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Sternoclavicular Dislocation

Topic updated on 04/05/14 12:52pm
Introduction
  • Sternoclavicular Dislocation 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) 
        • chronic posterior dislocations (> 3 weeks old) 
      • technique
        • sling for comfort
        • return to unrestricted activity at 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 mos.
      • 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
          • 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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Qbank (5 Questions)

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

1. Reduction may result in tracheal injury
2. They are usually stable following closed reduction
3. They require fusion to hold the reduction
4. They are rarely symptomatic when left unreduced
5. They should be treated acutely with medial clavicle excision

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Nonoperative treatment with a sling and swathe for six weeks
2. Nonoperative treatment with immediate active range of motion of the shoulder
3. Closed reduction in the emergency room
4. Open reduction and pinning of his medial clavicular physeal injury
5. Reduction in the operating room with thoracic surgery back-up

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Observation
2. Figure of eight brace for 6 weeks followed by progressive physical therapy
3. Resection arthroplasty of the sternoclavicular joint
4. Sternoclavicular and costoclavicular ligament reconstruction
5. Sternoclavicular arthrodesis

PREFERRED RESPONSE ▶
TAG
(OBQ06.22) A 33-year-old secretary presents three months after a motor vehicle collision with a mild asymmetry to her sternal area. She denies any complaints of respiratory distress, dysphagia, 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? Topic Review Topic
FIGURES: A          

1. Nonoperative treatment with a sling and unrestricted activity in 3 months
2. Nonoperative treatment with immediate unrestricted active range of motion of the shoulder
3. Closed reduction in the office with local anesthetic
4. Closed reduction in the operating room with thoracic surgery back-up
5. Open reduction in the operating room with thoracic surgery back-up

PREFERRED RESPONSE ▶
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