Distal Clavicle Osteolysis

Osteolysis is bone erosion, the bone is dissolving or lost. There is a localized area of inflammation, hyperemia, microfracture, bone resorption, and eventually arthritis of the AC joint. The condition affects the distal end of the clavicle due to micro stress fractures. It typically affects younger male patients. It occurs from activities that require overhead heavy lifting, repetitive motion, and the use of a jack hammer. The condition is also common in weight lifters.

acromion

During the examination, you will find localized pain, swelling, and tenderness over the AC joint area. Additionally, the provider will find a positive cross body adduction test. An x-ray will show erosion of the outer end of the clavicle. The acromion is okay. There may be osteopenia, osteolysis, tapering and cystic changes of the clavicle. An MRI may be obtained to rule out additional shoulder pathology. An MRI will show a high signal in the distal clavicle.

Imaging

Acromioclavicular Joint Radiography- Zanca View

imaging

Direction of the x-ray beam: The beam is directed with the cephalad angle of 10 degrees. Clavicular osteolysis can be assessed using the Zanca view. The acromion will be normal with the abnormality isolated to the distal clavicle. The Zanca view is also used for diagnosis of arthritis of the AC joint. It will show osteophytes and joint space narrowing. The findings of the x-rays may not represent the patient’s real symptoms.

Differential Diagnosis

Erosion or absence of the distal ends of the clavicle may be seen in a wide range of conditions.

Bilateral Erosions

  • Hyperparathyroidism
  • Rheumatoid arthritis
  • Scleroderma

Unilateral Erosionerosion of bone

  • Post-traumatic Osteolysis
  • Myeloma
  • Metastases
  • Osteomyelitis

 

Treatment consists of rest, NSAIDs, ice, and activity modification. Injections may be given blindly or with ultrasound guidance. If pain persists despite conservative methods, surgery may be considered. An arthroscopic or open resection of the distal clavicle may be performed. An arthroscopy allows for evaluation of the shoulder joint. In open surgery, repair the trapezius and deltoid fascia adequately. Surgery is successful in about 90% of cases. The surgeon will resect 5-10mm of bone and keep the posterior-superior ligament intact because it maintains horizontal stability of the clavicle.

 

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Management of the Unconscious Athlete

Athletes falling unconscious is not uncommon, especially in contact sports such as football, hockey, or rugby. When an athlete goes unconscious, you should first assess their ABC’s. This stands for airway, breathing, and circulation. In an unconscious patient, you must always assume a cervical spine injury and handle the patient with extreme caution. If the individual is found face down, proceed to slowly bring him on his back by using the log-rolling technique. This maneuver should be directed by the individual maintaining the patient’s airway and cervical spine alignment. Skilled personnel with adequate training should be involved in this step. Remove face masks to allow for boardairway access, but leave helmets and shoulder pads in place. The helmet can be removed if it isn’t stabilizing the head and cervical spine or if it is obstructing the airway. Transporting the patient onto the spine board is achieved by either the log-rolling or the five-man lift technique. Do not forget to securely strap the patient on the spine board before moving them. Advanced trauma and cardiac life support protocols should be performed promptly.

 

Traumatic Neonatal Distal Femoral Physeal Injury

physeal

A physeal injury in the distal femur in the neonate is rare. In general, traumatic neonatal physeal fracture usually occurs in the distal humerus and rarely occurs in the distal femur. The condition usually occurs due to birth trauma and usually results due to physeal separation which results in epiphyseal separation. The thigh will be swollen and there may be hypomobility of the extremity. The neonate will be fussy or irritated with significant swelling in the thigh. The condition is under diagnosed. The epiphysis is usually present at birth on x-rays. This condition can become complicated if the epiphysis is not completely ossified at birth or if the child is born prematurely. In this situation, the x-ray interpretation may be difficult. An MRI will be really helpful if the doctor is uncertain of the diagnosis. X-rays should be taken at the child at birth. The physician should look at the lateral x-ray and find the epiphysis is present and ossified at birth with varying degrees (may not be clear). Each epiphysis will line up with its corresponding bone. Epiphysis of the distal femur should line up with the femoral congenital kneeshaft. Epiphysis of the proximal tibia should line up with the tibial shaft. If the two epiphysis separate from each other, then this is a congenital dislocation of the knee. This can be a spectrum of injury that varies from hyperextension to subluxation, to frank dislocation. If the epiphysis is separated from its corresponding bone, for example, the epiphysis of the distal femur is separated from the shaft of the femur, then this is a physeal injury. Because the distal femur is mostly cartilaginous, you don’t see bone shifting, you see a little hint of the separation of the physis by seeing that the small ossified epiphysis is not in its normal position that corresponds with the axis of the bone. You need to know the difference between physeal injury and congenital dislocation of the knee. Accurate, gentle closed reduction with follow-up x-rays to confirm the reduction and to detect any early bony bridging.

 

 

 

Drop Arm Test

The Drop Arm Test is used for diagnosing rotator cuff tendon tears, specifically the supraspinatus tendon tear. The test helps in determining if there is a tear in the supraspinatus tendon and the can be done by many techniques. The patient should be instructed to fully abduct the arm. Then, the patient should slowly lower the arm to the side. If there is a tear in the rotator cuff tendon, the arm will drop from a position of about 90° of abduction. tearEven if the patient attempts this several times, the patient with a supraspinatus tendon tear cannot lower the arm smoothly and slowly. If the patient with the supraspinatus tendon tear is able to hold the arm in abduction, a small amount of pressure on the forearm will cause the arm to fall to the side.

Another method of performing the test begins with the physician instructing the patient to fully abduct the arm and the examiner supporting the arm so that it is able to be tested in 90° of abduction. The patient is asked to actively lower the arm from abduction to the side, slowly andtendon tear smoothly in a controlled way. A positive test occurs when the patient is unable to hold the arm in 90° of abduction or is unable to control lowering the arm to the side. The practical way of performing the test is when the examiner holds the arm fully abducted by the side of the patient and then will release it. If the arm drops, this will mean that there is a large rotator cuff tear present. The test is positive when pain and weakness causes the arm to drop to the side.