DISTAL CLAVICLE OSTEOLYSIS

 

Distal clavicle osteolysis is a unique disease most likely due to an overuse phenomenon. Distal clavicular osteolysis (DCO) follows both chronic repetitive stress and single acromioclavicular trauma. Acute distal clavicular osteolysis was first described in 1936.

The exact aetiopathogenesis is unclear, but AC-joint trauma and subchondral microfractures seem to be involved. Subsequent attempts at repair are insufficient and the final result is osteolysis. It is unclear why changes predominate in the distal clavicle while the acromion is relatively spared.)

Mostly affected males in their 20s and commonly seen in weightlifters, symptoms usually begin with an insidious aching pain in the AC region that is exacerbated by weight training. Clinical findings are often nonspecific and frequently overlap with those of labral or rotator cuff tears. On examination, patients have point tenderness over the affected AC joint and pain with a cross-body adduction maneuver.

Conventional radiographs may remain normal during the first months or years. A 15° cephalad inclination avoids superposition of the scapular spine with the AC-joint (Zanca view).

Radiographic changes include cortical thinning, irregularity and microcysts in distal clavicle and mild AC–joint widening. A late finding is tapering of the distal clavicle.

MRI is far more sensitive to detect DCO in an early stage. The most common MR-finding is bone marrow oedema in the distal clavicle, sometimes also in the articular part of the acromion, but less distinct.

Often, a hypointense line is seen in this area of clavicular bone marrow oedema, representing a subchondral fracture. AC-joint abnormalities are common, and include effusion, mild widening, intra-articular bone fragments and capsule hypertrophy. Other MR-findings are similar to those seen on radiographs, as described above.

Bone scan may also shows increased uptake in the distal clavicle, which could be seen earlier than radiographic changes.

Treatment is essentially conservative, consisting of rest and nonsteroidal anti-inflammatory drugs (NSAID's), and is usually successful. In severe cases, resection of the distal clavicle is indicated. If left untreated, the process may cause progressive resorption of lateral aspect of the clavicle, erosions and cupping of the acromion and dystrophic calcifications.

DCO should be considered in the differential diagnosis of shoulder pain in the appropriate population. Therefore, analysis of MR arthrographic studies of the shoulder should not be restricted to evaluation of the rotator cuff and capsulolabral system, but the AC-joint should be scrutinised as well.

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