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.

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

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 Erosion

• 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.

 

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 airway 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.