http://upload.orthobullets.com/topic/1009/images/Xray - AP - posterior dislocation_moved.jpg
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http://upload.orthobullets.com/topic/1009/images/Xray - AP - posterior dislocation 2_moved.jpg
http://upload.orthobullets.com/topic/1009/images/Xray - AP - posterior dislocation 3_moved.jpg
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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Questions (4)

(OBQ08.1) Which of the following is true regarding anterior sternoclavicular joint dislocations? Review Topic

QID:387
1

Reduction may result in tracheal injury

11%

(37/337)

2

They are usually stable following closed reduction

25%

(85/337)

3

They require fusion to hold the reduction

4%

(15/337)

4

They are rarely symptomatic when left unreduced

58%

(197/337)

5

They should be treated acutely with medial clavicle excision

0%

(1/337)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

From the Bicos article, ÔÇťAnterior SC joint instability should primarily be treated conservatively. The patients should be informed that there is a high risk of persistent instability with nonoperative or operative care, but that the persistent instability will be well tolerated and have little functional impact in the vast majority. Therefore, operative intervention for anterior SC joint instability is mainly cosmetic in nature."


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(OBQ06.4) A 16-year-old male fell from a roof onto his right shoulder and presents with decreased pulses in his right upper extremity. Imaging reveals a posterior sternoclavicular dislocation. What is the best treatment at this time? Review Topic

QID:15
1

Nonoperative treatment with a sling and swathe for six weeks

0%

(0/285)

2

Nonoperative treatment with immediate active range of motion of the shoulder

0%

(1/285)

3

Closed reduction in the emergency room

9%

(25/285)

4

Open reduction and pinning of his medial clavicular physeal injury

14%

(39/285)

5

Reduction in the operating room with thoracic surgery back-up

76%

(218/285)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Symptomatic acute posterior sternoclavicular dislocations in adolescents should undergo reduction with thoracic surgery back-up. If closed reduction is not successful (inability to reduce in up to 75% of cases), then open reduction is indicated. In patients younger than age 20-25, this is usually a physeal injury, as the medial clavicular physis does not close until this age range. Chronic anterior dislocations are recommended to be treated conservatively, especially if not symptomatic.

The review article by Wirth and Rockwood notes the following complications with posterior dislocation: respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. They recommend reconstruction of the costoclavicular ligaments with resection of the medial clavicular head as needed for unstable injuries.

The referenced article by Waters et al noted 100% excellent short-term outcomes in adolescents with open reduction and reconstruction of the costoclavicular ligament in pure dislocations or with suture fixation of the medial physis in physeal injuries.


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(OBQ06.5) A 33-year-old female is diagnosed with spontaneous atraumatic subluxation of the sternoclavicular joint. She notes mild, intermittent pain and a small amount of prominence to that area. She is noted to have 6 points out of a possible 9 points on the Beighton-Horan scale. What is the most appropriate treatment at this time? Review Topic

QID:16
1

Observation

78%

(885/1133)

2

Figure of eight brace for 6 weeks followed by progressive physical therapy

15%

(166/1133)

3

Resection arthroplasty of the sternoclavicular joint

2%

(17/1133)

4

Sternoclavicular and costoclavicular ligament reconstruction

3%

(35/1133)

5

Sternoclavicular arthrodesis

2%

(19/1133)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Spontaneous atraumatic subluxaton of the sternoclavicular joint is a rare condition and is generally associated with ligamentous laxity. A score of 5 or more on 9-point Beighton-Horan scale defines joint hypermobility. The treatment for spontaneous atraumatic subluxaton of the sternoclavicular joint is observation.

Higginbotham et al reported that spontaneous atraumatic anterior subluxation of the sternoclavicular joint may occur during overhead elevation of the arm. The majority of cases are not painful, and the subluxation usually reduces with lowering the arm. Surgery is rarely indicated. Nonsurgical management, including patient education of the benign nature of the condition, is recommended.

Rockwood et al reviewed a series of 37 patients with this condition and noted that at an average follow-up of eight years, the twenty-nine patients who were treated non-operatively had excellent results, with no limitations of activity or changes in lifestyle. The eight patients who were treated operatively (group II) had numerous problems, including noticeable scars, persistent instability, pain, or limitation of activity that resulted in an alteration in lifestyle.

Illustration A is a chart that outlines the Beigton-Horan scale and Illustration B demonstrates the clinical images associated with the criteria. A score of 5 or more on 9-point Beighton-Horan scale defines joint hypermobility.

ILLUSTRATIONS:

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(OBQ06.22) A 33-year-old secretary presents three months after a motor vehicle collision with a mild asymmetry to her sternal area and difficulty swallowing. She denies any complaints of respiratory distress or upper extremity paresthesias. Her upper extremity neurovascular exam shows no deficits. A 3-D computed tomography image is shown in Figure A. What is the most appropriate treatment for this patient? Review Topic

QID:33
FIGURES:
1

Nonoperative treatment with a sling and unrestricted activity in 3 months

4%

(38/898)

2

Open reduction in the operating room with thoracic surgery back-up

66%

(593/898)

3

Closed reduction in the office with local anesthetic

0%

(2/898)

4

Closed reduction in the operating room with thoracic surgery back-up

19%

(169/898)

5

Nonoperative treatment with immediate unrestricted active range of motion of the shoulder

10%

(86/898)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The clinical presentation is consistent with a chronic sternoclavicular dislocation, which is defined as being greater than 3 weeks old. The 3D CT image shows posterior displacement of the medial clavicle relative to the sternum. Chronic anterior dislocations are recommended to be treated conservatively, especially if not symptomatic, but as this is a posterior dislocations, current recommendations are to treat them with reduction in order to avoid delayed issues with the medial clavicle interacting with the mediastinal structures.

The review article by Wirth and Rockwood notes the following complications with posterior dislocation: respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. They recommend reconstruction of the costoclavicular ligaments with resection of the medial claviclar head as needed for unstable or symptomatic injuries.


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