DEFINITION

The most common pathologic disorder affecting the medial clavicle is osteoarthritis.

Others include rheumatoid arthritis, seronegative spondyloarthropathies, crystal deposition disease, sternoclavicular hyperostosis, condensing osteitis, and avascular necrosis.12

Infection, although rare, must be considered. When suspected, the sternoclavicular joint should be aspirated for culture, Gram stain, and cell counts and then treated with irrigation and débridement.

Traumatic instability of the sternoclavicular joint is rare and classified by the direction of displacement of the clavicular head as superior, anterior, or posterior.

Posterior instability has been associated with a variety of potentially fatal comorbidities.

Atraumatic instability is usually anterior and is often seen in patients with generalized ligamentous laxity.

Symptomatic traumatic instability is best treated with closed reduction and possible reconstruction of the joint, not resection of the clavicle head.

 

 

SURGICAL ANATOMY

 

The sternoclavicular joint is saddle-shaped and contains an intra-articular disc.22

 

Important ligamentous restraints to motion include the anterior capsule (restrains anterior and posterior translation), the posterior capsule (restrains posterior translation),20 and the costoclavicular ligament (which is the pivot point for motion in the axial plane).4

 

The interclavicular ligament seems to provide little function (FIG 1).

 

The anterior sternoclavicular ligament covers the disc and is the gateway into the clavicular and sternal side of the joint.22

 

Proximity to vital structures: brachiocephalic vein closest; common carotid (right) and aortic arch (left), next closest.17

PATHOGENESIS

 

Osteoarthritis is the most common cause for surgical excision.

 

Osteoarthritis is most commonly seen in male laborers, in women during the perimenopausal years, and after radical neck dissection.

 

Rheumatologic disorders can affect the sternoclavicular joint as part of the systemic disease. Involvement of the sternoclavicular joint is usually late.

 

Other atraumatic conditions are less common and the pathogenesis is largely unknown.

 

Traumatic instability typically develops from a blow to the shoulder girdle.

 

 

If the force impacts the anterior shoulder, it will push the shoulder girdle posteriorly. The clavicle pivots over the first rib, forcing the head of the clavicle anteriorly.

 

If the force impacts the posterior shoulder, it will push the shoulder girdle anteriorly. The clavicle pivots over the first rib, dislocating the head of the clavicle posteriorly.

 

 

Direct blows to the sternoclavicular joint can also dislocate the clavicle head posteriorly. Atraumatic instability develops insidiously without a history of trauma.

NATURAL HISTORY

 

Many people have asymptomatic sternoclavicular joint arthritis.

 

Patients with symptoms may find relief with activity modification and time. This is particularly true with the pain and swelling seen in perimenopausal women.

 

 

 

FIG 1 • Anterior and posterior anatomy of sternoclavicular joint. 1, capsule; 2, costoclavicular ligament; 3,

interclavicular ligament; 4, sternocleidomastoid tendon.

 

 

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Table 1 Clinical Features of Atraumatic Disorders of the Sternoclavicular Joint

 

Disorder

Age (y)

Gender

Side

Pain

Erythema

Associated Conditions and Risk Factors

 

Osteoarthritis	>40	M = F	B	+	Rare	Manual labor, radical neck dissection, postmenopausal women
Rheumatoid arthritis	Any	F ≥ M	B	+	+	Symmetric polyarthritis
Seronegative spondyloarthropathies	<40	M > F	B	Occasional	-	Urethritis, uveitis, nail pitting
Septic arthritis	Any	M = F	U	+ + +	+ + +	HIV, IVDA, DM
Crystal deposition disease	>40	M > F	U	+ + + during flare	+ +	Other joint involvement
Sternoclavicular	30-	M > F	B	+	-	Synovitis, acne,
hyperostosis	60					pustulosis, hyperostosis, osteitis
Condensing osteitis	25-	F > M	U	+	-	None
	40
Friedreich disease	Any	F > M	U	+	-	None
Atraumatic	10-	F > M	U	Infrequent	-	Generalized
subluxation	30					ligamentous laxity

 

M, male; F, female; B, bilateral; U, unilateral; IVDA, intravenous drug abuse; DM, diabetes mellitus.

 

 

Infection may present with a relatively benign clinical picture but will progress and may become serious.

 

 

It is rare for the sternoclavicular joint to be the primary joint involved in rheumatologic conditions or crystal deposition disease.

 

Traumatic instability may result from high-energy injuries (eg, motor vehicle collision) or may be related to contact in athletics.

 

 

Traumatic intra-articular fracture of the medial clavicle is also commonly associated with high-energy injury and a 20% 1-month mortality rate from multisystem trauma.21

 

Posterior instability may be life-threatening as the clavicular head may compress vascular structures, the trachea, or the esophagus.

 

Atraumatic instability may have an insidious onset and is often associated with other signs of generalized ligamentous laxity (eg, patellar subluxation, glenohumeral subluxation).

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Atraumatic disorders

 

 

 

Localized sternoclavicular joint pain, potentially referred up the sternocleidomastoid and trapezius11 Infection is typically unilateral with pain and significant erythema (Table 1).

 

Osteoarthritis, rheumatoid arthritis, seronegative spondyloarthropathies, and sternoclavicular hyperostosis are typically bilateral, with mild pain and rare erythema.

 

Crystal deposition diseases, condensing osteitis, and Friedreich disease are typically unilateral and mildly painful.

 

Traumatic disorders

 

 

Acute trauma presents with pain and unwillingness to raise the arm. Patients may describe difficulty with swallowing or breathing with posterior dislocations.

 

The sternoclavicular joint is often swollen and tender.

 

 

If vascular compression is present, the affected arm may demonstrate circulatory changes and swelling. Physical examination may not be helpful in determining if the instability is anterior or posterior.

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Special radiographic projections include the Rockwood (serendipity), Hobbs, Heinig, and Kattan views but are somewhat difficult to interpret (Table 2).9

 

Computed tomography (CT) is particularly useful in trauma as it demonstrates displacement of the joint including direction (anterior or posterior) and bony anatomy.9

 

Arteriography should be considered in posterior dislocations if vascular injury is suspected.

 

Magnetic resonance imaging (MRI) is helpful in atraumatic disorders to evaluate the soft tissues and can delineate marrow abnormalities, joint effusions, and disc and cartilage injury.9

 

Laboratory findings in atraumatic disorders of the sternoclavicular joint are covered in Table 3.

 

 

Table 2 Radiographic Features of Atraumatic Disorders of the Sternoclavicular Joint

 

Disorder

Radiographic Findings

Osteoarthritis

Sclerosis, osteophytes

Rheumatoid arthritis

Minimal change

Seronegative

spondyloarthropathies

Marginal erosions, cysts

Septic arthritis

Sclerotic, lytic, or mixed lesions

Crystal deposition disease

Calcification of soft tissue

Sternoclavicular hyperostosis

Hyperostosis, ossification of intercostal ligaments

Condensing osteitis

Medial clavicle enlargement, preserved joint space, marrow

obliteration

Friedreich disease

Irregular end of medial clavicle

Atraumatic subluxation

Normal

 

 

 

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Table 3 Laboratory Features of Atraumatic Disorders of the Sternoclavicular Joint

Disorder

Laboratory Findings

Osteoarthritis

Normal

Rheumatoid arthritis

May have +RF, +ANA

Seronegative spondyloarthropathies

+HLA-B27

Septic arthritis

WBC, ESR, CRP elevated

Crystal deposition disease

+BRFC, -BRFC

Sternoclavicular hyperostosis

ESR elevated, other markers of rheumatologic disease normal

Condensing osteitis

Normal

Friedrich disease

Normal

 

Atraumatic subluxation

Normal

RF, rheumatoid factor; ANA, antinuclear antibodies; HLA-B27, human leukocyte antigen B27; WBC,

white blood cell count; ESR, sedimentation rate; CRP, C-reactive protein; BRFC, birefringent crystals.

 

 

DIFFERENTIAL DIAGNOSIS

Atraumatic disorders Osteoarthritis

Rheumatoid or other serologic arthritis

Seronegative spondyloarthropathies Crystal deposition disease Sternoclavicular hyperostosis Condensing osteitis

Avascular necrosis Septic arthritis Instability

Traumatic disorders

Medial-third clavicle fracture Sternal fracture

First rib fracture

 

 

NONOPERATIVE MANAGEMENT

 

Most atraumatic conditions can be managed nonoperatively using nonsteroidal anti-inflammatory drugs (NSAIDs) and rest. Sometimes, topical lidocaine patches can help with pain.

 

Acute dislocations should undergo attempted closed reduction.

 

In posterior dislocations, open reduction and possible reconstruction of the joint is indicated if closed reduction fails.

 

SURGICAL MANAGEMENT

 

Surgery is indicated for atraumatic disorders of the sternoclavicular joint in every case of septic arthritis and when nonoperative management fails for the other conditions listed in the differential diagnosis.

 

When infection is suspected, surgeons should perform incision and drainage quickly to prevent late osteomyelitis or abscess formation (especially adjacent to vital structures).

 

 

Atraumatic instability is a contraindication for resection of the medial clavicle. Acute dislocations should undergo closed reduction.

 

In posterior dislocations, open reduction and possible reconstruction of the joint is indicated if closed reduction fails.

Preoperative Planning

 

Due to the vital structures that lie behind the sternoclavicular joint, it is important to have a thoracic surgeon available should complications develop.

 

Positioning

 

The patient is positioned supine on the operating room table with a small rolled towel behind the middle of the back (FIG 2A).

 

The entire chest is exposed and prepped for treatment of complications should they occur.

 

Important structures, including the clavicle, manubrium, sternocleidomastoid, and costoclavicular ligament, are marked (FIG 2B).

 

The ipsilateral hand is prepared and draped as well if the surgeon desires to use palmaris as an interposition graft in reconstruction.

 

For reconstructions of the sternoclavicular joint, an ipsilateral hamstring may be used; as such, the knee should be prepared and draped.

 

Approach

 

The approach is anterior. Care is taken to protect important structures during dissection, particularly the origin of the sternocleidomastoid muscle and the costoclavicular ligament.

 

 

 

FIG 2 • A. Patient positioning. B. Anatomy is identified and marked.

 

 

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TECHNIQUES

• Incision and Dissection

The incision is made in the lines of Langer, which follow a necklace pattern over the head of the clavicle and manubrium (TECH FIG 1A).

After undermining in the subcutaneous plane, the platysma is incised in line with the skin incision, exposing the joint capsule and sternocleidomastoid origin (TECH FIG 1B).

 

 

 

 

TECH FIG 1 • A. Location of incision. B. Incision of platysma. C. Incision in joint capsule.

 

 

The capsule of the joint is marked. Care must be taken to avoid incising the entire sternal head of the sternocleidomastoid tendon (TECH FIG 1C).

• Atraumatic Disorders: Removing the Bone

   

  Electrocautery can be used to carefully elevate the capsule from the clavicular head. It is important to avoid straying too far laterally to avoid detaching the capsule and injuring the costoclavicular ligament (TECH FIG 2A).

   

  The intra-articular disc is removed and the capsule is carefully dissected around the cartilaginous margin of the head of the clavicle (TECH FIG 2B).

   

  A self-retaining retractor is placed on the capsule, a blunt retractor is placed next to the articular surface, and a small oscillating saw is used to remove between 0.5 and 1.0 cm of the medial clavicle (TECH FIG 2C).

   

   

   

  TECH FIG 2 • A. Elevating the capsule from the clavicle. B. Removing the intra-articular disc. C. Using an oscillating saw to remove the medial clavicle. (continued)

   

   

  An osteotome may be used to lever the medial clavicle head out of the joint (TECH FIG 2D).

   

  Electrocautery is used to carefully dissect the posterior capsule from the back of the clavicular head (TECH FIG 2E).

   

  The resected head should be between 0.5 and 1.0 cm in size to preserve the costoclavicular ligaments (TECH FIG 2F).6

   

  Reported distance between inferior articular surface of the medial clavicle and the most medial insertion of the costoclavicular ligament is approximately 1.2 cm in men and 1.0 cm in women.6,7

   

  P.3704

   

   

   

  TECH FIG 2 • (continued) D. Levering the medial clavicle from the joint. E. Removing the posterior soft tissue attachments. F. The excised medial clavicle.

• Harvesting the Tendon

   

  The palmaris tendon is isolated with a small incision in the wrist crease (TECH FIG 3A).

   

  After sutures are passed in the end of the palmaris, the tendon is removed percutaneously with a tendon stripper (TECH FIG 3B).

   

  The harvested tendon is rolled over a small spool and sutured to itself to create a rolled tendon (TECH FIG 3C,D).

   

   

   

  TECH FIG 3 • A. Palmaris tendon is identified. B. Percutaneous harvesting of palmaris longus tendon. C. Rolling the palmaris tendon graft. D. The rolled palmaris is sutured to itself. E. Insertion of the palmaris as interposition graft.

   

   

  When resecting the clavicular head for atraumatic disorders, the rolled palmaris tendon is inserted into the defect to create a soft tissue interposition between the cut surface of the clavicle and the manubrial joint surface (TECH FIG 3E).

   

  Alternatively, the palmaris can be used to augment a reconstruction of an unstable sternoclavicular joint by passing it around the clavicle and first rib (see the following section).

• Reconstruction of the Sternoclavicular Joint in Instability

 

A variety of techniques have been described. A figure-8 reconstruction has the best biomechanical properties and will be described here.19

 

Additional described techniques include isolated2 or augmenting allograft reconstruction with sternocleidomastoid tendon reconstruction.14

 

With the assistance of a thoracic surgeon, the plane behind the manubrium is developed by dissecting above the sternal notch (TECH FIG 4A).

 

P.3705

 

 

 

TECH FIG 4 • A. Development of the surgical plane behind manubrium. B. Drill holes are in manubrium with protection of mediastinal structures with an Army-Navy retractor. C. Drill holes in clavicle. D-F. Semitendinosus graft is passed in figure-8 fashion. G. Palmaris is passed around clavicle and first rib for augmentation. (C and D: Adapted from Kuhn JE. Sternoclavicular joint reconstruction for anterior and posterior sternoclavicular joint instability. In: Zuckerman J, ed. Advanced Reconstruction of the Shoulder. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2007:255-264.)

 

 

With a ribbon retractor behind the manubrium, two drill holes are made in the manubrium and sutures are passed (TECH FIG 4B).

Two drill holes are placed in the medial clavicle from anterior to posterior (TECH FIG 4C).

The semitendinosus autograft is passed in figure-8 fashion and secured to itself (TECH FIG 4D-F).

Additionally, the palmaris tendon may be passed around the first rib. This dissection behind the first rib should be performed by the thoracic surgeon to avoid injury to the internal mammary artery (TECH FIG 4G).

P.3706

• Wound Closure

The capsule is closed with figure-8 interrupted permanent no. 2 suture and the sternal head of the sternocleidomastoid falls into place (TECH FIG 5A).

 

TECH FIG 5 • A. Repair of the joint capsule. B. Repair of the platysma. C. Surgical wound is closed.

 

The wound is closed in layers with 0 Vicryl in the platysma (TECH FIG 5B), 2-0 Vicryl in the subcutaneous layer, and 3-0 Monocryl in the skin (TECH FIG 5C).

 

 

 

PEARLS AND PITFALLS
	Diagnosis ▪ CT and MRI will help differentiate arthritis from other less common conditions. The surgeon must always be diligent for infection, which may have a relatively benign appearance. If it is unclear whether the sternoclavicular joint is the source of pain, a diagnostic injection with lidocaine can be helpful. CT is extremely helpful to determine if a dislocation is anterior or posterior.     Removing ▪ Great care must be taken to avoid perforating the posterior capsule and bone entering the mediastinum. It is better to do a partial resection and remove residual bone with a burr. Preserving the clavicular head is important for reconstructions of unstable sternoclavicular joints.     Preserving ▪ Maintaining the integrity of the joint capsule is of critical importance. If the capsule capsule is stripped completely off the clavicle, suture anchors in the clavicle can help restore stability.     If the costoclavicular ligament is sacrificed, the intra-articular disc and disc

General

surgery

• It is wise to have a thoracic surgeon available should complications develop in

the mediastinum.

ligament can be passed into the intramedullary canal.

Costoclavicular ligament

 

 

POSTOPERATIVE CARE

 

Patients are typically admitted overnight for observation. Beware of hematoma formation that can compress vital structures.

 

Patients wear a sling with pillow support to support the arm when upright for 6 weeks.

 

Patients are instructed to avoid moving the arm for 6 weeks to allow for capsular healing and preventing instability.

 

 

 

After 6 weeks, patients gradually increase range of motion. After 12 weeks, patients can begin strengthening activities. After 16 weeks, patients may return to unrestricted activity.

 

 

OUTCOMES

There is little reported on the outcomes after this procedure. All reports are level 4 case series.

Rockwood and colleagues18 reported that outcomes were improved if the costoclavicular ligament remained intact (eight of eight excellent with complete satisfaction). If the costoclavicular ligament was disrupted, however, the results were less predictable (three of five excellent).

Arcus and associates1 reported on 15 patients with a variety of pathologies. Sixty percent were graded as good to excellent, and 93% had significant pain relief and would have the procedure again.

Pingsmann and colleagues16 found seven of eight women with sternoclavicular joint arthritis had good to excellent results with medial clavicle excision after 31 months of follow-up.

Laffosse and colleagues13 reported on a minimum 12-month follow-up of posterior sternoclavicular joint dislocations or posteriorly displaced medial physeal fractures and found closed reduction successful in 5 of 10 patients and reconstruction in 18 of 25 patients with slightly improved functional scores after reconstruction.

Bae and colleagues3 reported 60% stable pain-free joints and a mean American Shoulder and Elbow Surgeons (ASES)

P.3707

score of 85 in 15 patients with chronic, recurrent anterior instability treated with reconstruction or medial excision at an average of 55 months follow-up.

Meis and coworkers15 modified the technique by interposing the sternal head of the sternocleidomastoid into the defect. Ten of 14 patients reported good to excellent outcomes; however, two patients reported incisional pain with head turning, and three patients had cosmesis concerns.

A variety of case reports exist for other sternoclavicular joint reconstructions. To date, no reports are in the peer-reviewed literature for the figure-8 reconstruction.

 

 

 

COMPLICATIONS

Rockwood and colleagues18 report that patients may have severe discomfort if instability persists or develops. Consequently, it is imperative to preserve the costoclavicular ligament. If the costoclavicular ligament is disrupted, the intra-articular disc and ligament can be transferred into the intramedullary canal of the resected clavicle. In addition, reconstructing the costoclavicular ligament with a tendon graft around the first rib should be considered.

Heterotopic ossification has been reported in about half of the patients but seems to be asymptomatic.1

Although not reported to date, intraoperative complications involving the great vessels, trachea, and other mediastinal contents are possible. A thoracic surgeon should be available.

Catastrophic postoperative complications are rare. Three separate case reports describe Kirschner wire (K-wire) late migration and penetration of the heart,10 or early penetration8 of the brachiocephalic vessels,5 causing cardiac tamponade or hemothorax. The use of K-wires is contraindicated.

 

 

REFERENCES

1. Acus RW III, Bell RH, Fisher DL. Proximal clavicle excision: an analysis of results. J Shoulder Elbow Surg 1995;4:182-187.

    

    

2. Armstrong AL, Dias JJ. Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle. J Bone Joint Surg Br 2008; 90(5):610-613.

    

    

3. Bae DS, Kocher MS, Waters PM, et al. Chronic recurrent anterior sternoclavicular joint instability: results of surgical management. J Pediatr Orthop 2006;26(1):71-74.

    

    

4. Bearn JG. Direct observations on the function of the capsule of the sternoclavicular joint in clavicular support. J Anat 1967;101:159-170.

    

    

5. Bensafi H, Laffosse JM, Taam SA, et al. Tamponade following sternoclavicular dislocation surgical fixation. Orthop Traumatol Surg Res. 2010;96(3):314-318.

    

    

6. Bisson LJ, Dauphin N, Marzo JM. A safe zone for resection of the medial end of the clavicle. J Shoulder Elbow Surg 2003;12:592-594.

    

    

7. Carrera EF, Archetti Neto N, Carvalho RL, et al. Resection of the medial end of the clavicle: an anatomic study. J Shoulder Elbow Surg 2007;16(1):112-114.

    

    

8. Durpekt R, Vojacek J, Lischke R, et al. Kirschner wire migration from the right sternoclavicular joint to the heart: a case report. Heart Surg Forum 2006;9(6):E840-E842.

    

    

9. Ernberg LA, Potter HG. Radiographic evaluation of the acromioclavicular and sternoclavicular joints. Clin Sports Med 2003;22:255-275.

    

    

10. Gulcan O, Sezgin AT, Bolat B, et al. Right ventricular penetration and cardiac tamponade as a late complication of Kirschner wire placement in the sternoclavicular joint. Interact Cardiovasc Thorac Surg 2005;4(4):295-296.

     

     

11. Hassett G, Barnsley L. Pain referral from the sternoclavicular joint: a study in normal volunteers. Rheumatology 2001;40:859-862.

     

     

12. Higgenbotham TO, Kuhn JE. Atraumatic disorders of the sternoclavicular joint. J Am Acad Orthop Surg 2005;13:138-145.

     

     

13. Laffosse JM, Espie A, Bonnevialle N, et al. Posterior dislocation of the sternoclavicular joint and epiphyseal disruption of the medial clavicle with posterior displacement in sports participants. J Bone Joint Surg Br 2010;92(1):103-109.

     

     

14. Lee SU, Park IJ, Kim YD, et al. Stabilization for chronic sternoclavicular joint instability. Knee Surg Sports Traumatol Arthrosc 2010;18(12):1795-1797.

     

     

15. Meis RC, Love RB, Keene JS, et al. Operative treatment of the painful sternoclavicular joint: a new technique using interpositional arthroplasty. J Shoulder Elbow Surg 2006;15:60-66.

     

     

16. Pingsmann A, Patsalis T, Michiels I. Resection arthroplasty of the sternoclavicular joint for the treatment of primary degenerative sternoclavicular arthritis. J Bone Joint Surg Br 2002;84B:513-517.

     

     

17. Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg 2013;22(7):993-999.

     

     

18. Rockwood CA Jr, Groh GI, Wirth MA, et al. Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg Am 1997;79A:387-393.

     

     

19. Spencer EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am 2004;86A: 98-108.

     

     

20. Spencer EE, Kuhn JE, Huston LJ, et al. Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

     

     

21. Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg 2007;16(1):49-54.

     

     

22. Van Tongel A, MacDonald P, Leiter J, et al. A cadaveric study of the structural anatomy of the sternoclavicular joint. Clin Anat 2012;25(7):903-910.