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Updated: 5/24/2021

Sternoclavicular Dislocation

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Flashcards
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Questions
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Evidence
21
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Videos / Pods
2
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https://upload.orthobullets.com/topic/1009/images/Xray - AP - posterior dislocation_moved.jpg
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https://upload.orthobullets.com/topic/1009/images/Xray - AP - posterior dislocation 2_moved.jpg
https://upload.orthobullets.com/topic/1009/images/Xray - 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
        • 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

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Flashcards (21)
Cards
1 of 21
Questions (10)

(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:

Nonsurgical management and follow-up CT scan in 6 weeks

1%

(52/4572)

Closed reduction in the emergency room under sedation

2%

(82/4572)

Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by immobilization for 4 weeks

80%

(3658/4572)

Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by compression plating

13%

(594/4572)

Open reduction in the operating room under general anesthesia, followed by transarticular pinning with K-wires

3%

(156/4572)

L 2 B

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

QID: 387

Reduction may result in tracheal injury

10%

(118/1224)

They are usually stable following closed reduction

28%

(348/1224)

They require fusion to hold the reduction

3%

(41/1224)

They are rarely symptomatic when left unreduced

58%

(706/1224)

They should be treated acutely with medial clavicle excision

0%

(3/1224)

L 2 C

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(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:

Nonoperative treatment with a sling and unrestricted activity in 3 months

2%

(90/3716)

Open reduction in the operating room with thoracic surgery back-up

65%

(2399/3716)

Closed reduction in the office with local anesthetic

0%

(18/3716)

Closed reduction in the operating room with thoracic surgery back-up

26%

(975/3716)

Nonoperative treatment with immediate unrestricted active range of motion of the shoulder

6%

(213/3716)

L 3 D

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(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

Observation

79%

(1882/2387)

Figure of eight brace for 6 weeks followed by progressive physical therapy

14%

(336/2387)

Resection arthroplasty of the sternoclavicular joint

1%

(28/2387)

Sternoclavicular and costoclavicular ligament reconstruction

3%

(69/2387)

Sternoclavicular arthrodesis

2%

(54/2387)

L 1 C

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(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

Nonoperative treatment with a sling and swathe for six weeks

1%

(8/1159)

Nonoperative treatment with immediate active range of motion of the shoulder

1%

(6/1159)

Closed reduction in the emergency room

5%

(57/1159)

Open reduction and pinning of his medial clavicular physeal injury

5%

(60/1159)

Reduction in the operating room with thoracic surgery back-up

88%

(1025/1159)

L 2 D

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Evidence (21)
VIDEOS & PODCASTS (4)
EXPERT COMMENTS (10)
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