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 presense of cardiothoracic (CT) surgery is controversial 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
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next (OBQ13.53) An 19-year-old male presents to the emergency room following an motor vehicle accident as an unrestrained driver. Examination reveals unilateral jugular vein engorgement. Chest and special view radiographs are seen in Figures A and B respectively. Following CT scan of the chest, the next step in management is QID: 4688 FIGURES: A B Type & Select Correct Answer 1 Nonsurgical management and follow-up CT scan in 6 weeks 1% (52/4572) 2 Closed reduction in the emergency room under sedation 2% (82/4572) 3 Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by immobilization for 4 weeks 80% (3658/4572) 4 Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by compression plating 13% (594/4572) 5 Open reduction in the operating room under general anesthesia, followed by transarticular pinning with K-wires 3% (156/4572) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.1) Which of the following is true regarding anterior sternoclavicular joint dislocations? QID: 387 Type & Select Correct Answer 1 Reduction may result in tracheal injury 10% (118/1224) 2 They are usually stable following closed reduction 28% (348/1224) 3 They require fusion to hold the reduction 3% (41/1224) 4 They are rarely symptomatic when left unreduced 58% (706/1224) 5 They should be treated acutely with medial clavicle excision 0% (3/1224) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 33 FIGURES: A Type & Select Correct Answer 1 Nonoperative treatment with a sling and unrestricted activity in 3 months 2% (90/3716) 2 Open reduction in the operating room with thoracic surgery back-up 65% (2399/3716) 3 Closed reduction in the office with local anesthetic 0% (18/3716) 4 Closed reduction in the operating room with thoracic surgery back-up 26% (975/3716) 5 Nonoperative treatment with immediate unrestricted active range of motion of the shoulder 6% (213/3716) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 16 Type & Select Correct Answer 1 Observation 79% (1882/2387) 2 Figure of eight brace for 6 weeks followed by progressive physical therapy 14% (336/2387) 3 Resection arthroplasty of the sternoclavicular joint 1% (28/2387) 4 Sternoclavicular and costoclavicular ligament reconstruction 3% (69/2387) 5 Sternoclavicular arthrodesis 2% (54/2387) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 15 Type & Select Correct Answer 1 Nonoperative treatment with a sling and swathe for six weeks 1% (8/1159) 2 Nonoperative treatment with immediate active range of motion of the shoulder 1% (6/1159) 3 Closed reduction in the emergency room 5% (57/1159) 4 Open reduction and pinning of his medial clavicular physeal injury 5% (60/1159) 5 Reduction in the operating room with thoracic surgery back-up 88% (1025/1159) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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