Surgical and Applied Anatomy
Principles of Diagnosis and Evaluation
Mechanisms of Injury
History and Physical Examination
Special Imaging Techniques
Classification and Differential Diagnosis
Current Treatment Options
Author’s Preferred Method of Treatment
Complications Following Operative Procedures
The Past, Present, and Future
The authors strongly recommend nonoperative treatment for spontaneous subluxation of the SC joint as surgical outcomes are not consistent and frequently worse or disabling compared to observation.
For mild sprains we recommend the use of cold packs for the first 12 to 24 hours and a sling to rest the joint. Ordinarily, after 5 to 7 days, the patient can use the arm for everyday activities.
In addition to the cold pack, we may use a soft, padded figure-of-eight clavicle strap to gently hold the shoulders back to allow the SC joint to rest. The harness can be removed after a week or so. Then the arm is placed in a sling for about another week, or the patient is allowed to return gradually to everyday activities.
In general, we manage anterior dislocations of the SC joint in adults by either a closed reduction or by “skillful neglect.” Most of the anterior dislocations are unstable, but we accept the deformity since we believe it is less of a problem than the potential problems of operative repair and internal fixation. In cases where symptoms persist and no other recourse exists outside of surgical management, the preferred technique is medial clavicle resection and figure-of-eight ligament reconstruction as described in the section below.
We recommend treatment with ice for 24 to 48 hours, and rest in a sling for 1 week. This is followed by range of motion as tolerated for the following 4 weeks but no contact sports during this time frame to allow healing and avoid recurrent posterior subluxation. It is important to emphasize that these patients should be monitored very closely as a missed diagnosis can have devastating consequences. If any doubt about SC stability emerges, liberal use of CT or MRI to confirm location is warranted.
After an appropriate history and physical examination (Table 42-2), radiographs and a CT scan should be obtained. If the patient has distention of the neck vessels, swelling or bluish discoloration of the arm, or difficulty swallowing or breathing, then the patient should be evaluated using a CT scan with contrast to assess the vascular structures. It is also important to determine if the patient has a feeling of choking or hoarseness. If any of these symptoms are present, indicating pressure on the mediastinal structures, the appropriate cardiovascular or thoracic specialist should be consulted urgently. The patient should always be consented for possible open reduction in the event a closed reduction fails.
We then proceed to the operating room urgently for closed reduction as outlined previously (Fig. 42-22). We prefer to start with the abduction traction technique. If reduction cannot be accomplished with the patient’s arm in abduction, we will use the adduction technique of Buckerfield and Castle36 that is described above (Fig. 42-23).
If these methods are not successful, we utilize the towel clip technique combined with downward pressure on the lateral clavicle and traction on the arm.
If all methods of closed reduction fail, an open reduction should be performed. It is critical that a thoracic surgeon and bypass team are immediately available when the patient is taken to the operating room to intervene if needed. The patient is positioned supine on a radiolucent operating table. The chest and abdomen along with the involved ipsilateral limb are prepped and draped free. A curvilinear incision is made over the SC joint with the horizontal limb in line with the clavicle and the vertical limb along the manubrium. Skin flaps are elevated and the periosteum is incised in a horizontal fashion. Care is taken to preserve the capsule for later repair and closure (Fig. 42-30). The posteriorly displaced clavicle is reduced with traction, towel clip elevation, and/or by gently leveraging the clavicle from posterior to anterior with a blunt retractor (Fig. 42-31). The posterior capsule along with the intra-articular disc ligament is then incorporated into a running locking suture using no. 2 Ethibond (Johnson & Johnson) (Fig. 42-32). Drill holes are then passed through the clavicle from anterior-to-posterior taking care to protect the neurovascular structures. A Hewson suture passer is used to shuttle sutures through the posterior cortex of the clavicle (Fig. 42-33). The defect in the posterior capsule is then repaired with interrupted permanent suture (Fig. 42-34). After the capsular defect is closed, the previously passed transosseous sutures are secured along the anterior cortex (Fig. 42-35). The remaining capsular sleeve is closed with absorbable sutures to complete the repair.
The medial clavicle may need to be acutely resected in certain scenarios as described by the senior author.190 Examples include severely damaged medial articulations, the need to decompress the posterior structures, and the necessity to provide improved access for the thoracic surgeon to the mediastinum. When operating on the SC joint, care must be taken to evaluate the residual stability of the medial clavicle. It is the same analogy as used when resecting the distal clavicle for an old AC joint problem. If the coracoclavicular ligaments are intact, an excision of the distal clavicle is indicated. In this case if the coracoclavicular ligaments are attenuated, then, in addition to excision of the distal clavicle, one must reconstruct the coracoclavicular ligaments. With an SC joint injury, if the costoclavicular ligaments are intact, the clavicle medial to the ligaments should be resected and beveled smooth. If the ligaments are torn, the clavicle must be stabilized to the first rib. If too much clavicle is resected, or if the clavicle is not stabilized to the first rib, residual joint instability and patient symptoms can result (Fig. 42-36). The patient is placed supine on the table, and three to four towels or a sandbag should be placed between the scapulae. The upper extremity should be draped out free so that lateral traction can be applied during the open reduction. In addition, a folded sheet around the patient’s thorax should be left in place so that it can be used for countertraction when traction is applied to the involved extremity. An anterior incision is used that parallels the superior border of the medial 7.62 to 10.16 cm (3 to 4 in) of the clavicle and then extends downward over the sternum just medial to the involved SC joint (Fig. 42-37). During exposure of the SC joint it is crucial to leave the anterior capsular ligament intact. The reduction can usually be accomplished with traction and countertraction while lifting up anteriorly on a clamp placed around the medial clavicle. Along with the traction and countertraction, it may be necessary to use an elevator to pry the clavicle back to its articulation with the manubrium.
When the reduction has been obtained, and with the shoulders held back, the reduction will be stable if the anterior capsule has been left intact. If the anterior capsule is damaged or is insufficient to prevent anterior displacement of the medial end of the clavicle, we recommend excision of the medial 2.54 to 3.81 cm (1 to 1.5 in) of the clavicle and securing the residual clavicle anatomically to the first rib with 1-mm Dacron tape. The medial clavicle is exposed by careful subperiosteal dissection (Fig. 42-38). When possible, any remnant of the capsular or intra-articular disc ligaments should be identified and preserved as these structures can be used to help stabilize the medial clavicle. The capsular ligament covers the anterosuperior and posterior aspects of the joint and represents thickenings of the joint capsule. This ligament is primarily attached to the epiphysis of the medial clavicle and is usually avulsed from this structure with posterior SC dislocations. The intra-articular disc ligament is a very dense, fibrous structure and may be intact. It arises from the synchondral junction of the first rib and sternum and is usually avulsed from its attachment site on the medial clavicle. If the sternal attachment sites of the intra-articular and/or capsular ligaments are intact, a nonabsorbable no. 1 cottony Dacron suture is woven back and forth through the ligament(s) so that the ends of the suture exit through the avulsed free end of the tissue. The medial 2.54 to 3.81 cm (1 to 1.5 in) end of the clavicle is resected, being careful to protect the underlying vascular structures, and being careful not to damage any of the residual costoclavicular (rhomboid) ligament. The vital vascular structures are protected by passing a curved Crego elevator or ribbon retractor around the posterior aspect of the medial clavicle to isolate them from the operative field during the bony resection.
Excision of the medial clavicle is facilitated by creating drill holes through both cortices of the clavicle at the intended site of clavicular osteotomy. Following this step, an air drill with a side-cutting bur is used to complete the osteotomy (Fig. 42-39). The anterior and superior corners of the clavicle are beveled smooth with an air bur for cosmetic purposes. The medullary canal of the medial clavicle is drilled and curetted to receive the transferred intra-articular disc ligament (Fig. 42-40). Two small drill holes are then placed in the superior cortex of the medial clavicle, approximately 1 cm lateral to the site of resection (Fig. 42-41). These holes communicate with the medullary canal and will be used to secure the suture in the transferred ligament. The free ends of the suture are passed into the medullary canal of the medial clavicle and out the two small drill holes in the superior cortex of the clavicle (Fig. 42-42). While the clavicle is held in a reduced AP position in relation to the first rib and sternum, the sutures are used to pull the ligament tightly into the medullary canal of the clavicle (Fig. 42-43). The suture is tied over the cortical bone bridge of the superior clavicle, thus securing the transferred ligament into the clavicle (Fig. 42-44). The stabilization procedure is completed by passing multiple (five or six) 1-mm cottony Dacron sutures around the reflected periosteal tube, the clavicle, and any of the residual underlying costoclavicular ligament and periosteum on the dorsal surface of the first rib (Figs. 42-45 to 42-47). The intent of the sutures passed around the periosteal tube and clavicle and through the costoclavicular ligament and periosteum of the first rib is to anatomically restore the normal space between the clavicle and the rib. To place sutures around the clavicle and the first rib and pull them tight would decrease the space and could lead to pain. We usually detach the clavicular head of the sternocleidomastoid, which temporarily eliminates the superior pull of the muscle on the medial clavicle. Postoperatively, the shoulders should be held back in a figure-of-eight dressing for 4 to 6 weeks to allow for healing of the soft tissues.
In 1997, Rockwood et al.190 reported on a series of 23 patients who had undergone a resection of the medial end of the clavicle. The patients were divided into two groups: Group I, those who underwent resection of the medial end of the clavicle with maintenance or reconstruction of the costoclavicular ligament; and group II, those who had a resection without maintaining or reconstructing the costoclavicular ligament. The outcome in all but one of the seven patients in group II was poor, with persistence or worsening of preoperative symptoms. The only patient of this group with a successful result had a posterior epiphyseal separation in which the costoclavicular ligament remained attached to the periosteum, thus preventing instability. All of the eight patients in group I who had a primary surgical resection of the medial end of the clavicle with maintenance of the costoclavicular ligaments had an excellent result. When the operation was performed as a revision of a previous procedure with reconstruction of the costoclavicular ligament, the results were less successful, but only one patient of seven was not satisfied with the outcome of treatment.
In cases where acute repair is not possible due to late presentation or poor tissue quality, the authors’ preferred technique for reconstruction of the SC joint is the figure-of-eight tendon graft described by Spencer and Kuhn.209 We expose the SC joint as above for acute repair with careful preservation of the periosteal sleeve for later closure. Drill holes are created in both the clavicle and the manubrium. The graft of choice is semitendinosus allograft or autograft which is prepared with a running locking permanent suture to reinforce the tendon and prevent graft fraying. A Hewston suture passer is used to facilitate graft passage and the tendon is tensioned to itself and secured with multiple no. 2 Ethibond sutures (Ethicon, Johnson & Johnson) (Figs. 42-48 and 42-49).
If open reduction is required, a figure-of-eight dressing is used for 6 weeks and this is followed by a sling for another 6 weeks. During this time, the patient is instructed to avoid using the arm for any and all strenuous activities of pushing, pulling, or lifting. They should not elevate or abduct the arm more than 60 degrees during the 12-week period. They can use the involved arm to care for bodily needs, that is, eating, drinking, dressing, and toilet care. This prolonged immobilization will allow the soft tissues a chance to consolidate and stabilize the medial clavicle to the first rib. After 12 weeks, the patient is allowed to gradually use the arm for usual daily living activities, including over the head activities. However, we do not recommend that the patients, after resection of the medial clavicle and ligament reconstruction, return to heavy laboring activities.
We do not recommend the use of K-wires, Steinmann pins, or any other type of metallic pins to stabilize the SC joint. The complications can be very serious and are discussed in the section on complications.
The treatment algorithm for posterior physeal injuries of the medial clavicle is essentially the same as for posterior dislocation. We perform the closed reduction maneuvers as described above. If unsuccessful, then an open reduction of the physeal injury is indicated. The open exposure is essentially the same as above for posterior SC acute repair and we repair the posterior capsule and costoclavicular ligament in the same fashion. If the medial epiphysis is large enough, sutures can be passed from the medial clavicle to the epiphysis to augment the soft tissue repair with bone fixation. After reduction, the shoulders are held back with a figure-of-eight strap or dressing for 3 to 4 weeks.
Before the epiphysis ossifies at the age of 18, one cannot be sure whether a displacement about the SC joint is a dislocation of the SC joint or a fracture through the physeal plate.202,236 Despite the fact that there is significant displacement of the medial shaft with either a type I or type II physeal fracture, the periosteal tube remains in its anatomic position and the attaching ligaments are intact to the periosteum (i.e., the costoclavicular ligament inferiorly and the capsular and intra-articular disc ligaments medially) (Fig. 42-50).
Bilateral dislocations are managed on the basis of the criteria for treatment of each individual dislocation separately. When patients have dislocations of both ends of the clavicle, the authors recommend stabilization of the AC joint with appropriate surgical techniques for type III, IV, V, and VI separations. The SC dislocation is generally left with nonoperative treatment with the exception of the unreduced posterior dislocation which is treated as per guidelines outlined earlier in this chapter. When the clavicle is fractured with an SC dislocation, the clavicle should be stabilized with internal fixation for posterior injuries and treated as appropriate for isolated clavicle fractures when the SC dislocation is anterior. In the rare case of a scapulothoracic dissociation and SC dislocation, the criteria for management of SC dislocation in isolation can be applied.