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Updated: Jun 3 2021

Distal Clavicle Osteolysis

Images clavicle osteolysis.jpg clavicle osteolysis xr.jpg
  • Summary
    • Distal clavicle osteolysis is the painful development of bony erosions and resorption of the distal clavicle caused by repetitive trauma to the AC joint.
    • Diagnosis is made with radiographs of the shoulder revealing osteolysis, cysts, erosions and resorption of the distal end of the clavicle.
    • Treatment is a trial of NSAIDs, activity modifications, and corticosteroid injections. Arthroscopic versus open distal clavicle excision is indicated for patients with persistent symptoms that have failed nonoperative treatment.
  • Epidemiology
    • Demographics
      • patients in their 20s, mostly male
      • commonly seen in weightlifters
    • Risk factors
      • history of traumatic injuries
  • Etiology
    • Pathophysiology
      • pathoanatomy
        • caused by repetitive stress and micro-fracture in distal clavicle which leads to osteopenia
  • Anatomy
    • Osteology
      • clavicle is
        • S-shaped bone
        • last bone to fuse
    • Medial growth plate fuses early 20s
    • Diarthrodial joint with fibrocartilage meniscus
    • Ligamentous
      • AC ligaments: horizontal stability
      • CC ligaments: vertical stability
  • Presentation
    • Similar to AC joint arthritis
    • Symptoms
      • pain
        • located at distal clavicle and anterior superior shoulder
        • insidious in onset
        • exacerbated by repetitive loading (ie. bench press or push-ups)
    • Physical exam
      • palpation
        • tenderness at the distal end of clavicle and AC joint
      • provocative test
        • pain with cross-body adduction
  • Imaging
    • Radiographs
      • recommended views
        • AP clavicle
        • Zanca view (15 degrees cephalad tilt)
      • findings of the distal clavicle (should not involve the acromion)
        • cysts
        • osteopenia
        • resorption and erosion
        • tapering of distal clavicle
        • AC joint widening
    • Advanced Imaging
      • MRI: increased signal of T2 sequences and bone marrow edema
      • bone scan: increased uptake in the distal clavicle (may be seen earlier than radiographic changes)
  • Treatment
    • Nonoperative
      • activity modification, NSAIDs
        • indications
          • first line of treatment
        • modification
          • avoid aggravating weight-lifting exercises or modify technique
            • ie. moving hand grip closer together and ending weight descent to 4 to 6 cm above the chest
      • corticosteroid injections
        • indications
          • diagnostic and therapeutic
        • technique
          • more accurate with ultrasound
    • Operative
      • open or arthroscopic distal clavicle excision
        • indications
          • persistent symptoms that have failed nonoperative treatment
        • technique
          • need to address associated pathology to the rotator cuff and long head of biceps
        • outcomes
          • open vs. arthroscopic based on surgeon preference and comfort
            • arthroscopic resection has the advantage of allowing evaluation of the glenohumeral joint
              • good results are shown with arthroscopic treatment
              • quicker recovery and return to activity
            • open procedures require meticulous repair of deltoid-trapezial fascia
  • Techniques
    • Arthroscopic distal clavicle resection (Mumford procedure)
      • should resect only 0.5-1cm of the distal clavicle
      • too large a resection can lead to AC joint instability
  • Complications
    • Horizontal instability
      • avoid violating the posterosuperior capsule during distal clavicle excision as will lead to horizontal instability
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