You are in: eMedicine Specialties > Orthopedic Surgery > SHOULDER Distal Clavicle OsteolysisArticle Last Updated: Oct 18, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Brett D Owens, MD, Consulting Staff, Department of Orthopedics, Keller Army Hospital, West Point Brett D Owens is a member of the following medical societies: American Academy of Orthopaedic Surgeons and Society of Military Orthopaedic Surgeons Coauthor(s): Robert Q Terrill, MD, Assistant Professor, Department of Orthopedic Surgery, University of Massachusetts Medical Center; Anthony Schena, MD, Assistant Professor of Orthopedic Surgery, Tufts University; Consulting Staff, Department of Orthopedics, St. Elizabeth's Medical Center and Caritas Orthopedics Editors: Cato T Laurencin, MD, PhD, University Professor, Lillian T Pratt Distinguished Professor and Chairman, Department of Orthopaedic Surgery, The University of Virginia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Pekka A Mooar, MD, Associate Professor, Department of Orthopedic Surgery, Temple University School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: clavicle osteolysis, shoulder pain, overuse injury, shoulder trauma, shoulder microtrauma, chronic shoulder pain, collar bone pain, broken collar bone, collar bone microtrauma INTRODUCTIONSection 2 of 11
  History of the ProcedureDistal clavicle osteolysis was first described in 1936 as a condition secondary to acute shoulder trauma. Today, distal clavicle osteolysis is described as a sequela of trauma associated with contact sports, falls, and motor vehicle accidents. In 1959, this condition was reported in an air-hammer operator without evidence of acute trauma. In 1982, Cahill reported on 45 male athletes with distal clavicle osteolysis, confirming repetitive microtrauma as an etiology. Forty-four of Cahill's patients were weight lifters. ProblemDistal clavicle osteolysis is a pathologic process involving resorption of subchondral bone in the distal clavicle. The condition usually presents as pain localized to the acromioclavicular (AC) joint. FrequencyThough more than 100 cases have been reported in the US literature, distal clavicle osteolysis may be an underdiagnosed disorder. The rate of incidence has been increasing with the growth in popularity of weight training in the past 20 years. As more women are participating in competitive and recreational weight lifting and sports that involve overhead throwing, more women are presenting with cases of distal clavicle osteolysis. EtiologyDifferent theories concerning the etiology of distal clavicle osteolysis have emerged:
PathophysiologyThere is one case report of hypertrophic synovial tissue that migrated across the articular cartilage and invaded subchondral bone, but most specimens show disruption of articular cartilage, subchondral cyst formation, and evidence of increased osteoclastic activity. ClinicalMost patients invariably present with pain over the distal end of the clavicle and AC joint that is usually described as a dull ache. Patients with an etiology of trauma report a specific event as the start of their symptoms. In patients with repetitive/overuse injuries, pain is exacerbated by athletic or work activity. Weight lifters report most symptoms occurring with the bench press and related exercises. Upon physical examination, patients have point tenderness over the affected AC joint, and cross-chest maneuvers elicit pain. Usually, the AC joint is not unstable; however, crepitation may be present. Range of motion (ROM) of the glenohumeral joint should be full. The differential diagnosis must include metabolic (hyperparathyroidism), autoimmune (rheumatoid arthritis), and neoplastic (multiple myeloma) etiologies. As distal clavicle osteolysis is usually a unilateral condition, inflammatory disease should be considered in bilateral cases. INDICATIONSSection 3 of 11
Patients in whom conservative treatment fails or those who refuse to limit their activity are candidates for surgical treatment. RELEVANT ANATOMYSection 4 of 11
The AC joint is a diarthrodial joint. The capsule of the AC joint is reinforced by the superior and inferior AC ligaments, with additional stability provided by the coracoclavicular ligaments. A fibrocartilaginous disk is present between the convex distal clavicle and the flat acromion, both of which are covered by hyaline cartilage. CONTRAINDICATIONSSection 5 of 11
The only contraindications noted are those general to surgery. Most surgical approaches are best performed with general anesthesia; therefore, patients with risks associated with general anesthesia should continue with nonoperative therapy. WORKUPSection 6 of 11
Imaging Studies
Diagnostic Procedures
TREATMENTSection 7 of 11
Medical therapyDistal clavicle osteolysis is a self-limiting disorder, with resolution within 1-2 years with activity modification.
Surgical therapyThe classic procedure for distal clavicle osteolysis is distal clavicle resection, a reliable procedure with good to excellent results. Recently, authors have reported excellent results with arthroscopic distal clavicle resection. This approach affords a more cosmetically appealing result, with an earlier return to activity, as well as providing a means to address concomitant intra-articular pathology. Arthroscopic resection can be performed through standard portals from the subacromial space, as well as via a direct superior portal. Intraoperative detailsThe necessary amount of distal clavicle to resect has been debated in the literature. Although Cahill reported excellent results with an open approach resecting 1-2 cm of bone, recent arthroscopic studies have shown that as little as 4 mm is effective. The distal clavicle should be resected enough to prevent AC impingement through a full range of shoulder motion. Postoperative detailsEarly passive ROM, including pendulum exercises, is important to prevent loss of shoulder motion. Because the open procedure requires partial detachment of the deltoid, active ROM is usually restricted in the early postoperative course. Activity is accelerated comparatively following arthroscopic treatment, with active ROM started within the first week. Follow-upRoutine postoperative follow-up at 1-2 weeks is recommended. COMPLICATIONSSection 8 of 11
Few complications from surgical treatment for distal clavicle osteolysis have been reported. One theoretical concern with aggressive distal clavicle resection is damage to the underlying neurovascular structures. Risk of infection always exists, although this is low. Development of frozen shoulder because of limited motion is a concern during the postoperative course. OUTCOME AND PROGNOSISSection 9 of 11
Although the outcome for conservative treatment is good, many patients are unable to limit their activity. These patients, and those who are recalcitrant to conservative treatment, can expect good to excellent results from surgical intervention. Patients with an etiology of trauma may have an increased risk of unfavorable results. Patients can also develop symptoms in the contralateral extremity. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Distal Clavicle Osteolysis excerpt Article Last Updated: Oct 18, 2006 | |||||||||||||||||||
