascertain whether this is a safe and appropriate first-line imaging investigation. MATERIALS AND METHODS: We retrospectively reviewed every patient who had undergone an SCJ digital tomogram (DT) over a 4-year period. We cross-referenced each patient with their records to assess the reason for referral, result, requirement for further investigation, diagnosis and management. RESULTS: We identified 132 SCJ tomograms over the study period. Twelve patients were referred from other hospitals with pre-existing imaging and were excluded. The reasons for radiological investigation in the remaining 120 patients were pain/lump without trauma (54.2%), pain/lump with trauma (30.8%) and post-operative review (15%). Of the 102 patients who had DT as their initial investigation, the most common diagnoses identified included osteoarthritis, normal SCJ, fracture and dislocation among others. Only 18 (17.6%) of these patients required further investigation with CT and/or MRI. CONCLUSION: Our study is the first to assess digital tomography in SCJ pathology. We have shown that digital tomograms are an accurate and economically beneficial investigation for SCJ pathology and propose that it should be used as a first-line imaging investigation.

Locking plate for treating traumatic sternoclavicular joint dislocation: a case series.

BACKGROUND: Traumatic sternoclavicular joint dislocations are rare; closed reduction is the primary treatment. The failure of closed reduction or a prominent insult to the skin may require surgery to ensure the best possible outcome. METHODS: The records of 5 patients operated at our institution for sternoclavicular joint dislocation were reviewed. All patients were treated with open reduction and single 3.5-mm locking plate was used for fixation. Outcomes were evaluated with the Constant Shoulder Score (CSS) and Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Intraoperative and postoperative complications were recorded. RESULTS: All the patients had an average follow-up of 14 months (range, 11-16 months). At the final follow-up, the mean CSS score was 89.5 (range, 78-98) and the mean DASH score was 9.0 (range, 4-16). There were no early complications, including wound infection or neurologic or vascular deficits; there were also no broken or loosened screws or plates. No case of redislocation or arthrosis was observed. CONCLUSION: Our study indicates that open reduction and fixation with a single locking plate for the treatment of traumatic sternoclavicular joint dislocation is a safe, relatively simple surgical procedure that can lead to satisfactory outcomes.

Comparison of imaging planes during CT-based evaluation of clavicular ossification: a multi-center study.

Determining the ossification stage of the medial clavicular epiphysis by computed tomography represents the currently recommended methodology for the question of whether a living individual has completed the 18th or 21st year of life. In the present study, thin-slice CT scans of 1078 sternoclavicular joints were reconstructed in axial and coronal image series and evaluated according to the two classification systems established for age diagnostics using the clavicle. Both image series (axial and coronal) were analyzed separately. When comparing the results of axial and coronal view, a different ossification stage was found in 35.6% of the clavicles. The results suggest an influence of the imaging plane on the process of stage determination. In order to further approximate the three-dimensional and asymmetrical structure of the epiphyseal ossification center, the usage of at least two different reformation types may be recommended. In practice, only those reference studies should be applied which exactly employed the same number and orientations of the reformation types that are going to be used in the respective routine case.