DEFINITION

Sternoclavicular dislocation is one of the rarest dislocations but one most shoulder surgeons will encounter several times during a career (more so if they are in a practice with significant exposure to high-energy trauma).

Sternoclavicular dislocations represented 3% of a series of 1603 injuries of the shoulder girdle reported by Cave.9

The true ratio of anterior to posterior dislocations is unknown because most reports focus on the rarer posterior type. Estimates range from a ratio of 20 anterior dislocations to each posterior by Nettles and

Linscheid,22 in a series of 60 patients (57 anterior and 3 posterior), to a ratio of approximately 3:1 (135 anterior and 50 posterior) in our series29 of 185 traumatic sternoclavicular injuries.

Not all sternoclavicular dislocations require surgery. Avoiding inappropriate patient selection, preventing hardwarerelated complications, and repairing or reconstructing the capsule and the rhomboid ligament if the medial clavicle has been resected require special emphasis.

Although this region can be intimidating because of the surrounding anatomic structures, a knowledgeable and careful surgeon can treat this joint safely and reliably produce good results.

 

ANATOMY

 

The epiphysis of the medial clavicle is the last epiphysis of the long bones to appear and the last to close. It does not ossify until the 18th to 20th year, and it generally fuses with the shaft of the clavicle around age 23 to 25 years.17,18 For this reason, many sternoclavicular “dislocations” in young adults are in fact physeal fractures.

 

The articular surface of the medial clavicle is much larger than that of the sternum. It is bulbous and concave front to back and convex vertically, creating a saddle-type joint with the curved clavicular notch of the sternum.17,18

 

A small facet on the inferior aspect of the medial clavicle articulates with the superior aspect of the first rib in 2.5% of subjects.8

 

There is little congruence and the least bony stability of any major joint in the body. Almost all of the joint's integrity comes from the surrounding ligaments.

 

Ligaments

 

The intra-articular disc ligament is dense and fibrous, arises from the synchondral junction of the first rib to the sternum, passes through the sternoclavicular joint, and divides it into two separate spaces17,18 (FIG 1). It attaches on the superior and posterior medial clavicle and acts as a checkrein against medial displacement of

the inner clavicle.

 

The costoclavicular (rhomboid) ligament attaches the upper surface of the medial first rib and upper surface of the first costal cartilage and to the rhomboid fossa on the inferior surface of the medial end of the clavicle.17,18 It averages 1.3 cm long, 1.9 cm wide, and 1.3 cm thick.8

 

The anterior fasciculus arises anteromedially, runs upward and laterally, and resists lateral displacement and upward rotation of the clavicle.

 

The posterior fasciculus is shorter, arises laterally, runs upward and medially, and resists medial displacement and excessive downward rotation3,8,17 (FIGS 1 and 2).

 

 

 

FIG 1 • A. Normal anatomy around the sternoclavicular joint. The articular disc ligament divides the sternoclavicular joint cavity into two separate spaces and inserts onto the superior and posterior aspects of the medial clavicle. B. The articular disc ligament acts as a checkrein for medial displacement of the proximal clavicle.

 

 

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FIG 2 • Normal anatomy around the sternoclavicular and acromioclavicular joints. The tendon of the subclavius muscle arises in the vicinity of the costoclavicular ligament from the first rib and has a long tendon structure.

 

 

The interclavicular ligament (see FIG 1) connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum. Comparable to the wishbone of birds, it helps the capsular ligaments to

produce “shoulder poise”; that is, to hold up the lateral aspect of the clavicle.18

 

The capsular ligaments cover the anterosuperior and posterior aspects of the joint and represent thickenings of the joint capsule (see FIGS 1 and 2). The clavicular attachment of the ligament is primarily onto the epiphysis of the medial clavicle, with some blending of the fibers into the metaphysis.5,11

 

In sectioning studies, the capsular ligaments are the most important structures in preventing upward displacement of the medial clavicle caused by a downward force on the distal end of the shoulder.3

 

This lateral poise of the shoulder (ie, the force that holds the shoulder up) is attributed to a locking mechanism of the ligaments of the sternoclavicular joint.

 

 

Other single ligament sectioning studies32 have shown that the posterior capsule is the most important primary stabilizer to anterior and posterior translation. The anterior capsule is an important restraint to anterior

translation. The costoclavicular ligament is unimportant if the capsule remains intact,32 although it may be an important secondary restraint if the capsular ligaments are torn, much like the coracoclavicular ligament laterally.

 

Applied Surgical Anatomy

 

A “curtain” of muscles—the sternohyoid, sternothyroid, and scalenus—lies posterior to the sternoclavicular joint and the inner third of the clavicle and blocks the view of vital structures— the innominate artery, innominate

vein, vagus nerve, phrenic nerve, internal jugular vein, trachea, and esophagus. A recent anatomic study demonstrated that the closest is the brachiocephalic vein, at an average distance of 6.6 mm.24

 

The anterior jugular vein lies behind the clavicle and in front of the curtain of muscles. Variable in size and as large as 1.5 cm in diameter, it has no valves and bleeds like someone has opened a floodgate when nicked.

 

The surgeon who is considering stabilizing the sternoclavicular joint by running a pin down from the clavicle into the sternum should not do it and should remember that the arch of the aorta, the superior vena cava, and the right pulmonary artery are also very close at hand.

 

PATHOGENESIS

 

Most sternoclavicular joint dislocations result from highenergy trauma, usually a motor vehicle accident. They occasionally result from contact sports.

 

A force applied directly to the anteromedial aspect of the clavicle can push the medial clavicle back behind the sternum and into the mediastinum.

 

More commonly, a force is applied indirectly, from the lateral aspect of the shoulder. If the shoulder is compressed and rolled forward, a posterior dislocation results; if the shoulder is compressed and rolled backward, an anterior dislocation results.

 

As noted earlier, many injuries of the sternoclavicular joint in patients younger than 25 years are, in fact, fractures through the medial physis of the clavicle.

 

NATURAL HISTORY

 

Mild or moderate sprain

 

 

The mildly sprained sternoclavicular joint is stable but painful.

 

The moderately sprained joint may be slightly subluxated anteriorly or posteriorly and may often be reduced by drawing the shoulders backward as if reducing and holding a fracture of the clavicle.

 

Anterior dislocation

 

 

Although most anterior dislocations are unstable after closed reduction, we still recommend an attempt to reduce the dislocation closed.

 

Occasionally, the clavicle remains reduced, but typically, the clavicle remains unstable after closed reduction. We usually accept the deformity because an anteriorly dislocated sternoclavicular joint typically becomes asymptomatic, and we believe that the deformity is less of a problem than the potential complications of operative fixation.

 

When the entire medial clavicle is stripped out of the deltotrapezial fascia, the deformity can be so severe that it may be poorly tolerated, so we consider primary fixation.

In those rare cases when a chronic anterior dislocation is symptomatic, one may perform a capsular reconstruction or a medial clavicle resection and costoclavicular ligament reconstruction.

 

Posterior dislocation

 

 

In contrast to anterior dislocations, the complications of an unreduced posterior dislocation are numerous: thoracic outlet syndrome, vascular compromise, and erosion of the medial clavicle into any of the vital structures that lie posterior to the sternoclavicular joint.

 

Closed reduction for acute posterior sternoclavicular dislocation can usually be obtained, and the reduction is generally stable. Often, general anesthesia is necessary. However, when a posterior dislocation is irreducible

or the reduction is unstable, an open reduction should be performed.

 

When chronic posterior dislocation is present, late complications may arise from mediastinal impingement, so we recommend medial clavicle resection and ligament reconstruction.

 

Physeal injuries

 

 

The typical history for physeal injuries is the same as for other traumatic dislocations. The difference between these

 

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injuries and pure dislocations is that most of these injuries will heal with time, without surgical intervention.

 

In very young patients, the remodeling process can eliminate deformity because of the osteogenic potential of an intact periosteal tube. Zaslav et al,39 Rockwood and Wirth,29 and Hsu et al19 have all reported successful treatment of displaced medial clavicle physeal injury in adolescents and provided radiographic evidence of

remodeling.

 

Anterior physeal injuries may be reduced, but if reduction cannot be obtained, they can be left alone without problem. Posterior physeal injuries should likewise undergo an attempt at reduction. If a posterior dislocation cannot be reduced closed and the patient is having no significant symptoms, the displacement can be observed while remodeling occurs. Even in older individuals, a posteriorly displaced fracture with moderate displacement and no mediastinal symptoms may be observed, as it usually becomes asymptomatic with fracture healing.

 

However, as with severely displaced dislocations, one may wish to consider operative repair for severely displaced physeal fractures. Suture repair through the medial shaft and the epiphysis and Balser plate fixation have both been successfully used in this situation.16,34,36

PATIENT HISTORY AND PHYSICAL FINDINGS

 

A history of high-energy trauma is almost a requirement for the diagnosis. Most cases will be due to a motor vehicle accident, a fall from a significant height, or a sports injury.

 

 

The absence of such a history suggests either an atraumatic instability or some other atraumatic condition of the joint.

 

Posterior displacement may be obvious, but anterior fullness can represent either anterior displacement or swelling overlying posterior displacement.

 

Careful examination is extremely important. Mediastinal injuries may occur when a traumatic dislocation is posterior, and the physician should seek evidence of damage to the pulmonary and vascular systems, such as hoarseness, venous congestion, and difficulty breathing or swallowing.

 

Evaluation should also include the remainder of the thorax, shoulder girdle, and upper extremity as well as the contralateral sternoclavicular joint.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain radiographs

 

 

Occasionally, routine anteroposterior chest radiographs suggest displacement compared with the normal side. However, these are difficult to interpret.

 

Serendipity view: A 45-degree cephalic tilt view is the most useful and reproducible plain radiograph for the sternoclavicular joint. The tube is centered directly on the sternum and a nongrid 11 × 14 cassette is placed

on the table under the patient's upper shoulders and neck, so the beam will project the medial half of both clavicles onto the film (FIG 3). The technique is the same as a posteroanterior view of the chest.

 

 

An anteriorly dislocated medial clavicle will appear to ride higher compared to the normal side. The reverse is true if the sternoclavicular joint is dislocated posteriorly (FIG 4).

 

 

 

FIG 3 • Serendipity view. Positioning of the patient to take the serendipity view of the sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children, the tube distance from the patient should be 45 inches; in thicker chested adults, the distance should be 60 inches.

 

 

More recently, ultrasound has been proposed as an alternate method of making the initial diagnosis of sternoclavicular dislocation.4

 

In the past, tomograms were useful in distinguishing a sternoclavicular dislocation from a fracture of the medial clavicle and defining questionable anterior and posterior injuries of the sternoclavicular joint. Although they provide more information than plain films, at present, they have been replaced with computed tomography (CT) scans.

 

Without question, CT scanning is the best technique to study the sternoclavicular joint. It distinguishes dislocations of the joint from fractures of the medial clavicle and clearly defines minor subluxations (FIG 5). With the increasing presence of O-arms in hospitals, intraoperative CT may become more readily available for both

closed and open reductions.33

 

 

The patient should lie supine. The scan should include both sternoclavicular joints and the medial halves of both clavicles so that the injured side can be compared with the normal.

 

If symptoms of mediastinal compression are present or displacement of the medial clavicle is severe, the use of intravenous contrast will aid in the imaging of the vascular structures in the mediastinum.

 

 

 

FIG 4 • Interpretation of the cephalic tilt films of the sternoclavicular joints. A. In a normal person, both clavicles appear on the same imaginary line drawn horizontally across the film. (continued)

 

 

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FIG 4 • (continued) B. In a patient with anterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is projected above the imaginary line drawn through the level of the normal left clavicle. C. If the patient has a posterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is displaced below the imaginary line drawn through the normal left clavicle.

 

DIFFERENTIAL DIAGNOSIS

Arthritic conditions: sternocostoclavicular hyperostosis, osteitis condensans, Friedrich disease, Tietze syndrome, and osteoarthritis

Atraumatic (spontaneous) subluxation or dislocation: One or both of the sternoclavicular joints may spontaneously subluxate or dislocate during abduction or flexion during overhead motion. Typically seen in ligamentously lax females in their late teens or early 20s, it is not painful, it is almost always anterior, and it

should almost always be managed nonoperatively.28

 

 

FIG 5 • CT scans of a 6-month-old medial clavicle fracture demonstrate anterior displacement without significant healing.

Congenital or developmental or acquired subluxation or dislocation:

Birth trauma, congenital defects with loss of bone substance on either side of the joint, or neuromuscular or other developmental disorders can predispose the patient to subluxation or dislocation.

Iatrogenic instability may be due to failure to reconstruct the ligaments of the sternoclavicular joint adequately or to an excessive medial clavicle resection. History is significant for a prior procedure on the sternoclavicular joint.

 

 

 

NONOPERATIVE MANAGEMENT

 

A mild sprain is stable but painful. We treat mild sprains with a sling, cold packs, and resumption of activity as comfort dictates.

 

A moderate sprain may be slightly subluxated anteriorly or posteriorly. Moderate sprains may be reduced by drawing the shoulders backward as if reducing a fracture of the clavicle. This is followed by cold packs and immobilization in a padded figure-8 strap for 4 to 6 weeks, then gradual resumption of activity as comfort dictates.

 

Anterior dislocations may undergo closed reduction with either local or general anesthesia, narcotics, or muscle relaxants.

 

 

The patient is supine on the table, with a 3- to 4-inch thick pad between the shoulders. Direct gentle pressure over the anteriorly displaced clavicle or traction on the outstretched arm combined with pressure on the medial clavicle will generally reduce the dislocation.

 

Posterior dislocation in a stoic patient may possibly be reducible under intravenous narcotics and muscle relaxation. However, general anesthesia is usually required for reduction of a posterior dislocation because of pain and muscle spasm.

 

 

Our preferred method is the abduction traction technique.

 

 

The patient is placed supine, with the dislocated side near the edge of the table. A 3- to 4-inch thick sandbag is placed between the scapulae (FIG 6). Lateral traction is applied to the abducted arm, which is then gradually

 

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brought back into extension. The clavicle usually reduces with an audible snap or pop and it is almost always stable. Too much extension can bind the anterior surface of the dislocated medial clavicle on the back of the manubrium.

 

 

 

FIG 6 • Technique for closed reduction of the sternoclavicular joint. A. The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. B. In posterior dislocations, in addition to the traction, it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge the clavicle from behind the manubrium. C. In stubborn posterior dislocations, it may be necessary to prepare the medial end of the clavicle sterilely and use a towel clip to grasp around the medial clavicle to lift it back into position.

 

 

Occasionally, it is necessary to grasp the medial clavicle with one's fingers to dislodge it from behind the sternum. If this fails, the skin is prepared, and a sterile towel clip is used to grasp the medial clavicle to apply lateral and anterior traction (see FIG 6C). If the joint is stable after reduction, the shoulders should be held back for 4 to 6 weeks with a figure-8 dressing to allow ligament healing.

 

Many investigators have reported that closed reduction usually cannot be accomplished after 48 hours. However, others have reported closed reductions as late as 4 and 5 days after the injury.6

 

Physeal fractures are reduced in the same manner as dislocations, with immobilization in a figure-8 strap for 4 weeks to protect stable reductions. Fractures that cannot be reduced and are being managed nonoperatively are treated with a figure-8 strap or a sling for comfort and mobilized as symptoms permit.

 

SURGICAL MANAGEMENT

 

A posterior displacement of the medial clavicle that is irreducible or redislocates after closed reduction is a well-

accepted surgical indication.

 

More controversial is anterior displacement that fails to maintain a stable reduction.

 

 

The traditional treatment for persistent anterior displacement is nonoperative, which, in the majority of cases, produces excellent function and minimal pain despite the persistent displacement and deformity.

 

However, when the entire medial clavicle is torn out of the deltotrapezial sleeve, the extreme displacement can result in either instability or abundant heterotopic bone formation with accompanying pain and limited motion. As a result, operative treatment for severe anterior displacement is gaining acceptance.

 

Preoperative Planning

 

Careful review of the history and examination for symptoms of mediastinal compression is crucial.

 

Review of the CT scan for the direction and degree of displacement and determination of a very medial fracture versus pure dislocation follows.

 

If a history or radiographic evidence of mediastinal compromise or potential compromise is present, a cardiothoracic surgeon should be either present or readily available.

 

Very medial fractures can occasionally be repaired with independent small fragment lag screws or orthogonal minifragment plates. For pure dislocations, heavy nonabsorbable suture will sometimes suffice. Suture anchors are useful for augmenting ligament repairs. Allograft tendons may be used if the capsule is irreparable and must be reconstructed.

 

 

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Closed reduction under anesthesia is then attempted and the stability of the joint is evaluated after reduction.

 

Positioning

 

To begin, the patient is positioned supine on the table, and three or four towels or a sandbag placed between the scapulae.

 

 

The upper extremity should be draped free so that lateral traction can be applied during the open reduction. A folded sheet may be left in place around the patient's thorax so that it can be used for countertraction.

 

If there is concern regarding the mediastinum, the entire sternum should be draped into the field.

 

Approach

 

An anterior incision that parallels the superior border of the medial 3 to 4 inches of the clavicle and then extends downward over the sternum just medial to the involved sternoclavicular joint is used (FIG 7A).

 

 

 

FIG 7 • A. Proposed skin incision for open reduction of a posterior dislocation. B. Subperiosteal exposure of the medial clavicle shows a posteriorly displaced medial clavicular shaft (left) resting posterior to the medial clavicular physis (arrow, right). C. The medial shaft of the clavicle has been lifted anteriorly with a clamp and now rests adjacent to the medial physis (arrow, right).

 

 

As an alternative, a necklace-type incision may be created in Langer lines, beginning at the midline and sweeping lateral and up along the clavicle.

 

Careful subperiosteal dissection around the medial clavicle and onto the surface of the manubrium allows exposure of the articular surfaces.

 

 

If the medial clavicle is resting posteriorly, it is safer to identify the shaft more laterally and then trace it back medially along the subperiosteal plane (FIG 7B).

 

Traction and blunt retractors can then be used to lever the medial clavicle back up into its anatomic location (FIG 7C). These retractors may be used behind the medial clavicle and manubrium to protect the posterior structures.

 

If one has chosen to operate on an anterior medial clavicle because of extreme displacement, it may generally be simply pushed back into place.

 

 

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TECHNIQUES

 

• Primary Repair: Medial Fracture

   

  In children and in young adults, the dislocation of the medial clavicle may occur through the medial physis or as a fracture, leaving a small amount of bone articulating with the manubrium.

   

  Because much of the capsule remains intact to this medial fragment, it can serve as an anchor for internal fixation of the medial clavicle shaft. Depending on the amount of bone, the type of fixation will vary.

   

   

   

  TECH FIG 1 • A. Heavy nonabsorbable suture has been placed through drill holes in the medial clavicle and through the physis to secure the fracture shown in FIG 7B,C. B,C. A symptomatic medial clavicle nonunion had a medial fragment large enough to allow fixation with three cortical lag screws.

   

   

  The smallest fragments will permit only osseous suture fixation, but the medial clavicle is cancellous bone and heals very quickly (TECH FIG 1A).

   

   

  As the fragment gets larger, independent lag screw fixation may be possible (TECH FIG 1B,C). For very medial shaft fractures, it may even be possible to use two orthogonal minifragment plates.

• Primary Repair: Capsular Ligaments and Suture Repair

   

  After reduction, the position of the clavicle may be maintained with either nonabsorbable osseous sutures through drill holes in the medial clavicle and manubrium,34,36 suture anchors21 (TECH FIG 2), sutures wrapped around screws placed as anchor points,7 or sternal cable20 until tissue healing occurs.

   

  The ligaments of the anterior and superior capsule may then be repaired primarily with heavy nonabsorbable suture. The costoclavicular ligament may occasionally be repaired primarily as well, but, for obvious reasons, the important posterior capsule cannot be easily repaired.

   

  These suture techniques were initially employed primarily in children but are also now used more frequently in adults as well.

   

   

   

  TECH FIG 2 • Suture anchors may be used to create a sling to hold the medial clavicle reduced while the capsular ligaments heal.

   

   

   

• Immediate Reconstruction: Capsular Ligaments

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  At times, the joint may be reducible but the ligaments are damaged to the point where primary repair is not feasible. In this circumstance, the ligaments may be immediately reconstructed using tendon graft.

  Variations of this technique are typically used for chronic instability. Autograft or allograft tendon may be used. Artificial ligaments have also been reported.25

   

  This may be done by passing a tendon in a simple fashion from the front of the sternum, through the articular surfaces and intraarticular disc, and out the front of the medial clavicle and tying the tendon to

  itself anteriorly.26 Suture anchors may also be used to anchor the graft.

   

  The capsule may also be reconstructed in the manner described by Spencer and Kuhn31 (TECH FIG 3). Since their initial description, numerous variations have been described

   

  Drill holes 4 mm in diameter are created from anterior to posterior through the medial clavicle and the adjacent manubrium.

   

   

   

  TECH FIG 3 • A. Semitendinosus may be used to reconstruct the capsular ligaments. B,C. The allograft tendon is pulled through the medial clavicle (left) and manubrium (right) and tied. D,E. Intraoperative images showing the technique illustrated in B and C. (A-C: Courtesy of Spencer EE Jr, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am 2004;86A:98-105.)

   

   

  A free semitendinosus tendon graft is woven through the drill holes so the tendon strands are parallel to each other posterior to the joint and cross each other anterior to it.

   

  The tendon is tied in a square knot and secured with no. 2 Ethibond suture (Ethicon Inc., Somerville, NJ).

   

  This technique has the advantage of reconstructing both the anterior and the posterior ligament in a very strong and secure manner.

   

  Recently, Armstrong and Dias1 and Uri et al35 have described the use of the sternocleidomastoid (SCM) tendon to moor the medial clavicle back to the manubrium in cases of sternoclavicular instability. Although their cases were done for more chronic conditions, the SCM tendon would also be readily available for additional stabilization in the acute setting.

   

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• Medial Clavicle Resection and Ligament Reconstruction

   

  If there is concern about the stability of a reconstruction or repair, if the dislocation is subacute and

  posterior, or if there is a question of impingement on the mediastinal structures, one may elect to resect the medial clavicle entirely. In this situation, it is important to repair or reconstruct the costoclavicular ligament (akin to a modified Weaver-Dunn procedure).

   

  The medullary canal can also be used to create an attachment point for an additional medial tether. We prefer to use the patient's own tissue, such as the sternoclavicular ligament, whenever possible (TECH FIG 4).

   

   

   

  TECH FIG 4 • The residual capsule may be used to reconstruct a medial clavicular restraint, akin to a medial Weaver-Dunn procedure, as described by Rockwood and Wirth.30

   

  The medial clavicle is resected and the canal curetted and prepared with drill holes on the superior surface.

   

  Grasping suture is woven through the remaining ligament, pulled through the superior drill holes, and tied

  over bone.

   

  Heavy nonabsorbable sutures are then passed through the remaining costoclavicular ligament and around the clavicle, and the periosteal tube is closed.

   

   

  If adequate local tissue is not present, an allograft such as Achilles tendon may also be used.2

   

• Reduction and Plate Fixation

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  The use of K-wires around the sternoclavicular joint has been routinely condemned, and they should not be used.

   

  There are reports, however, of temporary plate fixation from the medial clavicle to the sternum or to the

  opposite clavicle23 to maintain a reduced joint while the soft tissues heal. Hook plates, reconstruction plates, and locked plates have all been used. After several months, the hardware is usually removed.

   

  The Balser plate is a hook plate used in Europe for treatment of acromioclavicular joint separations and distal clavicle fractures. It has been used for sternoclavicular dislocations by placing the hook into the sternum and using screws to fix the plate onto the medial clavicle (TECH FIG 5).

   

  Franck et al15 published good results for 10 patients treated with Balser plates. They thought that the stability of this construct allowed a more rapid rehabilitation. The implant is quite bulky and removal is generally required.

   

   

   

  TECH FIG 5 • Intrasternal Balser (hook) plate insertion.

   

   

  PEARLS AND PITFALLS

   

  Diagnosis ▪ Conventional studies are unreliable. A high index of suspicion, a thorough examination, and a prompt CT scan will ensure correct diagnosis.

   

  Individualize treatment when necessary

  • Although anterior dislocations are generally treated nonoperatively, a severely anteriorly displaced medial clavicle may be reduced and fixed acutely, with a low risk of complications, in a reliable patient.

  • Posterior dislocations generally mandate surgery when closed reduction is unstable because delayed impingement on mediastinal contents may occur. However, there may be situations where displacement is mild and chronic and the risks of surgery may outweigh the benefits.

 

Prepare for complications

• Although complications are uncommon, they are spectacular but not in a good way. The surgeon needs to be ready for both pneumothorax and the unlikely possibility of a vascular injury. A cardiothoracic surgeon should be immediately available.

 

Use the medial clavicle

• Even a medial epiphysis or a tiny piece of medial clavicle in its anatomic location provides an excellent anchor for heavy suture or lag screws for primary fracture repair.

   

  Be flexible intraoperatively

• Preserving the native joint is an admirable goal, but poor ligament and bone quality sometimes precludes primary repair, especially in the subacute dislocation. If the stability of the joint cannot be ensured, medial clavicle resection and costoclavicular reconstruction should be strongly considered.

 

POSTOPERATIVE CARE

 

For sternoclavicular strains and anteriorly dislocated medial clavicles accepted in this position, a sling or figure-8 strap is prescribed, and the patient is allowed to mobilize the extremity as function permits.

 

Medial clavicle fractures that are stable after reduction are immobilized in a figure-8 strap for 4 to 6 weeks and then mobilized as comfort allows.

 

Acute dislocations that have been reduced and are stable or have been surgically repaired receive a sling or figure-8 strap for 6 weeks to protect the reduction and allow ligament healing.

 

Patients in the figure-8 strap are allowed use of the elbow and hand with the arm at the side for light activities of daily living, but the strap is conscientiously maintained.

 

At 4 to 6 weeks, they move to a sling and perform their own mobilization. Because the glenohumeral joint is unaffected, motion usually returns quickly to near full range.

 

When full range of motion has been obtained, gentle progressive strengthening and resumption of normal activities commence.

 

In general, patients treated with joint preservation can return to all activities, including heavy labor, but we have seen traumatic failure of costoclavicular reconstructions and do ask patients who have undergone medial

clavicle resection and ligament reconstruction to avoid heavy overhead labor for their lifetimes.

 

 

OUTCOMES

A recent Medline search for “sternoclavicular” and “dislocation” yielded 460 citations, most dealing with sternoclavicular instability and its sequelae. Most were case reports

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or a series of three or four patients or a discussion of the complications of the injury or its treatment. There are very few large series, which makes discussing outcomes difficult. However, several themes do emerge.

The need for proper patient selection becomes evident when one considers that some forms of sternoclavicular instability generally do well when treated without surgery.

Sadr and Swann30 and Rockwood and Odor28 have both documented the good long-term results obtained with nonoperative treatment of atraumatic sternoclavicular instability.

De Jong and Sukul10 has documented good long-term results in 13 patients with anterior dislocations treated nonoperatively.

Several larger series13,14,35,37 have reported on a dozen or more patients treated with open reduction, ligament repair or reconstruction, and fixation with pins or sternoclavicular wiring. Good results were obtained when the medial clavicle was successfully stabilized.

Eskola,12 however, noted a high failure rate if the remaining medial clavicle was not successfully stabilized to the first rib.

In a separate study, Rockwood et al27 reported on seven patients who had previously undergone medial clavicle resection without ligament reconstruction. Six of the seven had worse symptoms than before their index procedure.

 

 

COMPLICATIONS

Complications of injury

Anterior dislocation: cosmetic “bump” (which may occasionally be pronounced) and late degenerative changes

Posterior dislocation: Great vessel injuries, including laceration, compression, and occlusion; pneumothorax; rupture of the esophagus with abscess and osteomyelitis of the clavicle; fatal tracheoesophageal fistula; brachial plexus compression; stridor and dysphagia; hoarseness of the voice; onset of snoring; and voice changes from normal to falsetto with movement of the arm have all been reported. These all may occur acutely or in a delayed fashion.

Worman and Leagus38 reported that 16 of 60 patients with posterior dislocations had suffered complications of the trachea, esophagus, or great vessels.

Errors of patient selection

 

Operating in unindicated circumstances introduces another set of complications. Rockwood and Odor28 reviewed 37 patients with spontaneous atraumatic subluxation.

Twenty-nine managed without surgery had no limitations of activity or lifestyle at over 8 years average follow-up. Eight treated (elsewhere) with surgical reconstruction had increased pain, limitation of activity,

alteration of lifestyle, persistent instability, and significant scars.

 

Before surgery, most of these patients had minimal discomfort and excellent motion and complained only of a bump that slipped in and out of place with certain motions.

 

Intraoperative complications

 

Little has been written about these, but a veritable jungle of vitally important structures lurks immediately behind the sternoclavicular joint. We always perform these operations with an available, in-house cardiothoracic surgeon on notice and request his or her presence in the operating suite for all but the most routine cases.

 

Postoperative complications

 

Hardware migration: Because of the motion at the sternoclavicular joint, tremendous leverage is applied to pins that cross it; fatigue breakage of the pins is common. Numerous authors have reported deaths and many neardeaths from K-wires and Steinmann pins migrating into the heart, pulmonary artery, innominate artery, aorta, and elsewhere in the mediastinum. Despite numerous admonitions in the literature regarding the use of sternoclavicular pins, there have been continued reports of K-wire migration to intrathoracic and other remote locations.

 

For this reason, we do not recommend the use of any transfixing pins—large or small, smooth or threaded, bent or straight—across the sternoclavicular joint.

 

Iatrogenic instability: Failure to preserve the costoclavicular ligament when it is intact and failure to reconstruct it when it is deficient both severely compromise the surgical result. As noted earlier, both

Rockwood et al27 and Eskola12 noted vastly inferior results when the residual medial clavicle was not stabilized to the first rib, and an inability to obtain equivalent results when the costoclavicular ligament was reconstructed in a delayed fashion.

 

Iatrogenic instability: An excessive resection that removes bone to a point lateral to the costoclavicular ligament is an extremely difficult problem that is best avoided because there is no reconstructive option. In these difficult cases, we have occasionally performed a subtotal claviculectomy to a point just medial to the coracoclavicular ligaments. This leaves the extremity without a “strut” connecting it to the thorax but can produce substantial relief of pain and improvement in motion and activity.

 

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