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Introduction
  • Traumatic or Atraumatic
    • traumatic dislocation
      • direction
        • anterior (more common)
        • posterior (mediastinal structures at risk)
        • important to distinguish from medial clavicle physeal fracture (physis doesn't fuse until age 20-25) 
      • mechanism
        • usually high energy injury (MVA, contact sports)
    • atraumatic subluxation
      • occurs with overhead elevation of the arm
      • affected patients are younger
        • many demonstrate signs of generalized ligamentous laxity
      • subluxation usually reduces with lowering the arm
      • treatment is reassurance and local symptomatic treatment
Anatomy
  • Medial clavicle
    • first bone to ossify and last physis to close (age 20-25)
  • Sternoclavicular joint
    • osteology
      • diarthrodial saddle joint
      • incongruous (~50% contact)
      • fibrocartilage 
    • stability
      • stability depends on ligamentous structures 
        • posterior capsular ligament 
          • most important structure for anterior-posterior stability
        • anterior sternoclavicular ligament
          • primary restraint to superior displacement of medial clavicle
        • costoclavicular (rhomboid) ligament
          • anterior fasciculus resists superior rotation and lateral displacement
          • posterior fasciculus resists inferior rotation and medial displacement
        • intra-articular disk ligament
          • prevents medial displacement of clavicle
          • secondary restraint to superior clavicle displacement
Presentation
  • Symptoms
    • anterior dislocation
      • deformity with palpable bump
    • posterior dislocations
      • dyspnea or dysphagia
      • tachypnea and stridor worse when supine
  • Physical exam
    • palpation
      • prominence that increases with arm abduction and elevation  
    • ROM and instability
      • decreased arm ROM
    • neurovascular
      • parasthesias in affected upper extremity
      • venous congestion or diminished pulse when compared with contralateral side
    • provocative maneuvers
      • turning head to affected side may relieve pain
Imaging
  •  Radiographs
    • recommended views
      • AP and serendipity views
    • findings
      • difficult to visualize on AP   
      • serendipity views ( beam at 40 cephalic tilt) 
        • anterior dislocation
          • affected clavicle above contralateral clavicle
        • posterior dislocation
          • affected clavicle below contralateral clavicle
  • CT scan
    • study of choice
      • axial views can visualize mediastinal structures and injuries  
      • can differentiate from physeal fractures
Treatment
  • Nonoperative
    • reassurance and local symptomatic treatment 
      • indications
        • atraumatic subluxation 
        • chronic anterior dislocation (> 3 weeks old) 
      • technique
        • sling for comfort
        • return to unrestricted activity by 3 months
    • closed reduction under general anesthesia +/- thoracic surgery 
      • indications
        • acute anterior dislocations (< 3weeks old)
        • acute posterior dislocations (< 3weeks old)
      • if reduction stable
        • velpeau bandage for 6 weeks
          • may need plaster jacket or figure of eight bandage to distract shoulder
          • elbow exercises at 3 weeks
          • return to sports at 3 months
      • if reduction unstable
        • accept deformity or medial clavicle excision (below)
  • Operative
    • open reduction and soft-tissue reconstruction with thoracic surgery back-up  post 
      • indications
        • posterior dislocation with
          • dysphagia
          • shortness of breath
          • decreased peripheral pulses 
    • medial clavicle excision
      • indications
        • chronic/recurrent SC dislocation (anterior or posterior)
        • persistent sternoclavicular pain
Techniques
  • Closed reduction under general anesthesia
    • reduction technique
      • place patient supine with arm at edge of table and prep entire chest
      • abduct and extend arm while applying axial traction and direct pressure
      • simultaneously apply direct posterior pressure over medial clavicle 
      • manipulate medial clavicle with towel clip or fingers
  • Medial clavicle excision
    • approach
      • incision made over medial clavicle 
    • resection
      • costoclavicular ligaments must be preserved 
        • preserve by resecting < 15mm of medial clavicle
        • repair if injured
Complications
  • Cosmetic deformity
 

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