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Updated: Feb 21 2024

Sternoclavicular Dislocation

Images - AP - posterior dislocation_moved.jpg - AP - posterior dislocation 2_moved.jpg - AP - posterior dislocation 3_moved.jpg
  • summary
    • Sternoclavicular Dislocations are uncommon injuries to the chest that consist of traumatic or atraumatic dislocations of the sternoclavicular joint.
    • Diagnosis can be made with plain serendipity radiographic views. CT studies are generally required to assess for direction of displacement. 
    • Treatment is generally observation of atraumatic or chronic anterior dislocations. Closed versus open reduction is indicated for acute dislocations. 
  • Etiology
    • Pathophysiology
      • 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 that is minimally symptomatic (> 3 weeks old)
        • technique
          • sling for comfort
          • return to unrestricted activity by 3 months
    • Operative
      • closed reduction under general anesthesia +/- thoracic surgery back-up
        • 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 open reduction and soft-tissue reconstruction
      • open reduction and soft-tissue reconstruction +/- thoracic surgery back-up
        • indications
          • acute posterior dislocation with failed closed reduction
            • dysphagia
            • shortness of breath
            • decreased peripheral pulses
          • chronic anterior or posterior dislocation that remains persistently symptomatic
        • presence of cardiothoracic (CT) surgery is recommended
          • recent studies state that the recommendation for routine involvement of thoracic surgeons in all cases may not be necessary 
      • medial clavicle excision
        • indications
          • outdated procedure
            • rarely performed 
  • 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
    • Open reduction and soft-tissue reconstruction
      • approach
        • curvilinear incision overlying medial 1/4th of clavicle, SC joint and top of manubirum
        • care to not disrupt the SCM tendon sheath
        • clean incision through the SCJ capsule to allow for repair at the end
      • technique
        • figure of 8 tendon reconstruction using 2 drill holes in the manibrium and 2 in the medial distal clavicle
        • holes should be 1 cm apart to avoid cortical fracture
        • gracilis or semitendinosus allograft/autograft most commonly used
    • 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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