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Introduction
  • Suspect in any young individual (< 25 yrs) with a medial clavicle or sternoclavicular injury
  • Usually Salter-Harris Type I or II
  • Delay in diagnosis 
Anatomy
  • Medial clavicle ossification center
    • appears during later teenage years
    • last physis to close in body (20-25yrs)
      • sternoclavicular dislocations in teenagers/young adults are usually physeal fracture-dislocations
Imaging
  • Radiographs
    • difficult to visualize on AP, and radiographs usually unreliable to assess for fracture and degree of displacement
    • obtain serendipity views ( beam at 40 deg cephalic tilt)  
      • anterior dislocation/fxs - affected clavicle is above contralateral clavicle
      • posterior dislocation/fxs - affected clavicle is below contralateral clavicle
  • Axial CT scan
    • is study of choice
    • can differentiate from sternoclavicular dislocations
    • can visualize mediastinal structures and injuries
Treatment
  • Nonoperative
    • observation
      • indications 
        • controversial 
        • most asymptomatic injuries
          • will remodel and do not require intervention
        • anterior displaced physeal fracture
          • have good functional results treated nonoperatively
  • Operative
    • closed reduction in operating room under anesthesia
      • indications
        • controversial
        • acute posterior displaced physeal fx with
          • hoarsness
          • blunt or direct trauma to subclavian vessels
          • thoracic outlet syndrome
          • pneumothorax
      • contraindications
        • late presenting posterior dislocations
          • do not attempt closed reduction because medial clavicle may be adherent to vascular structures in mediastinum
      • failure to reduce
        • more difficult to reduce > 48 hours due to progressive callus formation in dislocated state
    • open reduction
      • indications
        • late presenting symptomatic posterior dislocations
        • unreducible and symptomatic
        • unstable after closed reduction
      • postreduction management
        • obtain CT to confirm stable
      • immobilization
        • figure of 8 harness or sling and swathe x 4 weeks (anterior displaced)
Technique
  • Closed reduction in operating room under anesthesia
    • approach
      • thoracic surgeon available
    • reduction  
      • traction and abduction of arm, while applying direct pressure
      • posterior displaced fractures usually require sterile towel clip for manipulation
      • if irreducible by closed means, consider open approach
  • Open Reduction
    • approach
      • horizontal incision over media clavicle
    • reduction
      • towel clip to reduce
    • fixation
      • wire/suture from medial clavicle to sternum/medial epiphysis
Complications
  • Persistent instability
    • increased risk with delay of reduction
  • Vacular Injury
    • do not attempt closed reduction in late presenting posterior dislocations because medial clavicle may be adherent to vascular structures in mediastinum
 

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