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Introduction
  • Pathophysiology
    •  repetitive trauma inducing inflammatory cascade leading to micro-fracture and osteolysis in distal clavicle 
  • Epidemiology
    • demographics
      • young males most common
      • weight lifters (particularly those performing overhead lifts)
    • risk factors
      • history of traumatic injuries
Anatomy
  • Osteology
    • clavicle is
      • S-shaped bone
      • last bone to fuse
      • medial growth plate fuses around 20 years (+/- 2)
  • AC Joint 
    • stabilized by
      • AC ligaments (primarly resists anterior-posterior displacement)
      • CC ligaments (primarily resits superior-inferior displacement)
      • CA ligament (prevents anterosuperior humeral head migration)
    • A convex fibrocartilaginous disk resides inside the joint analagous to the meniscus of the knee
    • Innervated by lateral pectoral, axillary and suprascapular nerves
Presentation
  • Similar to AC joint arthritis
  • Symptoms
    • Pain at distal clavicle
  • Physical exam
    • Tenderness at distal end of clavicle
    • Cross-body adduction test
    • O'Brien's Test
    • AC resisted extension test  
      • The shoulder and elbow are flexed to 90 degrees
      • Positive if resisted shoulder extension produces pain at AC joint 
Imaging
  • Radiographs
    • recommended views
      • Standard shoulder series
      •  Zanca view (AP of clavicle with less penetration) 
    • findings  
      • cysts at distal end of clavicle (acromion is spared)  
      • osteopenia
      • resorption and erosion
      • tapering of distal clavicle
Treatment
  • Nonoperative
    • activity modification, NSAIDS, corticosteroid injections
      • indications
        • first line of treatment
      • technique
        • modifying lifting technique by placing hands farther apart during bench press and avoiding lifts that place the elbows posterior to the plane of the torso
  • Operative
    • open or arthroscopic distal clavicle excision
      • indications
        • severe symptoms that have failed nonoperative treatment
      • outcomes
        • open vs. arthroscopic based on surgeon preference and comfort
          • arthroscopic resection has the advantage of allowing evaluation of the glenohumeral joint
            • good results shown with arthroscopic treatment 
          • open procedures require meticulous repair of deltoid-trapezial fascia
Techniques
  • Arthroscopic distal clavicle resection (Mumford procedure) 
    • May use either indirect (subacromial) or direct (superior) approach
    • should resect only 0.5-1cm of distal clavicle

Complications

  • Distal clavicle excision
    • avoid violating the posterosuperior capsule as will lead to horizontal instability
 

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