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Which of the following is true regarding anterior sternoclavicular joint dislocations?
Reduction may result in tracheal injury
They are usually stable following closed reduction
They require fusion to hold the reduction
They are rarely symptomatic when left unreduced
They should be treated acutely with medial clavicle excision
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From the Bicos article, “Anterior 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."
Bicos J, Nicholson GP.
Clin Sports Med. 2003 Apr;22(2):359-70. PMID: 12825536 (Link to Abstract)
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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?
Nonoperative treatment with a sling and swathe for six weeks
Nonoperative treatment with immediate active range of motion of the shoulder
Closed reduction in the emergency room
Open reduction and pinning of his medial clavicular physeal injury
Reduction in the operating room with thoracic surgery back-up
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.
Wirth MA, Rockwood CA Jr.
J Am Acad Orthop Surg. 1996 Oct;4(5):268-278. PMID: 10797194 (Link to Abstract)
Waters PM, Bae DS, Kadiyala RK
J Pediatr Orthop. 2003 Jul-Aug;23(4):464-9. PMID: 12826944 (Link to Abstract)
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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?
Figure of eight brace for 6 weeks followed by progressive physical therapy
Resection arthroplasty of the sternoclavicular joint
Sternoclavicular and costoclavicular ligament reconstruction
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.
Rockwood CA Jr, Odor JM.
J Bone Joint Surg Am. 1989 Oct;71(9):1280-8. PMID: 2793879 (Link to Abstract)
Higginbotham TO, Kuhn JE.
J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):138-45. PMID: 15850371 (Link to Abstract)
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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?
Nonoperative treatment with a sling and unrestricted activity in 3 months
Open reduction in the operating room with thoracic surgery back-up
Closed reduction in the office with local anesthetic
Closed reduction in the operating room with thoracic surgery back-up
Nonoperative treatment with immediate unrestricted active range of motion of the shoulder
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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Educational video describing open reduction of posterior sternoclavicular joint...