Distal Clavicle Excision: Clinical and Radiographic Findings:

- Clinical Findings:
      - patients may note pain with activities that occur in adduction (golf back swing);
      - local tenderness to palpation and to hyper-adduction;
      - trapezial spasm;
      - patients will often note pain located posterior to the AC joint;
      - steroid-lidocaine injection:
            - remember that AC joint injections are often a difficult "stick" and are often painful;
            - if dx is in question, consider a subacromial lidocaine-steroid injection;
            - if the patient does not receive relief from the subacromial injection, then AC joint arthrosis is a more likely diagnosis; 
            - references:
                  - Diagnostic value of physical tests for isolated chronic acromioclavicular lesions
                  - Diagnostic values of tests for acromioclavicular joint pain.
                  - Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint.
                  - The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. 
                  - Intra-Articular Versus Periarticular Acromioclavicular Joint Injection: A Multicenter, Prospective, Randomized, Controlled Trial

- cautions:
be sure to consider a slap tear or biceps tendonitis in the differential diagnosis;
       - reference: The SLAP lesion: A cause of failure after distal clavicle resection

- Radiographs: (Zanca view):
        - AC joint subluxation;
        - narrowing of the joint space w/ sclerosis of distal end of the clavicle;
        - inferior osteophytes;
        - in some cases distal clavicular resorption may be present, which might indicate RA, scleroderma, or which may occur in weight lifters); 

- MRI:
        - reactive bone edema on MRI is most reliable predictor of symptomatic AC pathology than degenerative changes seen on MRI
        - other findings include caudal osteophytes, capsular hypertrophy, and subchondral cysts;
        - in the study by Stein et al, the authors sought to detection of AC joint pathology in asymptomatic shoulders with magnetic resonance imaging;
        - ACJ arthritic changes were graded on a scale from 1 to 4 (none, mild, moderate, and severe), based on the amount of subacromial fat effacement,
                  joint space narrowing, irregularity, capsular distension, and osteophyte formation;
        - 41 (82%) of 50 shoulders had abnormalities consistent with arthritis on MRI;
        - references:
A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients. 
                - Atraumatic osteolysis of the distal clavicle: MR findings
                - Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging.
                - A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients.
                - Increased T2 signal intensity in the distal clavicle: incidence and clinical implications.
                - MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection.
                - The MRI geyser sign: acromioclavicular joint cysts in the setting of a chronic rotator cuff tear

- Indications For Excision:
         - pts w/ incomplete AC separation (type I & II) who develop degenerative changes & persistant symptoms may require excision of distal clavicle;
         - references:
                 - The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty.
                 - The management of acromioclavicular joint osteoarthrosis: débride, resect, or leave it alone.

- Contra-indications:
          - it is inappropriate to excise the distal clavicle in chronic type III, IV, V or VI AC separations;
          - this may increase the patients symptoms, by converting a displaced long clavicle, into a short displaced clavicle; 

- references:
        - Arthroscopic resection of the distal clavicle with a superior approach
        - Sequential Resection of the Distal Clavicle and Its Effects on Horizontal Acromioclavicular Joint Translation

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, December 5, 2013 10:32 am