Friedrick's Disease

Friedrich's Disease ICD-9 Classification / Treatment Etiology / Epidemiology / Natural History Associated Injuries / Differential Diagnosis Anatomy Complications Clinical Evaluation Follow-up Care Xray / Diagnositc Tests Review References synonyms: aseptic osteonecrosis of the medial clavicle, Friedrich's Disease ICD-9 Friedrich's Disease Etiology / Epidemiology / Natural History osteonecrosis of the medial clavicle Rare Friedrich's Disease Anatomy 50% of the medial head of the clavicle articulates with the sternum. SC joint allows 35° upward motion, 35° arc of A/P motion, 50° of rotation. SC joint is a diarthrodial joint. The only true articulation between the upper extremity and the axial skeleton. The medial clavicle epiphysis does not ossify until 17 or 18.  In pts whose epiphysis is unossifed it is impossible to differential between a physeal fx and a dislocation, although fx is much more likely. Anterior capsular ligament is the strongest of the SC ligaments and prevents upward displacement of the medial clavicle. Costoclavicular ligament (rhomboid ligament): consists of anterior and posterior fasciculus. Anterior fasciculus arises from the anteriomedial aspect of the first rib and insert more laterally on the clavicle. Posterior fasciculus arises lateral to the anterior fasciculus and inserts more medially. Intra-articular Disk Ligament: dense, fibrous ligament arising from the synchondral junction of the first rib to the sternum; passes through the sternoclavicular joint, dividing it into two joint spaces. Interclavicular ligament: arises from the upper sternum, inserts on superomedial clavicle. Posterior capsule most important structure in AP stability of the medial clavicle. Friedrich's Disease Clinical Evaluation Atraumatic pain, swelling and crepitus in the sternoclavicular joint. May demonstrate decreased shoulder ROM. Friedrich's Disease Xray / Diagnositc Tests AP view, apical lordotic view, serendipity view. May demonstrate irregularity or deformation of the medial clavicle. CT provides improved diagnostic value. MRI: demonstrates metaphyseal necrosis. Labs: normal ESR, CRP. WBC Biospy: cystic degeneration with necrotic bone fragments surrounded by intact bone consistent with osteonecrosis. Friedrich's Disease Classification / Treatment Generally responds well to ice, NSAIDs, activity modifications. (Levy M, JBJS 1981;63BR:539). May consider excision or curettage if fails to improve with prolonged non-op treatment, or if diagnosis is in question. Friedrich's Disease Associated Injuries / Differential Diagnosis Spontaneous sternoclavicular subluxation Seronegative Spondyloarthropathy Crystal deposition disease Sternoclavicular Septic Arthritis Sternoclavicular Hyperostosis Sternoclavicular osteoarthritis Condensing Osteitis Tietze’s syndrome Rheumatoid arthritis Friedrich's Disease Complications Continued pain Friedrich's Disease Follow-up Care Reportedly resolves spontaneously (1.5yrs) (Levy M, JBJS 1981;63BR:539). Friedrich's Disease Review References Higginbotham TO, JAAOS 2005;13:138 Levy M, JBJS 1981;63BR:539