The Bone School

Aetiology

 

Post-traumatic (type III clavicle fractures)

Idiopathic

 

4 patterns 

 

1. OA with osteophytes 

-  contribute to impingement

 

 

 

2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)

 

 

3. RA

 

4. Hyperparathyroidism

 

Symptoms

 

Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm

 

Signs

 

 

Tenderness to direct palpation is most reliable sign

- may feel osteophytes

- must compare to ensure other side is not tender (but may have bilateral ACJ OA)

 

Cross body adduction of arm 

- tends to overlap with impingement

 

Diagnosis

 

LA + Cortisone

- inject into joint

- diagnostic / therapeutic

 

DDx

 

Intrinsic

- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis

 

Extrinsic

- Cervical root C4/5

- shoulder tip pain from abdominal pathology

 

Xray

 

Zanca view

- AP 10° cephalic tilt with 50% penetration 

 

 

Bone Scan

 

Not usually necessary

 

 

Management

 

Non-operative

 

Most patients respond well

NSAIDs

Activity modification

Steroid injection

 

Operative

 

Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment

 

Aim

 

Resect sufficient distal clavicle to prevent abutment

 

Options

 

1.  Open excision distal clavicle

2.  Arthroscopic resection

 

Open Excision of distal clavicle

 

 

Technique

- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact

 

90% success rate

 

Arthroscopic ACJ Resection

 

Advantage

- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation

 

Results

 

Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

- identified subtle intra-articular changes not seen on MRI  which were treated

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection

 

Technique

 

1.  Identify distal clavivle

- remove bursa and perform SAD

- use electrocautery from lateral portal to identify the distal clavicle (push down on clavicle repetitively)

- clean and identify clavicle anterior and posterior

 

 

2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

- must remove full thickness of distal clavicle superiorly / be able to visualise superior AC ligament

- must not leave posterior edge