Chapter 42: Injuries to the Sternoclavicular Joint

Anil K. Dutta, Aaron J. Bois, Michael A. Wirth, Charles A. Rockwood, Jr

Chapter Outline

Introduction to Sternoclavicular Joint Injuries

In Sir Astley Cooper’s 1824 text, sternoclavicular (SC) injuries are discussed as injuries that can essentially be managed with a sling and swathe.50 The first case reports of SC injury are attributed to Rodrigues192 who described a patient with posterior dislocation presenting with signs of suffocation following a compression injury between a wall and a cart. Isolated 19th century reports in Europe were followed by those of American authors in the 1920s and 1930s.55,64,140 SC joint injuries are uncommon and are usually relatively benign injuries. However, the more severe posterior injury patterns can represent true medical emergencies and require the orthopedic surgeon to be knowledgeable regarding the proper steps in diagnosis and treatment. Computed tomography (CT) remains the imaging modality of choice for diagnosing SC joint injuries. Early and prompt reduction is indicated for posterior dislocations and posterior physeal injuries. A variety of reconstructive techniques are available if needed, but are rarely required. 

Surgical and Applied Anatomy of the Sternoclavicular Joint

Surgical Anatomy of the Sternoclavicular Joint

The surgeon who is planning an operative procedure on or near the SC joint should be completely knowledgeable about the vast array of anatomic structures immediately posterior to the SC joint. There is a “curtain” of muscles (the sternohyoid, sternothyroid, and scaleni) posterior to the SC joint and the inner third of the clavicle, and this curtain blocks the view of the vital structures. Some of these vital structures include the innominate artery, innominate vein, vagus nerve, phrenic nerve, internal jugular vein, trachea, and esophagus (Fig. 42-1). It is important to remember that the arch of the aorta, the superior vena cava, and the right pulmonary artery are also very close to the SC joint. Another structure to be aware of is the anterior jugular vein, which is between the clavicle and the curtain of muscles. 
Figure 42-1
Applied anatomy of the vital structures posterior to the sternoclavicular joint.
 
A: Sagittal and (B) transverse views in cross section demonstrating the structures posterior to the sternoclavicular joint. C: A diagram demonstrating the close proximity of the major vessels posterior to the sternoclavicular joint. D: An aortogram showing the relationship of the medial end of the clavicle to the major vessels in the mediastinum.
A: Sagittal and (B) transverse views in cross section demonstrating the structures posterior to the sternoclavicular joint. C: A diagram demonstrating the close proximity of the major vessels posterior to the sternoclavicular joint. D: An aortogram showing the relationship of the medial end of the clavicle to the major vessels in the mediastinum.
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Figure 42-1
Applied anatomy of the vital structures posterior to the sternoclavicular joint.
A: Sagittal and (B) transverse views in cross section demonstrating the structures posterior to the sternoclavicular joint. C: A diagram demonstrating the close proximity of the major vessels posterior to the sternoclavicular joint. D: An aortogram showing the relationship of the medial end of the clavicle to the major vessels in the mediastinum.
A: Sagittal and (B) transverse views in cross section demonstrating the structures posterior to the sternoclavicular joint. C: A diagram demonstrating the close proximity of the major vessels posterior to the sternoclavicular joint. D: An aortogram showing the relationship of the medial end of the clavicle to the major vessels in the mediastinum.
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Applied Anatomy of the Sternoclavicular Joint

The SC joint is a diarthrodial joint and is the only true articulation between the upper extremity and the axial skeleton. The articular surface of the clavicle is much larger than that of the sternum, and both are covered with hyaline cartilage.59 The enlarged bulbous medial end of the clavicle is concave front to back and convex vertically, and therefore creates a saddle-type joint with the clavicular notch of the sternum.95,190 The clavicular notch of the sternum is curved, and the joint surfaces are not congruent. Cave45 demonstrated that in 2.5% of patients there is a small facet on the inferior aspect of the medial clavicle, which articulates with the superior aspect of the first rib at its synchondral junction with the sternum. Because less than half of the medial clavicle articulates with the upper angle of the sternum, the SC joint has the distinction of having the least amount of bony stability of the major joints of the body. 

Ligaments of the Sternoclavicular Joint

There is so much joint incongruity that the integrity of the SC joint has to come from its surrounding ligaments: The intra-articular disc ligament, the extra-articular costoclavicular ligament (rhomboid ligament), the capsular ligament, and the interclavicular ligament. 
Intra-articular Disc Ligament.
The intra-articular disc ligament is a very dense, fibrous structure that arises from the synchondral junction of the first rib and the sternum and passes through the SC joint. It divides the joint into two separate spaces.95,190 The upper attachment is on the superior and posterior aspects of the medial clavicle. DePalma57 has shown that the disc is perforated only rarely; the perforation allows a free communication between the two joint compartments. Anteriorly and posteriorly, the disc blends into the fibers of the capsular ligament. The disc acts as a checkrein against medial displacement of the inner clavicle. Histologic observations71 have demonstrated that the sternal side of the disc is composed of fibrocartilage and dense connective tissue, whereas the clavicular side of the disc is composed of only fibrocartilage. Therefore, it is the clavicular side of the articular disc that has the function of resisting the compressive load to the clavicular surface. 
Costoclavicular Ligament.
The costoclavicular ligament, also called the rhomboid ligament, is short and strong and consists of an anterior and a posterior fasciculus.17,44,95 Cave44 reported that the average length is 1.3 cm, the maximum width is 1.9 cm, and the average thickness is 1.3 cm. Bearn17 has shown that there is always a bursa between the two components of the ligament. Because of the two different parts of the ligament, it has a twisted appearance.95 The costoclavicular ligament attaches below to the upper surface of the first rib adjacent to the portion comprising the synchondral junction with the sternum. It attaches above to the margins of the impression on the inferior surface of the medial end of the clavicle, sometimes known as the rhomboid fossa.95,190 Cave has shown, in a study of 153 clavicles, that the attachment point of the costoclavicular ligament to the clavicle can be one of the three types: (a) a depression, the rhomboid fossa (30%); (b) flat (60%); or (c) an elevation (10%). 
The fibers of the anterior fasciculus arise from the anteromedial surface of the first rib and are directed upward and laterally. The fibers of the posterior fasciculus are shorter and arise lateral to the anterior fibers on the rib and are directed upward and medially. The fibers of the anterior and posterior components cross and allow for stability of the joint during rotation and elevation of the clavicle. The two-part costoclavicular ligament is in many ways similar to the two-part configuration of the coracoclavicular ligament on the outer end of the clavicle. 
Bearn17 has shown experimentally that the anterior fibers resist excessive upward rotation of the clavicle and that the posterior fibers resist excessive downward rotation. Specifically, the anterior fibers also resist lateral displacement, and the posterior fibers resist medial displacement. 
Interclavicular Ligament.
The interclavicular ligament connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum. According to Grant,93 this band may be comparable to the wishbone of birds. This ligament helps the capsular ligaments to produce “shoulder poise,” that is, to hold up the shoulder. This can be tested by putting a finger in the superior sternal notch; with elevation of the arm, the ligament is quite lax, but as soon as both arms hang at the sides, the ligament becomes tight. 
Spencer et al.210 have shown experimentally that the costoclavicular and interclavicular ligaments have little effect on anterior or posterior translation of the SC joint. In an anatomic study Tubbs et al.223 found that the interclavicular ligament prevented superior displacement of the clavicle with shoulder adduction and depression and failure occurred at 53.7 N. 
Capsular Ligament.
The capsular ligament covers the anterosuperior and posterior aspects of the joint and represents thickenings of the joint capsule. 
According to the original work of Bearn,17 this may be the strongest ligament of the SC joint, and it is the first line of defense against the upward displacement of the inner clavicle caused by a downward force on its distal end. The clavicular attachment of the ligament is primarily onto the epiphysis of the medial clavicle, with some secondary blending of the fibers into the metaphysis. The senior author has demonstrated this, as have Poland,178 Denham and Dingley,56 and Brooks and Henning.32 Although some authors report that the intra-articular disc ligament greatly assists the costoclavicular ligament in preventing upward displacement of the medial clavicle, Bearn has shown that the capsular ligament is the most important structure in preventing upward displacement of the medial clavicle.17 In experimental postmortem studies, he determined, after cutting the costoclavicular, intra-articular disc, and interclavicular ligaments, that they had no effect on clavicle poise. However, the division of the capsular ligament alone resulted in a downward depression on the distal end of the clavicle. Bearn’s findings have many clinical implications for the mechanisms of injury of the SC joint. 
Through a cadaver study Spencer et al.210 measured anterior and posterior translation of the SC joint. Anterior and posterior translation was measured in intact specimens and following transection of randomly chosen ligaments about the SC joint. Cutting the posterior capsule resulted in significant increases in anterior and posterior translation. Cutting the anterior capsule produced significant increases in anterior translation. This study demonstrated that the posterior SC joint capsule is the most important structure for preventing both anterior and posterior translation of the SC joint, with the anterior capsule acting as an important secondary stabilizer. 

The Subclavius Muscle

Reis et al.184 studied the function of the subclavius muscle and found that the basic function of the subclavius was to stabilize the SC joint. They also stated that the subclavius could act as a substitute for the ligaments of the SC joint. We believe that this is an important study as it might explain why some people, after loss of the medial clavicle and the SC ligament, do not have instability of the medial end of the clavicle. It also gives a reason for leaving the subclavius muscle intact during operations on the SC joint. 

Range of Motion of the Sternoclavicular Joint

The SC joint is freely movable and functions almost like a ball-and-socket joint with motion in almost all planes, including rotation.26,141 In normal shoulder motion the clavicle, via motion through the SC joint, is capable of 30 to 35 degrees of upward elevation, 35 degrees of combined forward and backward movement, and 45 to 50 degrees of rotation around its long axis (Fig. 42-2). It is most likely the most frequently moved joint of the long bones in the body, because almost any motion of the upper extremity is transferred proximally to the SC joint. 
Figure 42-2
Motions of the clavicle at the sternoclavicular joint.
 
A: With full overhead elevation the clavicle elevates 35 degrees. B: With adduction and extension, the clavicle displaces anteriorly and posteriorly 35 degrees. C: The clavicle rotates on its long axis 45 degrees, as the arm is elevated to the full overhead position.
A: With full overhead elevation the clavicle elevates 35 degrees. B: With adduction and extension, the clavicle displaces anteriorly and posteriorly 35 degrees. C: The clavicle rotates on its long axis 45 degrees, as the arm is elevated to the full overhead position.
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Figure 42-2
Motions of the clavicle at the sternoclavicular joint.
A: With full overhead elevation the clavicle elevates 35 degrees. B: With adduction and extension, the clavicle displaces anteriorly and posteriorly 35 degrees. C: The clavicle rotates on its long axis 45 degrees, as the arm is elevated to the full overhead position.
A: With full overhead elevation the clavicle elevates 35 degrees. B: With adduction and extension, the clavicle displaces anteriorly and posteriorly 35 degrees. C: The clavicle rotates on its long axis 45 degrees, as the arm is elevated to the full overhead position.
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Epiphysis of the Medial Clavicle

Although the clavicle is the first long bone of the body to ossify (fifth intrauterine week), the epiphysis at the medial end of the clavicle is the last of the long bones in the body to appear and the last epiphysis to close (Fig. 42-3). The medial clavicular epiphysis does not ossify until the 18th to 20th year, and it fuses with the shaft of the clavicle around the 23rd to 25th year.93,95,178 Webb and Suchey,234 in an extensive study of the physis of the medial clavicle in 605 males and 254 females at autopsy, reported that complete union may not be present until 31 years of age. This knowledge of the epiphysis is important, because many of the SC dislocations in young adults are injuries through the physeal plate. 
Figure 42-3
CT scan demonstrating the thin, wafer-like disc of the epiphysis of the medial clavicle.
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Principles of Diagnosis and Evaluation of Sternoclavicular Joint Injuries

Mechanisms of Injury of the Sternoclavicular Joint

Either direct or indirect force can produce a dislocation of the SC joint. Because the SC joint is subject to practically every motion of the upper extremity and because the joint is small and incongruous, one would think that it would be the most commonly dislocated joint in the body. However, the supporting ligamentous structures are strong and so designed that it is, in fact, one of the least commonly dislocated joints. For this reason, a traumatic dislocation of the SC joint usually occurs only after tremendous forces, either direct or indirect, have been applied to the shoulder. 

Direct Force

When a force is applied directly to the anteromedial aspect of the clavicle, the clavicle is pushed posteriorly behind the sternum and into the mediastinum (Fig. 42-4). This may occur in a variety of ways: An athlete lying on his/her back is jumped on and the knee of the jumper lands directly on the medial end of the clavicle; a kick is delivered to the front of the medial clavicle; a person lying supine is run over by a vehicle; or a person is pinned between a vehicle and a wall (Fig. 42-5). Anatomically, it is essentially impossible for a direct force to produce an anterior SC dislocation. 
Figure 42-4
Cross sections through the thorax at the level of the sternoclavicular joint.
 
A: Normal anatomical relations. B: Posterior dislocation of the SC joint. C: Anterior dislocation of the SC joint.
A: Normal anatomical relations. B: Posterior dislocation of the SC joint. C: Anterior dislocation of the SC joint.
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Figure 42-4
Cross sections through the thorax at the level of the sternoclavicular joint.
A: Normal anatomical relations. B: Posterior dislocation of the SC joint. C: Anterior dislocation of the SC joint.
A: Normal anatomical relations. B: Posterior dislocation of the SC joint. C: Anterior dislocation of the SC joint.
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Figure 42-5
Computed axial tomogram of a posterior sternoclavicular joint dislocation that occurred when the driver’s chest impacted the steering wheel during a motor vehicle accident.
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Indirect Force

A force can be applied indirectly to the SC joint from the anterolateral or posterolateral aspects of the shoulder. This is the most common mechanism of injury to the SC joint. Mehta et al.154 reported that three of four cases of posterior SC dislocations resulted from indirect force, and Heinig103 reported that indirect force was responsible for eight of nine cases of posterior SC dislocations. If the shoulder is compressed and rolled forward, an ipsilateral posterior dislocation results; if the shoulder is compressed and rolled backward, an ipsilateral anterior dislocation results (Fig. 42-6). 
Figure 42-6
Mechanisms that produce anterior or posterior dislocation of the sternoclavicular joint.
 
A: If the patient is lying on the ground and a compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle will be displaced posteriorly. B: When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly.
A: If the patient is lying on the ground and a compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle will be displaced posteriorly. B: When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly.
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Figure 42-6
Mechanisms that produce anterior or posterior dislocation of the sternoclavicular joint.
A: If the patient is lying on the ground and a compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle will be displaced posteriorly. B: When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly.
A: If the patient is lying on the ground and a compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle will be displaced posteriorly. B: When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly.
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Most Common Cause of Injuries

The most common cause of dislocation of the SC joint is vehicular accidents, followed by an injury sustained during participation in sports.121,124,163,167,181,196,231 Omer,167 in his review of patients from 14 military hospitals, found 82 cases of SC joint dislocations. He reported that almost 80% of these occurred as a result of vehicular accidents (47%) or in athletics (31%). 

Incidence of Injury

The incidence of SC dislocation, based on the series of 1,603 injuries of the shoulder girdle reported by Cave et al.,46 is 3% (specific incidences in the study were glenohumeral dislocations, 85%; acromioclavicular [AC] injuries, 12%; and SC injuries, 3%). In the series by Cave, and in our experience, dislocation of the SC joint is not as rare as posterior dislocation of the glenohumeral joint. 
In a study of 3,451 injuries during alpine skiing, Kocher and Feagin,124 showed that injuries involving the shoulder complex accounted for 39.1% of upper-extremity injuries and 11.4% of all alpine skiing injuries. Of the 393 injuries involving the shoulder complex, SC injuries accounted for 0.5%. 
The largest published series from a single institution is reported by Nettles and Linscheid163 who studied 60 patients with SC dislocations (57 anterior and 3 posterior). Fery and Sommelet79 found a ratio of 40 anterior to 8 posterior dislocations. Waskowitz231 reviewed 18 cases of SC dislocations, none of which was posterior. However, in our series of 185 traumatic SC injuries, there was 135 patients with anterior dislocation and 50 patients with posterior dislocation. 

Associated Injuries with the Sternoclavicular Joint

SC injury can be accompanied by significant trauma to the critical surrounding structures in the neck and thorax and/or by other musculoskeletal injuries. Significant concomitant injuries of the mediastinum must be considered to avoid catastrophic outcomes. These injuries almost always occur in the setting of posterior SC fractures and dislocations and include the following: 
  1.  
    Tracheal compression: From the initial case report of Rodrigues192 to multiple recent case reports, the trachea can be displaced by the posteriorly displaced medial aspect of the clavicle. Acute airway compromise or subacute dyspnea are key symptoms.143,161
  2.  
    Pneumothorax: Pleural violation by the clavicle has been noted with SC dislocation and should be especially considered in high-energy direct trauma.172
  3.  
    Laceration/compression of the great vessels: The great vessels of the mediastinum can be directly transected or compressed and multiple case reports of both arterial and venous injuries exist,51,84,101,109,168,207,240 including the pulmonary artery,240 brachiocephalic vein,51 superior vena cava,172 and innominate artery.147 Compression of any of the great vessels without frank laceration can also occur20,164,168 and may present as a thrombosis.47
  4.  
    Esophageal perforation/rupture: Cases of esophageal rupture are often described in relation to local sequelae. Howard110 reported a case of rupture complicated by osteomyelitis of the clavicle. Wasylenko and Busse232 reported on a fatal tracheoesophageal fistula.
  5.  
    Plexus injury/compression: A high index of suspicion should be maintained for brachial plexus injury which may occur concomitantly with the overall injury pattern or from the static posterior position of the clavicle after dislocation.85 Careful evaluation of associated cervical spine injury should be completed as it cannot be assumed that neurological injury is located in the brachial plexus.134

Orthopedic Injuries Associated with the Sternoclavicular Joint

Bilateral Dislocations

In 1896, Hotchkiss108 reported a bilateral traumatic dislocation of the SC joint. The senior author has treated four cases of bilateral SC dislocation. A recent case of bilateral posterior physeal fracture–dislocations treated operatively has been reported by Baumann et al.16 Bilateral subluxation91 and compression of the brachiocephalic vein from bilateral posterior dislocation has also been described.67 

Dislocations of Both Ends of the Clavicle

When dislocation of both ends of the clavicle occurs, the SC dislocation is usually anterior.97,172,199 To our knowledge the first reported case of dislocation of both ends of the clavicle was by Porral180 in 1831. In 1923, Beckman18 reported a single case and reviewed 15 cases that had been previously reported. With the exception of this single patient, all patients had been treated conservatively with acceptable function. Dieme et al.62 reported 3 cases of “floating clavicle.” In 1990, Sanders et al.197 reported six patients who had a dislocation of both ends of the clavicle; two patients with lower demands did well following nonoperative management with only minor symptoms. The other four patients had persistent symptoms that were localized to the AC joint. Each of these patients had a reconstruction of the AC joint, which resulted in a painless, full range of motion, and a return to normal activity (Fig. 42-7). AC joint dislocation can also accompany medial clavicle physeal fracture/dislocation.88 Wade et al.230 reported a irreducible posterior inferior AC dislocation associated with a medial epiphyseal fracture which required open reduction of the AC joint and exploration of the SC injury with a good result. 
Figure 42-7
Dislocation of both ends of the clavicle.
 
A: Clinical view demonstrating anterior dislocation of the right sternoclavicular joint. B: The axillary x-ray reveals posterior dislocation of the acromioclavicular joint. C: These injuries are generally treated by acromioclavicular joint repair/reconstruction with return of near normal function.
A: Clinical view demonstrating anterior dislocation of the right sternoclavicular joint. B: The axillary x-ray reveals posterior dislocation of the acromioclavicular joint. C: These injuries are generally treated by acromioclavicular joint repair/reconstruction with return of near normal function.
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Figure 42-7
Dislocation of both ends of the clavicle.
A: Clinical view demonstrating anterior dislocation of the right sternoclavicular joint. B: The axillary x-ray reveals posterior dislocation of the acromioclavicular joint. C: These injuries are generally treated by acromioclavicular joint repair/reconstruction with return of near normal function.
A: Clinical view demonstrating anterior dislocation of the right sternoclavicular joint. B: The axillary x-ray reveals posterior dislocation of the acromioclavicular joint. C: These injuries are generally treated by acromioclavicular joint repair/reconstruction with return of near normal function.
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Combined Sternoclavicular Injury and Fractures and Dislocations of the Clavicle

Fracture of the midshaft of the clavicle with either anterior or posterior subluxation/dislocation of the SC joint has been noted. It is important to assess the AC joint and the SC joint in the face of the more obvious midshaft clavicle fracture to avoid a delay in diagnosis. Tanlin,215 Arenas et al.,4 Friedl and Fritz,82 and Thomas and Friedman216 have all reported on patients who had an anterior dislocation of the SC joint and a fracture of the midclavicle. Several authors have reported on a skeletally immature patient who had an ipsilateral clavicle fracture and a posterior physeal injury of the SC joint.3,160,162,219 Velutini and Tarazona228 reported a bizarre case of posterior dislocation of the left medial clavicle, the first rib, and a section of the manubrium. Elliott68 reported on a tripartite injury about the clavicle region in which the patient had an anterior subluxation of the right SC joint, a type II injury to the right AC joint, and a fracture of the right midclavicle. Pearsall and Russell174 reported a patient who had an ipsilateral clavicle fracture, an anterior SC joint subluxation, and a long thoracic nerve injury. All of these injuries involving the SC joint and the clavicle were associated with severe trauma to the shoulder region. 

Combined Sternoclavicular Dislocation and Scapulothoracic Dissociation

Tsai et al.221 reported a patient with an SC dislocation associated with a scapulothoracic dissociation. This patient had also sustained a transection of the axillary artery and an avulsion of the median nerve. Following a vascular repair and an above the elbow amputation this patient was left with a complete brachial plexopathy. 

History and Physical Examination of Sternoclavicular Joint Injuries

Elucidating the mechanism of injury can alert the initial treating physician to associated injuries and to the direction of dislocation. The patient should be questioned about pain in the adjacent AC joint and glenohumeral joint. The patient with a posterior dislocation usually has more pain than a patient with an anterior dislocation. The usually palpable medial end of the clavicle is displaced posteriorly and as a consequence the anterosuperior fullness of the chest normally produced by the clavicle is less prominent when compared with the unaffected side.87 The corner of the sternum is easily palpated as compared with the normal SC joint. Venous congestion may be present in the neck or in the upper extremity.94 Symptoms may also include a dry irritating cough and hoarseness.69,176 Breathing difficulties, shortness of breath, or a choking sensation may be noted. Circulation to the ipsilateral arm may be decreased although the presence of pulses does not exclude vessel injury. The patient may complain of difficulty in swallowing or a tight feeling in the throat or may be in a state of complete shock or possibly have a pneumothorax. The distal neurologic examination may reveal diminished sensation or weakness secondary to brachial plexus compression. Complete nerve deficits suggest more severe injury patterns. The examination should include assessment of the Wynne-Davies signs241 of generalized ligamentous laxity as these patients are predisposed to atraumatic anterior SC joint subluxation. As a cautionary note, we have seen a number of patients who clinically appeared to have an anterior dislocation of the SC joint, but on x-ray studies were shown to have complete posterior dislocation, reinforcing that one cannot always rely on clinical findings to differentiate between anterior and posterior dislocations. 

Radiographic Assessment of the Sternoclavicular Joint Injuries

Anteroposterior Views

Occasionally, the routine anteroposterior (AP) or posteroanterior x-rays of the chest or SC joint suggest something is wrong with one of the clavicles, because it appears to be displaced as compared with the normal side. McCulloch et al.151 reported that on nonrotated frontal radiographs, a difference in the relative craniocaudal positions of the medial clavicles of greater than 50% of the width of the heads of the clavicles suggests dislocation. It would be ideal to take a view at right angles to the AP plane, but because of the anatomy, it is impossible to obtain a true 90-degree cephalic-to-caudal lateral view. Lateral x-rays of the chest are at right angles to the AP plane, but they cannot be interpreted because of the density of the chest and the overlap of the medial clavicles with the first rib and the sternum. Regardless of a clinical impression that suggests an anterior or posterior dislocation, x-rays and preferably a CT scan must be obtained to confirm one’s suspicions (Fig. 42-8). 
Figure 42-8
 
A: A 34-year-old patient was involved in a motorcycle accident and sustained an anterior blow to the chest. Note the symmetric anterior chest wall ecchymosis. B: Computed tomography reveals a left medial clavicle fracture without disruption of the sternoclavicular joint.
A: A 34-year-old patient was involved in a motorcycle accident and sustained an anterior blow to the chest. Note the symmetric anterior chest wall ecchymosis. B: Computed tomography reveals a left medial clavicle fracture without disruption of the sternoclavicular joint.
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Figure 42-8
A: A 34-year-old patient was involved in a motorcycle accident and sustained an anterior blow to the chest. Note the symmetric anterior chest wall ecchymosis. B: Computed tomography reveals a left medial clavicle fracture without disruption of the sternoclavicular joint.
A: A 34-year-old patient was involved in a motorcycle accident and sustained an anterior blow to the chest. Note the symmetric anterior chest wall ecchymosis. B: Computed tomography reveals a left medial clavicle fracture without disruption of the sternoclavicular joint.
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Special Projected Views

There have been numerous special x-ray projections recommended for the SC joint.74,78,103,105,117,129,186,200,220 While the serendipity view is frequently obtained as a front-line image for evaluation of the SC joint, the Heinig and Hobbs views are rarely obtained if CT is available. However, the Hobbs and Heinig views can be useful when suspicion is high on clinical examination and confirmation is needed before obtaining a CT, especially in the outpatient setting when delayed presentation often leads to misdiagnosis. 
Heinig View.
With the patient in a supine position, the x-ray tube is placed approximately 76.2 cm (30 in) from the involved SC joint and the central ray beam is directed tangential to the joint and parallel to the opposite clavicle. The cassette is placed against the opposite shoulder and centered on the manubrium (Fig. 42-9). 
Figure 42-9
Heinig view.
 
A: Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as described by Heinig. B: Heinig view demonstrating a normal relationship between the medial end of the clavicle (C) and the manubrium (M).
A: Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as described by Heinig. B: Heinig view demonstrating a normal relationship between the medial end of the clavicle (C) and the manubrium (M).
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Figure 42-9
Heinig view.
A: Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as described by Heinig. B: Heinig view demonstrating a normal relationship between the medial end of the clavicle (C) and the manubrium (M).
A: Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as described by Heinig. B: Heinig view demonstrating a normal relationship between the medial end of the clavicle (C) and the manubrium (M).
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Hobbs View.
In the Hobbs view, the patient is seated at the x-ray table, high enough to lean forward over the table. The cassette is placed on the table, and the lower anterior rib cage is against the cassette (Fig. 42-10). The patient leans forward so that the nape of his flexed neck is almost parallel to the table. The flexed elbows straddle the cassette and support the head and neck. The x-ray source is above the nape of the neck, and the beam passes through the cervical spine to project the SC joints onto the cassette. 
Figure 42-10
Hobbs view.
 
Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as recommended by Hobbs. (Modified from: Hobbs DW. Sternoclavicular joint: A new axial radiographic view. Radiology 1968;90:801–802.)
Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as recommended by Hobbs. (Modified from: Hobbs DW. Sternoclavicular joint: A new axial radiographic view. Radiology 1968;90:801–802.)
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Figure 42-10
Hobbs view.
Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as recommended by Hobbs. (Modified from: Hobbs DW. Sternoclavicular joint: A new axial radiographic view. Radiology 1968;90:801–802.)
Positioning of the patient for x-ray evaluation of the sternoclavicular joint, as recommended by Hobbs. (Modified from: Hobbs DW. Sternoclavicular joint: A new axial radiographic view. Radiology 1968;90:801–802.)
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Serendipity View.
The “serendipity view” is rightfully named because that is the way it was developed. The senior author accidentally noted that the next best thing to having a true cephalocaudal lateral view of the SC joint was a 40-degree cephalic tilt view. The patient is positioned supine squarely and in the center of the x-ray table. The tube is tilted at a 40-degree angle of the vertical and is centered directly on the sternum (Figs. 42-11 to 42-14). A nongrid 27.94- × 35.56-cm (11- × 14-in) cassette is placed squarely on the table and under the patient’s upper shoulders and neck so that the beam aimed at the sternum will project both clavicles onto the film. 
Figure 42-11
Serendipity view.
 
Positioning of the patient to take the “serendipity” view of sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children the tube distance from the patient should be 114.3 cm (45 in); in thicker-chested adults the distance should be 152.4 cm (60 in).
Positioning of the patient to take the “serendipity” view of sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children the tube distance from the patient should be 114.3 cm (45 in); in thicker-chested adults the distance should be 152.4 cm (60 in).
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Figure 42-11
Serendipity view.
Positioning of the patient to take the “serendipity” view of sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children the tube distance from the patient should be 114.3 cm (45 in); in thicker-chested adults the distance should be 152.4 cm (60 in).
Positioning of the patient to take the “serendipity” view of sternoclavicular joints. The x-ray tube is tilted 40 degrees from the vertical position and aimed directly at the manubrium. The nongrid cassette should be large enough to receive the projected images of the medial halves of both clavicles. In children the tube distance from the patient should be 114.3 cm (45 in); in thicker-chested adults the distance should be 152.4 cm (60 in).
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Figure 42-12
When viewed from around the level of the patient’s knees, it is apparent that the left clavicle (patient’s right) is dislocated anteriorly.
Rockwood-ch042-image012.png
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Figure 42-13
Posterior dislocation of the right medial clavicle as seen on 40-degree cephalic tilt serendipity x-ray.
 
The right clavicle is inferiorly displaced as compared to the normal left clavicle.
The right clavicle is inferiorly displaced as compared to the normal left clavicle.
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Figure 42-13
Posterior dislocation of the right medial clavicle as seen on 40-degree cephalic tilt serendipity x-ray.
The right clavicle is inferiorly displaced as compared to the normal left clavicle.
The right clavicle is inferiorly displaced as compared to the normal left clavicle.
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Figure 42-14
Interpretation of the cephalic tilt (serendipity view) x-ray films of the sternoclavicular joints.
 
A: In the normal person, both clavicles appear on the same imaginary line drawn horizontally across the film. B: In a patient with an anterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is projected above the imaginary line drawn through the level of the normal left clavicle. C: If the patient has a posterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is displaced below the imaginary line drawn through the normal left clavicle.
A: In the normal person, both clavicles appear on the same imaginary line drawn horizontally across the film. B: In a patient with an anterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is projected above the imaginary line drawn through the level of the normal left clavicle. C: If the patient has a posterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is displaced below the imaginary line drawn through the normal left clavicle.
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Figure 42-14
Interpretation of the cephalic tilt (serendipity view) x-ray films of the sternoclavicular joints.
A: In the normal person, both clavicles appear on the same imaginary line drawn horizontally across the film. B: In a patient with an anterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is projected above the imaginary line drawn through the level of the normal left clavicle. C: If the patient has a posterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is displaced below the imaginary line drawn through the normal left clavicle.
A: In the normal person, both clavicles appear on the same imaginary line drawn horizontally across the film. B: In a patient with an anterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is projected above the imaginary line drawn through the level of the normal left clavicle. C: If the patient has a posterior dislocation of the right sternoclavicular joint, the medial half of the right clavicle is displaced below the imaginary line drawn through the normal left clavicle.
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Special Imaging Techniques

Tomograms

Tomograms can be very helpful in distinguishing between an SC dislocation and a fracture of the medial clavicle. They are also helpful in questionable anterior and posterior injuries of the SC joint to distinguish fractures from dislocations and to evaluate arthritic changes. 
In 1959, Baker10 recommended the use of tomography, which was developed in the late 1920s, and said it was “far more valuable than routine radiographs and the fingertips of the examining physician.” In 1975, Morag and Shahin159 reported on the value of tomography, which they used in a series of 20 patients, and recommended that it should be used routinely to evaluate problems of the SC joint. From a study of normal SC joints, they pointed out the variation in the x-ray appearance in different age groups. 
CT Scans.
Without question, the CT scan is the best technique to study problems of the SC joint (Fig. 42-15). CT clearly distinguishes injuries of the joint from fractures of the medial clavicle and defines minor subluxations of the joint. One must remember to request CT scans of both SC joints and the medial half of both clavicles so the injured side can be compared with the normal side. Numerous authors have reported on the value of using a CT scan as the method of choice for radiographic evaluation of the SC joint.37,52,53,60,61,63,131,135,142 While plain films may be suggestive of the nature of the injury, it is critical that a CT scan is obtained for the superior specificity and sensitivity of CT in the diagnosis of SC joint pathology. Lucet et al.142 used CT scans to evaluate the SC joints in 60 healthy subjects homogeneously distributed by sex and decade of life from 20 to 80 years old. They reported that 98% of the subjects had at least one sign of various abnormalities, such as sclerosis, osteophytes, erosion, cysts, and joint narrowing. The number of signs increased with age and the number of clavicular signs was greater than those in the sternum. 
Figure 42-15
 
A: Routine anteroposterior (AP) x-ray of posteriorly dislocated right sternoclavicular joint. B: The AP view is suggestive of a posterior dislocation. However, the computed tomography (CT) scan clearly demonstrates the posteriorly displaced right medial clavicle. Note the displacement of the trachea.
A: Routine anteroposterior (AP) x-ray of posteriorly dislocated right sternoclavicular joint. B: The AP view is suggestive of a posterior dislocation. However, the computed tomography (CT) scan clearly demonstrates the posteriorly displaced right medial clavicle. Note the displacement of the trachea.
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Figure 42-15
A: Routine anteroposterior (AP) x-ray of posteriorly dislocated right sternoclavicular joint. B: The AP view is suggestive of a posterior dislocation. However, the computed tomography (CT) scan clearly demonstrates the posteriorly displaced right medial clavicle. Note the displacement of the trachea.
A: Routine anteroposterior (AP) x-ray of posteriorly dislocated right sternoclavicular joint. B: The AP view is suggestive of a posterior dislocation. However, the computed tomography (CT) scan clearly demonstrates the posteriorly displaced right medial clavicle. Note the displacement of the trachea.
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Tuscano et al.224 obtained CT scans from 104 healthy subjects free from SC joint pathology and demonstrated that greater than 10% of patients show substantial asymmetry in the SC joints (i.e., SC joint space and distance between the manubrium and anterior margin of clavicular head), which may be interpreted as pathologic. These authors suggest exercising caution in attributing a disease state to asymmetry because of the frequency of this finding in the asymptomatic population. These findings become clinically useful in the setting of chronic subluxation or dislocation of the SC joint. 
Magnetic Resonance Imaging.
Brossman et al.33 correlated magnetic resonance imaging (MRI) scans with anatomic sections in 14 SC joints from elderly cadavers. They concluded that MRI did depict the anatomy of the SC joint and surrounding soft tissues (Fig. 42-16). T2-weighed images were superior to T1-weighted images in depicting the intra-articular disc. Magnetic resonance arthrography allowed the delineation of perforations in the intra-articular disc. In children and young adults when there are questions of diagnosis between SC joint dislocation and physeal injury, the MRI scan can be used to determine if the epiphysis has displaced with the clavicle or is still adjacent to the manubrium.86,98 Some have also advocated the use of MRI in young children to avoid radiation exposure in this age group.132 Benitez et al.19 evaluated 41 patients with SC trauma at an average of 9 months post injury and found an 80% incidence of articular disc injury and a 59% incidence of subluxation. MRI may be useful in this clinical scenario to better understand the in vivo mechanisms of injury of the SC joint and to elucidate causes of pain well after the traumatic event. 
Figure 42-16
Magnetic resonance imaging (MRI) of the sternoclavicular joint.
 
The epiphysis on both medial clavicles is clearly visible.
The epiphysis on both medial clavicles is clearly visible.
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Figure 42-16
Magnetic resonance imaging (MRI) of the sternoclavicular joint.
The epiphysis on both medial clavicles is clearly visible.
The epiphysis on both medial clavicles is clearly visible.
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Ultrasound.
Ultrasound can be used to observe abnormal contour in the joint, hematoma, and occlusion of vessels. Proper ultrasound technique requires a linear array probe placed parallel to the clavicle.76 Pollock et al.179 and more recently Blakeley et al.25 reported the use of ultrasound in the diagnosis of posterior dislocation of the SC joint. An additional application of ultrasound may be the use of intraoperative sonography to confirm whether a closed reduction has been successful or not.22,205 The ability of ultrasound to obtain the diagnosis of posterior SC dislocation has shown promise, but does require knowledge of ultrasound technology for the accurate and reliable diagnosis of SC joint pathology. In addition, sonography is dependent on operator experience and knowledge of regional anatomy. As such, a CT scan remains the gold standard and must be obtained to confirm the diagnosis of a SC joint dislocation and to assess the quality of closed reduction. In 2012, Sullivan et al.213 described the use of an O-arm intraoperative CT system to verify reduction in two cases of posterior SC joint dislocation. 
Lastly, duplex ultrasonography can be obtained for the diagnosis of thrombosis and vessel occlusion in cases where vascular insult is suspected.47,101 However, CT angiography remains the gold standard vascular study to define the location and extent of vessel injury. 
CT Angiography.
The role for advanced vascular imaging cannot be understated and should be performed if vascular injury is present or suspected acutely, and for all chronic or late presentations. Multiple reports have shown the value of CT angiography in diagnosing vascular injury before taking the patient to the operating room.20,67,101,106,147,157 

Classification and Differential Diagnosis

Two methods can be used to classify SC joint subluxations and dislocations; first, the anatomic position of the injury, and second, the etiology of the problem. The OTA classification is simply based on the direction of the dislocation and not on etiology. 

OTA Classification

The anterior and posterior dislocations are well described (Fig. 42-17). A recent case report confirms the possibility of a superior dislocation which occurred after an indirect force mechanism. The authors noted that only the interclavicular and intra-articular disc ligaments were ruptured.137 
Figure 42-17
 
OTA classification of sternoclavicular injuries (From: Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium–2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S104–S107, with permission.)
OTA classification of sternoclavicular injuries (From: Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium–2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S104–S107, with permission.)
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Figure 42-17
OTA classification of sternoclavicular injuries (From: Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium–2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S104–S107, with permission.)
OTA classification of sternoclavicular injuries (From: Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium–2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S104–S107, with permission.)
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Anatomic Classification

Anterior Subluxation and Dislocation.
Anterior dislocations are the most common. The medial end of the clavicle is displaced anteriorly or anterosuperiorly to the anterior margin of the sternum. 
Posterior Dislocation.
Posterior SC dislocations are uncommon. The medial end of the clavicle is displaced posteriorly or posterosuperiorly with respect to the posterior margin of the sternum. 

Etiologic Classification

Atraumatic Problems
Spontaneous Subluxation or Dislocation.
This condition typically occurs in women during the late teens or young adult life and usually occurs in patients who have generalized ligament laxity of other joints. While both SC joints can be affected,91 usually one joint is more of a problem than the other (Fig. 42-18). In middle-aged women, spontaneous anterior or anterior/superior subluxation can occur and may be in association with condensing osteitis of the clavicle.226 In some patients, the atraumatic anterior dislocation of the SC joint is painful and is associated with a snap or pop as the arm is elevated overhead, and another snap occurs when the arm is returned to the patient’s side. Atraumatic posterior dislocation149 and subluxation have also been reported.150 
Figure 42-18
Spontaneous anterior subluxation of the sternoclavicular joint.
 
A: With the arm in the overhead position, the medial end of the right clavicle spontaneously subluxates anteriorly without any trauma. B: When the arm is brought back down to the side, the medial end of the clavicle spontaneously reduces. Usually this is not associated with significant discomfort. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
A: With the arm in the overhead position, the medial end of the right clavicle spontaneously subluxates anteriorly without any trauma. B: When the arm is brought back down to the side, the medial end of the clavicle spontaneously reduces. Usually this is not associated with significant discomfort. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Figure 42-18
Spontaneous anterior subluxation of the sternoclavicular joint.
A: With the arm in the overhead position, the medial end of the right clavicle spontaneously subluxates anteriorly without any trauma. B: When the arm is brought back down to the side, the medial end of the clavicle spontaneously reduces. Usually this is not associated with significant discomfort. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
A: With the arm in the overhead position, the medial end of the right clavicle spontaneously subluxates anteriorly without any trauma. B: When the arm is brought back down to the side, the medial end of the clavicle spontaneously reduces. Usually this is not associated with significant discomfort. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Traumatic Injuries
Sprains. In a mild sprain, all the ligaments are intact and the joint is stable. There may be local damage to the capsule and the joint may develop an effusion, but there is no increased translation of the clavicle or loss of congruity. 
Subluxation. In a moderate sprain, there is subluxation of the SC joint. The capsular, intra-articular disc, and costoclavicular ligaments may be partially disrupted. The subluxation is usually anterior but posterior subluxation can occur. 
Acute Dislocation. In a dislocated SC joint, the capsular and intra-articular ligaments are ruptured. Occasionally, the costoclavicular ligament is intact but stretched out enough to allow dislocation of the joint. 
Chronic Dislocation. If the initial acute traumatic dislocation does not heal, mild to moderate forces may produce recurrent dislocations; this is rare. 
The original dislocation may go unrecognized, it may be irreducible, or the physician may decide not to reduce certain dislocations. 
Physeal Injury
Acute Physeal Fracture.
The medial clavicular physis is the last physis to close and typically fuses around the age of 23 to 25. As such, most SC separations in childhood and adolescence are actually physeal fractures with displacement of the clavicle, not dislocation of the joint. The injury can be anterior or posterior. 
Chronic Physeal Fracture.
Like SC dislocations, physeal fractures of the SC joint are at risk for being missed on initial presentation and unfortunately a delayed presentation is not uncommon. Chronic dislocation is not specifically defined by any absolute time from injury, but as a general rule injuries that present 7 to 10 days after initial injury are categorized as chronic. This is because closed reduction is not likely to be an option and indeed successful closed reduction after 48 hours is rarely reported in the literature. After 7 to 10 days, scarring and adhesions increase the risk of vascular injury with attempted reduction and place the injury in a separate category of management as described later in this chapter. 

Other Conditions of the Sternoclavicular Joint Injuries

It is important to consider other pathologies particular to the SC joint during the diagnostic process. Infection may mimic trauma and should especially be considered in patients with history of IV drug abuse, immunocompromise, or indwelling subclavian catheters. Sternoclavicular hyperostosis is an inflammatory condition of the SC joint and medial ribs which results in new bone formation and even ankylosis of the SC joint. This condition is associated with Japanese ethnicity and dermatologic lesions in the palms and plantar regions. Three conditions which predominate in women are condensing osteitis, Friedrich’s disease, and osteoarthritis.237 Condensing osteitis of the medial clavicle typically occurs in women of late childbearing age and presents as a painful joint with sclerosis on radiographs, similar to condensing osteitis of the ilium and pubis seen in the same demographic group. Friedrich’s disease is osteonecrosis of the medial clavicle. Osteoarthritis typically manifests in the postmenopausal years and can appear as a pseudosubluxation anteriorly.30 

Current Treatment Options for Sternoclavicular Joint Injuries

The majority of injuries to the SC joint can be successfully managed by nonoperative measures (observation or closed reduction). This includes most of the acute and chronic anterior subluxations and dislocations, the acute traumatic posterior subluxations and dislocations, and, remembering that the physis of the medial clavicle does not close until the 23rd to 25th year, the acute traumatic anterior and posterior physeal injuries of the medial clavicle. 
In contrast, chronic posterior dislocations and acute irreducible posterior dislocations require an open surgical procedure. This is an area of consensus as it is critical to avoid the sequelae of the posterior intrusion of the clavicle on the mediastinum. Some authors also recommend open reduction and internal fixation of acute and chronic anterior dislocations; however, this remains controversial and is reserved for special circumstances. 

Anterior Sternoclavicular Joint Injuries

Atraumatic Anterior Sternoclavicular Joint Instability

As with the classification of glenohumeral joint instability, the importance of distinguishing between traumatic and atraumatic instability of the SC joint must be recognized if complications are to be avoided with this condition. Rowe (personal communication, 1988) described several patients who had undergone one or more unsuccessful attempts to surgically stabilize the SC joint. In all cases the patient was able to voluntarily dislocate the clavicle after surgery. 
We have seen a number of patients with spontaneous subluxation or dislocation of the SC joint. Many of these patients have the characteristic finding of generalized ligamentous laxity (i.e., hyperextension of the elbows, knees, and fingers as well as hypermobility of the glenohumeral joints) (Fig. 42-19). Bilateral symptoms is a feature of atraumatic anterior subluxation. Certain activities or sports may also predispose to atraumatic instability.65 About the only symptom such patients seem to complain about is that the medial end of the clavicle subluxes or dislocates anteriorly when they raise their arms over their head (Fig. 42-18)191 and only occasionally complain of pain during the displacement. Because it is difficult to surgically stabilize the joint and prevent its subluxation/dislocation and allow pain-free range of motion, we manage the problem with skillful neglect. 
Figure 42-19
This patient has developed spontaneous subluxation of her sternoclavicular joint.
 
She also has generalized ligamentous laxity of the wrists, fingers, and elbows.
She also has generalized ligamentous laxity of the wrists, fingers, and elbows.
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Figure 42-19
This patient has developed spontaneous subluxation of her sternoclavicular joint.
She also has generalized ligamentous laxity of the wrists, fingers, and elbows.
She also has generalized ligamentous laxity of the wrists, fingers, and elbows.
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In a review by Rockwood and Odor,191 of 37 patients with spontaneous atraumatic subluxation, 29 were managed without surgery and 8 were treated (elsewhere) with surgical reconstruction. With an average follow-up of more than 8 years, all 29 patients treated nonoperatively were doing just fine without limitations of activity or lifestyle. The eight patients treated with surgery had increased pain, limitation of activity, alteration of lifestyle, persistent instability, and significant scars. In many instances, before reconstruction or resection, these patients had minimal discomfort, excellent range of motion, and only complained of a “bump” that slipped in and out of place with certain motions. Postoperatively, these patients still had the bump, along with scars and painful range of motion (Fig. 42-20). 
Figure 42-20
 
Patients treated with surgery for spontaneous, atraumatic subluxation of the sternoclavicular joint often have increased pain, limitation of activity, alteration of lifestyle, persistent instability of the joint, and a significant scar. A: Not only was the cosmetic scarring a problem (B) but also motion and pain were worse than before the reconstruction. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
Patients treated with surgery for spontaneous, atraumatic subluxation of the sternoclavicular joint often have increased pain, limitation of activity, alteration of lifestyle, persistent instability of the joint, and a significant scar. A: Not only was the cosmetic scarring a problem (B) but also motion and pain were worse than before the reconstruction. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Figure 42-20
Patients treated with surgery for spontaneous, atraumatic subluxation of the sternoclavicular joint often have increased pain, limitation of activity, alteration of lifestyle, persistent instability of the joint, and a significant scar. A: Not only was the cosmetic scarring a problem (B) but also motion and pain were worse than before the reconstruction. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
Patients treated with surgery for spontaneous, atraumatic subluxation of the sternoclavicular joint often have increased pain, limitation of activity, alteration of lifestyle, persistent instability of the joint, and a significant scar. A: Not only was the cosmetic scarring a problem (B) but also motion and pain were worse than before the reconstruction. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Crosby and Rubino54 reported a case of spontaneous atraumatic anterior dislocation secondary to pseudoarthrosis of the first and second ribs. Despite a 6-month course of conservative treatment this 14-year-old girl was still painful. A computed tomographic scan of the chest with three-dimensional (3D) reconstruction was performed. The scan revealed a pseudoarthrosis anteriorly between the first and second ribs underlying the medial part of the clavicle. Resection of the anterior portions of the first and second ribs containing the pseudoarthrosis relieved her symptoms and allowed the patient to return to her normal activities. The authors recommended chest radiographs and a possible CT scan with 3D reconstruction to completely evaluate an underlying congenital condition if the subluxation is rigid and unresponsive to nonoperative care. 

Traumatic Anterior Sternoclavicular Joint Injuries

Anterior Sprain/Subluxation.
The treatment of sprain or subluxation is nonoperative. Application of ice is recommended for the first 12 hours, followed by heat for the next 24 to 48 hours. The joint may be subluxated anteriorly or posteriorly, which may be reduced by drawing the shoulders backward as if reducing and holding a fracture of the clavicle. For both anterior and posterior subluxations that are stable, a clavicle strap can be used to hold the reduction. A sling and swath can also be used to support the shoulder and to prevent motion of the arm. The patient should be protected from further injury for 4 to 6 weeks. 
Anterior Dislocation
Method of Closed Reduction.
In most instances, even knowing that the anterior dislocation will be unstable, we still try to reduce the anterior displacement. Muscle relaxants and narcotics are administered intravenously, and the patient is placed supine on a table with a stack of three or four towels between the shoulder blades. While an assistant gently applies downward pressure on the anterior aspect of both shoulders, the medial end of the clavicle is pushed backward where it belongs. On some occasions, rare as they may be, the medial clavicle will stay adjacent to the sternum. However, in most cases, either with the shoulders still held back or when they are relaxed, the anterior displacement promptly recurs. We explain to the patient that the joint is unstable and that the hazards of internal fixation are too great, and we prescribe a sling for a couple of weeks and allow the patient to begin using the arm as soon as tolerated. 
Most of the anterior injuries that we have treated in patients 25 years of age or younger are not dislocations of the SC joint. Rather they are type I or II physeal injuries, which heal and remodel without operative treatment. Patients older than 25 years with anterior dislocations of the SC joint do have persistent prominence of the anterior clavicle. However, this does not seem to interfere with usual activities and, in some cases, has not interfered with heavy manual labor. 
Postreduction Care of Anterior Dislocations.
After reduction, to allow ligament healing, the shoulders should be held back for 4 to 6 weeks with a figure-of-eight dressing or one of the commercially available figure-of-eight straps used to treat fractures of the clavicle. If the reduction is unstable, the arm is placed into a sling for a week or so, and then the patient can begin to use the arm for gentle everyday activities. 
Acute Anterior Dislocation.
There still is some controversy regarding the treatment of acute anterior dislocation of the SC joint. A large series of SC injuries was published in 1988 by Fery and Sommelet.79 They reported on 40 anterior dislocations, 8 posterior dislocations, and 1 unstable SC joint. Fifteen injuries were managed closed, 17 patients were managed operatively, and 17 patients were not treated. They had good and excellent results with both closed and operative treatment, but recommended that closed reduction should be initially undertaken. In 1990, de Jong and Sukul55 reported the long-term results in 10 patients with traumatic anterior SC dislocations. All patients were treated nonoperatively with analgesics and immobilization. The results of treatment were good in seven patients, fair in two patients, and poor in one patient at an average follow-up of 5 years. In summary, most acute anterior dislocations are unstable following reduction, and many operative procedures have been described to repair or reconstruct the joint. At this time, the mixed results of these procedures have not clearly advanced a case for their use instead of observation. 
Anterior Physeal Injuries of the Medial Clavicle.
Many so-called dislocations of the SC joint in adolescents and young adults (≤ 25 years) are not dislocations but physeal injuries. Most of these injuries will heal without surgical intervention. In time, the remodeling process eliminates any bone deformity or displacement. Anterior physeal injuries can certainly be left alone without problems. If an anterior physeal injury is recognized, closed reduction, as described above for anterior dislocation of the SC joint, can be performed. The shoulders should be held back in a clavicular strap or figure-of-eight dressing for 3 to 4 weeks, even if the reduction is stable. Healing is prompt, and remodeling will occur at the site of the deformity. 
Chronic Anterior Dislocation.
Chronic or unreduced anterior dislocations can be reconstructed, but do not generally require such procedures. Most patients with an unreduced and permanent anterior dislocation of the SC joint have few symptoms, have nearly full range of motion, and can work and even perform manual labor with few limitations. Because the joint is so small and incongruous and because the results following attempted reconstruction are inconsistent, we recommend a plan of “skillful neglect.” 
If the patient has persistent symptoms of post-traumatic arthritis for 6 to 12 months following a dislocation or a previous arthroplasty, and if the symptoms can be completely relieved by injection of local anesthesia into the SC joint region, we perform an excision arthroplasty of the SC joint (Fig. 42-21). Occasionally, following conservative treatment of a subluxation of the SC joint, the pain lingers on and the symptoms of popping and grating persist. Joint exploration may be required as several authors have reported symptom relief following joint exploration, removal of the torn or degenerated intra-articular disc along with a capsulorrhaphy.6,14,64 Many authors have included chronic or unreduced anterior dislocations with posterior dislocations in their series of operative results. This makes it difficult to understand the true benefits of surgery in this situation. Postoperatively, recurrent instability,79 limitations of activity,8 and pain72 often occur and patient expectations should be adjusted accordingly. 
Figure 42-21
 
A: CT scan of the sternoclavicular joint. This 42-year-old patient had a symptomatic chronic anterior sternoclavicular joint dislocation. Note joint space narrowing, medial clavicle osteophytes, and manubrial cysts. B: This patient’s symptoms were completely relieved by injection of local anesthesia into the sternoclavicular joint.
A: CT scan of the sternoclavicular joint. This 42-year-old patient had a symptomatic chronic anterior sternoclavicular joint dislocation. Note joint space narrowing, medial clavicle osteophytes, and manubrial cysts. B: This patient’s symptoms were completely relieved by injection of local anesthesia into the sternoclavicular joint.
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Figure 42-21
A: CT scan of the sternoclavicular joint. This 42-year-old patient had a symptomatic chronic anterior sternoclavicular joint dislocation. Note joint space narrowing, medial clavicle osteophytes, and manubrial cysts. B: This patient’s symptoms were completely relieved by injection of local anesthesia into the sternoclavicular joint.
A: CT scan of the sternoclavicular joint. This 42-year-old patient had a symptomatic chronic anterior sternoclavicular joint dislocation. Note joint space narrowing, medial clavicle osteophytes, and manubrial cysts. B: This patient’s symptoms were completely relieved by injection of local anesthesia into the sternoclavicular joint.
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Panzica et al.170 recently reported the long-term operative results of 11 patients with anterior SC joint instability who were managed with either resection arthroplasty (6 patients) or ligament reconstruction (5 patients). Treatment occurred an average of 19.1 months after injury or diagnosis in the resection group and within 2 weeks of injury in the reconstruction group. The results of treatment were evaluated at a mean of 9.9 years using the ASES, DASH, and Constant-Murley outcome scores. The outcome evaluation and postoperative pain scores did not differ significantly between the two operative groups; however, overall results were worse in the reconstruction group when the SC joint reconstruction was not performed soon after injury and in the resection arthroplasty group if the costoclavicular ligament was not preserved or reconstructed. 
In 2012, Van Tongel et al.227 conducted a survey regarding treatment options in acute and chronic symptomatic anterior SC dislocation among three groups of orthopedic surgeons (from a general orthopedic society and from two societies with special interest in shoulder and elbow surgery). There were a total of 212 respondents (212 of 753, or 28%). A majority of surgeons would not perform an open reduction in an acute situation if a closed reduction failed or redislocation occurred. Concerning the treatment for chronic symptomatic anterior SC dislocation, 60% of all respondents chose conservative treatment. However, the majority of surgeons (34 of 48, or 71%) from the American Shoulder and Elbow Society indicated they would perform open treatment (i.e., ligamentous reconstruction or medial claviculectomy) for a chronic symptomatic anterior SC dislocation. 

Posterior Sternoclavicular Joint Injuries

Atraumatic Posterior Sternoclavicular Joint Instability

Spontaneous posterior subluxation or dislocation has only been noted in a few isolated case reports. We have never seen a spontaneous posterior subluxation or dislocation of the SC joint. Martin et al.149 described a case of spontaneous atraumatic posterior dislocation in a 50-year-old previously healthy woman who awoke one morning with a painful SC joint. A CT scan confirmed the posterior dislocation. She later developed dysphagia, and a closed reduction was unsuccessful. At 1 year without any other treatment, she was back to playing golf and was asymptomatic. More recently, Martinez et al.150 reported on the operative treatment of a 19-year-old woman with a symptomatic spontaneous posterior subluxation. The posteriorly displaced medial clavicle was stabilized with a figure-of-eight suture technique using a gracilis autograft. At follow-up the patient was pain free; however, a repeat CT scan demonstrated posterior subluxation of the medial clavicle with erosion of the clavicle and manubrium. In light of the recurrence of subluxation after reconstruction, the authors recommended conservative treatment of atraumatic posterior subluxation of the SC joint. 

Traumatic Posterior Sternoclavicular Joint Injuries

Posterior Sprain/Subluxation.
In mild sprains, the ligaments remain intact and the patient complains of moderate discomfort. The joint may be swollen and tender to palpation. Care must be taken to rule out the more significant posterior dislocation, which may have initially occurred and spontaneously reduced. When in doubt, it is best to protect the SC joint with a figure-of-eight bandage for 2 to 6 weeks. As with all injuries to the SC joint, it must be carefully evaluated by CT scan. 
Posterior Dislocation.
Posterior SC dislocation is considered a true orthopedic emergency as it can be a life-threatening injury. As a general rule, whenever a posterior dislocation of the SC joint is suspected, the physician must perform a very careful examination of the patient to rule out injury to the adjacent posterior structures such as the trachea, esophagus, brachial plexus, great vessels, and lungs. A careful physical examination, special radiographs, and CT scan of both medial clavicles are pertinent for proper diagnosis. Whenever vascular injuries are suspected, the CT scan will need to be combined with an arteriogram of the great vessels. 
From a review of the earlier literature, it would appear that the treatment of choice for posterior SC dislocation was operative. However, since the 1950s, the treatment of choice has been closed reduction.40,49,53,77,99,103,152,153,158,173,196,212 Closed reduction should be performed in an operating room with the capacity for cardiac bypass, with instruments prepared for sternotomy, and with the cardiothoracic team available. 
For appropriate pain control, general anesthesia is usually required for reduction of a posterior dislocation of the SC joint. However, for the stoic patient, some authors have performed the reduction using intravenous narcotics and muscle relaxants. 
Closed Reduction/Closed Treatment.
Most posterior SC dislocations are successfully reduced closed if attempted within 48 hours of injury. Closed reduction after 48 hours is rarely reported but has been noted even at 10 days post injury.97 The experience of the senior author at our institution is that most closed reductions are stable when performed acutely.97 The most common techniques for closed reduction are described below. 
Abduction Traction Technique.
For the abduction traction technique,58,77,119,148,152,158,187 the patient is placed supine with the injured shoulder near the edge of the table. A 3- to 4-inch thick sandbag is placed between the shoulders (Fig. 42-22). Lateral traction is applied to the abducted arm, which is then gradually brought back into extension. This may be all that is necessary to accomplish the reduction. The clavicle usually reduces with an audible pop or snap and can be noted visibly and by palpation and is almost always stable. Too much extension can bind the anterior surface of the dislocated medial clavicle on the back of the manubrium. Occasionally, it may be necessary to grasp the medial clavicle with one’s fingers to dislodge it from behind the sternum. If this fails, the skin is prepared, and a sterile towel clip is used to grasp the medial clavicle to apply lateral and anterior traction to it. 
Figure 42-22
Technique for closed reduction of a posterior dislocation of the sternoclavicular joint.
 
A: The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. B: In addition to the traction it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge it from behind the manubrium. C: In stubborn posterior dislocations, it may be necessary to sterilely prepare the medial end of the clavicle and use a towel clip to grasp around the medial clavicle to lift it back into position.
A: The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. B: In addition to the traction it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge it from behind the manubrium. C: In stubborn posterior dislocations, it may be necessary to sterilely prepare the medial end of the clavicle and use a towel clip to grasp around the medial clavicle to lift it back into position.
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Figure 42-22
Technique for closed reduction of a posterior dislocation of the sternoclavicular joint.
A: The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. B: In addition to the traction it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge it from behind the manubrium. C: In stubborn posterior dislocations, it may be necessary to sterilely prepare the medial end of the clavicle and use a towel clip to grasp around the medial clavicle to lift it back into position.
A: The patient is positioned supine with a sandbag placed between the two shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. In anterior dislocations, direct pressure over the medial end of the clavicle may reduce the joint. B: In addition to the traction it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge it from behind the manubrium. C: In stubborn posterior dislocations, it may be necessary to sterilely prepare the medial end of the clavicle and use a towel clip to grasp around the medial clavicle to lift it back into position.
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Adduction Traction Technique (Buckerfield and Castle Technique).
In this technique,36 the patient is supine on the table with a 3- to 4-inch bolster between the shoulders. Traction is then applied to the arm in adduction, while a downward pressure is exerted on the shoulder (Fig. 42-23). The clavicle is levered over the first rib into its normal position. Buckerfield and Castle36 reported that this technique was successful in seven patients when the abduction traction technique had failed. 
Figure 42-23
The Buckerfield–Castle technique.
 
A, B: The patient is lying on the table with a bolster between the shoulders. Traction is applied to the arm in adduction while a downward force is applied on the shoulder.
A, B: The patient is lying on the table with a bolster between the shoulders. Traction is applied to the arm in adduction while a downward force is applied on the shoulder.
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Figure 42-23
The Buckerfield–Castle technique.
A, B: The patient is lying on the table with a bolster between the shoulders. Traction is applied to the arm in adduction while a downward force is applied on the shoulder.
A, B: The patient is lying on the table with a bolster between the shoulders. Traction is applied to the arm in adduction while a downward force is applied on the shoulder.
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Direct Reduction with Towel Clip.
If the traction techniques described above are not successful, an assistant grasps or pushes down on the clavicle in an effort to dislodge it from behind the sternum. Occasionally, in a stubborn case, especially in a thick-chested person or a patient with extensive swelling, it is impossible to obtain a secure grasp on the clavicle with the fingers alone. The skin should then be surgically prepared and a sterile towel clip used to gain purchase on the medial clavicle percutaneously (Fig. 42-22). The towel clip should encircle the shaft of the clavicle as the dense cortical bone prevents the purchase of the towel clip into the clavicle (Fig. 42-24). Then the combined traction through the arm plus the anterior lifting force on the towel clip will reduce the dislocation. Following the reduction, the SC joint is usually stable, even with the patient’s arm at their side. 
Figure 42-24
Posterior dislocation of the right sternoclavicular joint.
 
A: A 16-year-old boy has a 48-hour-old posterior dislocation of the right medial clavicle that occurred from a direct blow to the anterior right clavicle. He noted the immediate onset of difficulty in swallowing and some hoarseness in his voice. B: A 40-degree cephalic tilt x-ray confirmed the posterior displacement of the right medial clavicle as compared with the left clavicle. Because of the patient’s age, this was considered most likely to be a physeal injury of the right medial clavicle. C: Because the injury was 48 hours old, we were unable to reduce the dislocation with simple traction on the arm. The right shoulder was surgically cleansed so that a sterile towel clip could be used. D: With the towel clip placed securely around the clavicle and with continued lateral traction, a visible and audible reduction occurred. E: Postreduction x-rays showed that the medial clavicle had been restored to its normal position. The reduction was quite stable, and the patient’s shoulders were held back with a figure-of-eight strap. F: The right clavicle has remained reduced. Note the periosteal new bone formation along the superior and inferior borders of the right clavicle. This is the result of a physeal injury, whereby the epiphysis remains adjacent to the manubrium while the clavicle is displaced out of a split in the periosteal tube.
A: A 16-year-old boy has a 48-hour-old posterior dislocation of the right medial clavicle that occurred from a direct blow to the anterior right clavicle. He noted the immediate onset of difficulty in swallowing and some hoarseness in his voice. B: A 40-degree cephalic tilt x-ray confirmed the posterior displacement of the right medial clavicle as compared with the left clavicle. Because of the patient’s age, this was considered most likely to be a physeal injury of the right medial clavicle. C: Because the injury was 48 hours old, we were unable to reduce the dislocation with simple traction on the arm. The right shoulder was surgically cleansed so that a sterile towel clip could be used. D: With the towel clip placed securely around the clavicle and with continued lateral traction, a visible and audible reduction occurred. E: Postreduction x-rays showed that the medial clavicle had been restored to its normal position. The reduction was quite stable, and the patient’s shoulders were held back with a figure-of-eight strap. F: The right clavicle has remained reduced. Note the periosteal new bone formation along the superior and inferior borders of the right clavicle. This is the result of a physeal injury, whereby the epiphysis remains adjacent to the manubrium while the clavicle is displaced out of a split in the periosteal tube.
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Figure 42-24
Posterior dislocation of the right sternoclavicular joint.
A: A 16-year-old boy has a 48-hour-old posterior dislocation of the right medial clavicle that occurred from a direct blow to the anterior right clavicle. He noted the immediate onset of difficulty in swallowing and some hoarseness in his voice. B: A 40-degree cephalic tilt x-ray confirmed the posterior displacement of the right medial clavicle as compared with the left clavicle. Because of the patient’s age, this was considered most likely to be a physeal injury of the right medial clavicle. C: Because the injury was 48 hours old, we were unable to reduce the dislocation with simple traction on the arm. The right shoulder was surgically cleansed so that a sterile towel clip could be used. D: With the towel clip placed securely around the clavicle and with continued lateral traction, a visible and audible reduction occurred. E: Postreduction x-rays showed that the medial clavicle had been restored to its normal position. The reduction was quite stable, and the patient’s shoulders were held back with a figure-of-eight strap. F: The right clavicle has remained reduced. Note the periosteal new bone formation along the superior and inferior borders of the right clavicle. This is the result of a physeal injury, whereby the epiphysis remains adjacent to the manubrium while the clavicle is displaced out of a split in the periosteal tube.
A: A 16-year-old boy has a 48-hour-old posterior dislocation of the right medial clavicle that occurred from a direct blow to the anterior right clavicle. He noted the immediate onset of difficulty in swallowing and some hoarseness in his voice. B: A 40-degree cephalic tilt x-ray confirmed the posterior displacement of the right medial clavicle as compared with the left clavicle. Because of the patient’s age, this was considered most likely to be a physeal injury of the right medial clavicle. C: Because the injury was 48 hours old, we were unable to reduce the dislocation with simple traction on the arm. The right shoulder was surgically cleansed so that a sterile towel clip could be used. D: With the towel clip placed securely around the clavicle and with continued lateral traction, a visible and audible reduction occurred. E: Postreduction x-rays showed that the medial clavicle had been restored to its normal position. The reduction was quite stable, and the patient’s shoulders were held back with a figure-of-eight strap. F: The right clavicle has remained reduced. Note the periosteal new bone formation along the superior and inferior borders of the right clavicle. This is the result of a physeal injury, whereby the epiphysis remains adjacent to the manubrium while the clavicle is displaced out of a split in the periosteal tube.
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Postreduction Care of Posterior Dislocations.
We always hold the shoulders back in a well-padded figure-of-eight clavicle strap for 3 to 4 weeks to allow for soft tissue and ligamentous healing, even when the reduction is quite stable in the operating room. 

Acute Posterior Physeal Injuries of the Medial Clavicle

Posterior physeal injuries, like posterior SC dislocations, should be reduced when they present acutely. The techniques for closed reduction are identical to those described for SC dislocations. After a stable reduction is achieved, the SC joint is protected with the shoulders held back in a figure-of-eight dressing or strap. Immobilization should continue for 3 to 4 weeks. 
Closed reduction maneuvers have been reported with varied success.28,32,36,42,56,72,97,107,111,130,136,212,233,236,242 New strategies can be employed to confirm reduction intraoperatively,213 but in some cases redislocation may occur unexpectedly, even when the surgeon is confident of the intraoperative stability. Cases of late recurrence even after 1 week have been noted.130 As such, it is important to note that confirmed intraoperative reduction may still require further imaging when clinical suspicion warrants. 
The singular difference in treatment between posterior physeal separations and posterior SC dislocations occurs when a posterior physeal dislocation cannot be reduced by closed means and the patient is having no significant symptoms. In this scenario the displacement can in theory be observed while remodeling occurs.243 Generally, this situation occurs when an attempted closed reduction is performed and postreduction CT shows residual posterior displacement or when a patient presents after 48 hours with no symptoms but with a confirmed posterior fracture separation on imaging. The patient may then be counseled regarding open treatment options (Fig. 42-25). Indeed, as with other physeal injuries, the potential for remodeling is significant and may extend until the 23rd to 25th year. The senior author188 has demonstrated a similar mechanism to support conservative treatment of adolescent AC joint injuries or “pseudo-dislocations,” in which there is a partial tear of the periosteal tube containing the distal clavicle. The coracoclavicular ligaments remain secured to the periosteal tube. Because of its high osteogenic potential, spontaneous healing and remodeling to the preinjury “reduced” position occurs within this periosteal conduit. The potential for late complications must be emphasized (see Chronic Posterior Physeal Injuries) and patients should be monitored closely both clinically and radiographically at regular intervals for several years to confirm adequacy of the mediastinal space. 
Figure 42-25
CT scan of a 19-year-old patient who was involved in a motor vehicle accident and presented with complaints of chest pain and a “choking sensation” that was exacerbated by lying supine.
Note the physeal injury of the medial clavicle and compression of the trachea.
Note the physeal injury of the medial clavicle and compression of the trachea.
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If the posterior displacement is symptomatic and cannot be reduced by closed means, the displacement must be reduced surgically and reconstructed as is required for posterior SC dislocations in adults. Waters et al.233 reported successful operative treatment of 13 traumatic posterior SC fracture–dislocations in children and adolescents and other authors have also reported the successful open treatment of similar injuries in adolescents.42,107,111,242,243 In 2010, Lafosse130 reported a large multicenter series of 30 patients with posterior dislocations and posterior physeal separations. The success rate of closed reduction with posterior dislocation was 50% (5/10) and 0% with posterior physeal separations (0/4). These authors recommended open reduction for posterior physeal separations and suggested that closed reduction is hampered by the metaphyseal spike of the type II Salter–Harris fracture line. The emphasis on more aggressive open treatment of posterior physeal injuries underscores the need for vigilance in these patients and the need for more studies to evaluate the natural history of residual displacement in asymptomatic patients treated expectantly over time. 

Chronic Posterior Dislocation

Complications accompanying unreduced posterior dislocations include late thoracic outlet syndrome, late and significant vascular problems, respiratory compromise, and dyspnea on exertion.31,85,139,220 We have treated patients with a medial clavicle resection and reconstruction who have had complaints of swelling and arm discoloration, in addition to signs and symptoms of effort thrombosis and dysphagia secondary to a posteriorly displaced medial clavicle. In the adult, because of the potential problems that can be associated with the clavicle remaining displaced posteriorly into the mediastinum, an arthroplasty is performed as described in the author’s preferred technique section with a figure-of-eight reconstruction (Fig. 42-26). Chronic posterior SC dislocation can be divided into late presentation (>48 hours) and late chronic (months to years after injury). As mentioned previously, after 48 hours closed reduction becomes much less likely to succeed and open reduction is usually necessary. Importantly, it is around 1 to 2 weeks post injury when the surrounding tissues scar to the posterior clavicle increasing the risk of vascular injury during the reduction maneuver.147 In these cases, it is especially critical to obtain a CT angiogram preoperatively to assess the vascular status prior to surgery and be prepared for vascular and bypass surgical team presence in the operating room. 
Figure 42-26
Chronic posterior sternoclavicular joint dislocation.
 
A: An osteophyte projecting from medial clavicle corresponds to the area of capsular injury. B: 3D reconstruction CT scan demonstrating the osteophyte.
A: An osteophyte projecting from medial clavicle corresponds to the area of capsular injury. B: 3D reconstruction CT scan demonstrating the osteophyte.
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Figure 42-26
Chronic posterior sternoclavicular joint dislocation.
A: An osteophyte projecting from medial clavicle corresponds to the area of capsular injury. B: 3D reconstruction CT scan demonstrating the osteophyte.
A: An osteophyte projecting from medial clavicle corresponds to the area of capsular injury. B: 3D reconstruction CT scan demonstrating the osteophyte.
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Late chronic posterior dislocations can present with consequences not initially present in the acute or subacute phase of the injury. Stankler211 reported on two cases of nonoperative management of posterior dislocation, with one patient having mild symptoms of vascular congestion with activity, while the other developed an actual subclavian vein thrombosis 4.5 years later. Mehta et al.154 presented a case report of a delayed subclavian artery occlusion 6 months post injury. Ege et al.67 reported a case of bilateral chronic posterior dislocations which presented 2 years post injury and resulted in vascular compression on CT angiography. These symptoms resolved with resection of both clavicular heads. In addition to vascular consequences, multiple other sequelae from chronic unreduced retrosternal dislocations are noted in the section “Complications.”154 As such, operative treatment is strongly recommended for skeletally mature patients with posterior SC dislocations. 

Chronic Posterior Physeal Injuries of the Medial Clavicle

In cases of late presentation or chronic posterior physeal injury with symptoms or with evidence of vascular compression on imaging, treatment is identical to chronic posterior SC dislocations in adults. Open reduction is performed and the emphasis on preoperative vascular and/or cardiothoracic surgical collaboration is again paramount. However, controversy persists in young adults and adolescents who have no symptoms and present with chronic posterior physeal dislocations. In this situation, the physician can wait to see if the physeal plate remodeling process removes the posteriorly displaced bone.189 Zaslav et al.243 reported on a 13-year-old male with a late presentation of a posterior physeal injury. At 6-months post injury, the patient was asymptomatic and had complete remodeling on CT. In contrast, Emms et al.70 reported on a subclavian thrombosis which occurred 2 years after an initial injury which was treated nonoperatively for what was originally diagnosed as a posterior subluxation. The patient had a new injury at 2 years which precipitated vascular symptoms 3 weeks later and on CT had evidence of a remodeled old medial physeal injury. The patient required a first rib resection to decompress the subclavian vein. Carbone et al.41 reported on a similar case of superior vena cava obstruction after abnormal remodeling of a medial physeal fracture, and a second injury precipitated the occlusion. As such, close observation for the first 2 years, with serial vascular studies and/or serial CT scans, appears to be an important element of nonoperative care in the skeletally immature patient as most case reports of delayed complications occur in this time frame.67,70,154,212 

Surgical Techniques for the Sternoclavicular Joint Injuries

Surgical Reconstructions

There are several procedures described to maintain the medial end of the clavicle in its normal articulation with the sternum (Table 42-1). In general, these techniques can be used to surgically reconstruct the SC joint in the setting of either anterior or posterior instability. This is because the fundamental objective of the operation is stabilization of the medial end of the clavicle to an adjacent structure, regardless of the initial direction of displacement. Much like the AC joint, the recent literature has focused on case reports of technique descriptions and modifications of existing surgeries. Given the rarity of the injury and even rarer necessity for surgery, there is no large experience with any of the techniques. However, certain basic principles should be adhered to in the midst of this creative atmosphere. 
 
Table 42-1
Surgical Techniques for Sternoclavicular Reconstruction
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Table 42-1
Surgical Techniques for Sternoclavicular Reconstruction
1. Open excision with intramedullary ligament repair Use intra-articular disc ligament as a transfer into medial clavicle, reinforced with local tissue repair188
2. Soft tissue graft used for figure-of-eight reconstruction Reconstitute capsular ligaments with graft. Technique described using either semitendinosus43,183 or plantaris tendon graft7
3. Subclavius tenodesis: Technique of burrows Use a slip of subclavius to reconstruct the costoclavicular ligament. Modification is to use graft (fascia lata) to recreate costoclavicular ligament39
4. Sternocleidomastoid reconstruction to first rib and clavicle Use a partial slip of sternocleidomastoid through first rib and clavicle to recreate costoclavicular ligament26
5. Sternocleidomastoid to clavicle and manubrium Use a partial slip of sternocleidomastoid to recreate capsular ligaments, no exposure of first rib5,34
6. Plate stabilization Balser Plate: Inserted into manubrium, repair of local capsule, plate removal required81
Ledge Plating: Standard 3.5-mm LC/DCP 6-hole plate placed anteriorly with medial two holes over manubrium104
Locking Plate: 2-, 3.5-mm precontoured locking plates placed 90 degrees to each other204
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The operative procedure should be performed in a manner that disrupts as few of the anterior ligament structures as possible. If the procedure can be performed with the anterior ligaments intact, then the reduction may be stable with the shoulders held back in a figure-of-eight dressing. If all the ligaments are disrupted, a decision has to be made whether to try to stabilize the SC joint or to resect the medial 2.54 to 3.81 cm (1 to 1.5 in) of the clavicle and anatomically stabilize the remaining clavicle to the first rib. Resection alone cannot be performed in the setting of disrupted ligaments as doing so may worsen the instability of the residual medial clavicle, requiring even greater attention to the need for ligament reconstruction in such a scenario.23 
Once faced with the need for reconstruction, the surgeon has to embrace a surgical strategy from the existing armamentarium. Procedures can be viewed from two different perspectives - tissue and stabilization routes. Tissue options include: (a) local ligaments and capsule, (b) tendon transfers (subclavius or sternocleidomastoid), or (c) grafts. Stabilization options include: (a) stabilize to the first rib, (b) stabilize to the manubrium, or (c) stabilize to the first rib and manubrium. Fixation is generally provided by soft tissue tensioning and suture, although augments with pins, plates, or screws have all been proposed. 
Three broad technical philosophies have been characterized by Spencer et al.210: (a) intramedullary ligament transfer; (b) costoclavicular ligament reconstruction; (c) SC ligament reconstruction. Spencer et al.210 through a biomechanical analysis evaluated the three different reconstruction techniques in a cadaver model. The intramedullary ligament,190 the subclavius tendon transfer,39 and a semitendinosus graft placed in a figure-of-eight fashion through drill holes in the clavicle and manubrium were used to reconstruct the SC joint. Each of the three reconstruction methods was subjected to anterior or posterior translation to failure, and the changes in stiffness compared with the intact state were analyzed statistically. The figure-of-eight semitendinosus reconstruction showed superior initial mechanical properties to the other two techniques. The authors believed that this method reconstructs both the anterior and posterior joint capsules providing an initial stiffness that is closer to that of the intact SC joint. This technique has now been described with some success in young adults with refractory anterior and posterior instability.8,43,183 A plethora of other techniques abound in the literature. Some of the literature from the 1960s and 1970s recommended stabilization of the SC joint with Kirschner wires (K-wires) or Steinmann pins.32,35,56,58,69 These techniques have become largely historical due to their high complication rate as will be discussed later. Other authors have recommended the use of various types of suture wires across the joint,11,38,82,100,118,166,177,182,212,214 reconstruction using local tendons,7,12,26,144,146 or the use of a special plate.102,104,175,193,204 Screw fixation across the joint, osteotomy of the medial clavicle, and resection of the medial end of the clavicle have also been advocated.2,11,12,34,39,95,121,140,144,156,167,190,208 
Transfer of the sternocleidomastoid has been revisited in different forms. Booth and Roper26 described transferring the sternal head of the tendon around the first rib and through the clavicle and back upon itself. Brown34 used the clavicular head of the sternocleidomastoid as an anterior sling across the SC joint augmented with pins. Armstrong and Dias5 have modified the use of the sternocleidomastoid by using only a slip of the sternal head and passing it through a medial clavicle bone tunnel. The graft is sutured to itself to recreate the anterior SC ligament without exposure of the first rib. 
Thomas et al.217 reported a safe surgical technique for stabilization of the SC joint with the use of suture material. Their technique involved tying the suture material on the superficial aspects of the medial clavicle and manubrium. This avoids the exposure of the first rib and avoids drilling through the inner cortex of the clavicle and manubrium. Abiddin et al.1 has described a similar technique with the use of suture anchors in the manubrium and drill holes in the clavicle. In 2010, Rotini et al.193 described using a hybrid fixation technique for a traumatic anterior SC joint dislocation. Suture anchors are first placed within the manubrium; transosseous sutures are then passed through the medial end of the clavicle and secured through holes of a “rotator cuff miniplate” that is stabilized on the medial clavicle. 
While smooth pin and wire fixation is now taboo, fixation of the SC joint with other metal implants is still considered a valid option, although the implants do require removal. Franck et al.81 reported an alternative therapy for traumatic SC instability using a plate for stabilization. A Balser plate was contoured to match the shape of the clavicle and the hook of the plate was used for sternal fixation. A retrosternal hook position was used for seven anterior dislocations and an intrasternal position was used for three posterior dislocations. For each patient the plate was attached to the clavicle with screws and the torn ligaments were repaired. All plates were removed by 3 months. At 1-year follow-up 9 of 10 patients had excellent results with no cases of redislocation. One patient developed a postoperative seroma that required surgical drainage, and one patient developed arthrosis. Using a similar technique, Hecox and Wood104 described the use of a “ledge plate” for an unstable posterior SC joint dislocation. A standard 3.5-mm LC/DCP plate is contoured and fixed to the medial clavicle in a position that allows two holes of the plate to serve as a “ledge” over the manubrium. 
Two other plate techniques have recently been described. Shuler and Pappas204 used two, 3.5-mm locking reconstruction plates placed at 90 degrees across the SC joint for an unstable posterior dislocation. Pensey and Eglseder175 described the use of combined suture anchor fixation and a long pelvic reconstruction plate that was contoured to the ipsilateral clavicle, manubrium, and contralateral clavicle for a posterior SC joint fracture–dislocation. No screws were placed in the manubrium, and fixation was achieved with three screws each in the right and left clavicle. 
In 1997, Brinker et al.31 described another technique of hardware fixation across the joint. The authors used two 75-mm cannulated screws to stabilize an unstable posterior dislocation of the SC joint. The screws were removed at 3 months, and at 10 months the patient had full range of motion without pain and returned to college level football. 
Interpositional arthroplasty techniques have also emerged in recent years. Battaglia et al.15 presented three cases of an Achilles tendon allograft and bone plug used to treat anterior instability in two patients and a medial clavicle fracture nonunion in one. The graft was fixed to a trough in the medial clavicle resection with screws, passed through bone tunnels in the manubrium and sutured upon itself. Meis et al.155 reported using an intramedullary transfer of the sternocleidomastoid as an interposition for degenerative SC joint pain after resection. 
Since 1982, various authors have recommended open reduction and internal fixation for acute injuries, as well as for chronic problems. In 1982, Pfister and associates176,177 recommended open reduction and repair of the ligaments over nonoperative treatment. In 1988, Fery and Sommelet79 reported 49 cases of SC joint dislocations. In these patients, if closed reduction was not successful, they performed open reduction. In symptomatic chronic unreduced dislocations, they either performed a myoplasty or excised the medial end of the clavicle if the articular surfaces were damaged. They were able to follow 55% of their patients, for an average of more than 6 years. They had 42% excellent results among the operative cases. Of those patients who were treated with closed reduction, 58% were satisfied. Ferrandez et al.75 reported 18 subluxations and dislocations of the SC joint. Seven had moderate sprains and 11 had dislocations. Of the three patients with a posterior dislocation, all had symptoms of dysphagia. All of the subluxations were treated nonoperatively with excellent results. The remaining 10 patients with dislocations were treated with surgery (i.e., open reduction with suture of the ligaments and K-wires placed across the clavicle and the sternum). The wires were removed 3 to 4 weeks following surgery. At 1- to 4-year follow-up, most of the operative cases had a slight deformity. In two patients, migration of the K-wires was noted but was without clinical significance. 
Eskola72,73 strongly urged operative repair of chronic dislocations of the SC joint. In 1989, they reported on 12 patients treated for painful SC joints. The average time from injury was 1.5 years, and the average follow-up after surgery was 4.7 years. In five patients, the SC joint was stabilized with a palmaris longus or plantaris tendon graft placed between the first rib and the manubrium; in four patients, the medial 2.5 cm of the clavicle was resected without any type of stabilization; and in three patients, the clavicle was fixed to the first rib with a fascia lata graft. They reported good results in four patients, three treated with tendon grafts and one with a fascia lata graft. They had four fair results and four poor results in those patients who had only resection of the medial clavicle. There was little discussion of the patients’ preoperative symptoms, work habits, or range of motion, or the degree of joint reduction following the surgery. In 1990, Tricoire et al.220 reported six retrosternal dislocations of the medial end of the clavicle. They recommended reduction of these injuries to avoid the possible complications arising from protrusion of the clavicle into the mediastinum. SC capsulorrhaphy was performed in two patients and a subclavius tenodesis was used in the remaining four patients. All joints were temporarily stabilized with SC pins for 6 weeks. Results were satisfactory in all cases at a mean follow-up of 27 months. 
Two recent systematic reviews of the available literature have been performed in 2011 to determine the ideal reconstruction technique for symptomatic, chronic anterior and irreducible or recurrent posterior SCJ dislocations.90,218 The only available articles in the literature were Level IV retrospective case series and two biomechanical studies. In cases of failed closed reduction, the option for open reduction is always available, and the data have shown that its effectiveness is not negatively affected by the failed reduction attempt. If an open reduction is necessary there is evidence that repair of the joint capsule is sufficient surgical treatment; however, a tenodesis or ORIF are also effective and recommended treatments. In cases of chronic instability (anterior and posterior), reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstruction with local tissue and is supported not only in biomechanical, but also clinical studies. Perhaps one of the most important factors that affect the success of treatment is the duration of time elapsed after the injury. The functional outcomes for patients with acute dislocations are significantly better than for those with chronic dislocations; therefore, accurate diagnosis and prompt treatment as close to the time of injury is optimal. 

Resection of the Medial End of the Clavicle

McLaughlin,153 Breitner and Wirth,29 Pridie,181 Bateman,13,14 and Milch156 have all recommended excision of the medial clavicle when degenerative changes are noted in the joint. If the medial end of the clavicle is to be removed because of degenerative changes, the surgeon should be careful not to damage the costoclavicular ligament (Fig. 42-27). 
Figure 42-27
Resection of the right medial clavicle, retaining the costoclavicular ligament.
 
White structure within the depth of the wound represents hyaline cartilage covering the clavicular notch of the manubrium (patient’s head at top of image).
White structure within the depth of the wound represents hyaline cartilage covering the clavicular notch of the manubrium (patient’s head at top of image).
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Figure 42-27
Resection of the right medial clavicle, retaining the costoclavicular ligament.
White structure within the depth of the wound represents hyaline cartilage covering the clavicular notch of the manubrium (patient’s head at top of image).
White structure within the depth of the wound represents hyaline cartilage covering the clavicular notch of the manubrium (patient’s head at top of image).
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Recently, using the results of an anatomic study of 86 cadavers, Bisson et al.24 recommended a safe resection length that would result in no or minimal disruption of the costoclavicular ligament of 1 cm in men, and 0.9 cm in women. 

Arthrodesis

Arthrodesis was once reported185 in the treatment of a habitual dislocation of the SC joint. However, this procedure should not be done because it prevents the previously described normal elevation, depression, and rotation of the clavicle. The end result would be a severe restriction of shoulder movement (Fig. 42-28). 
Figure 42-28
The effect of an arthrodesis of the sternoclavicular joint on shoulder function.
 
A: As a result of a military gunshot wound to the left sternoclavicular joint, this patient had a massive bony union of the left medial clavicle to the sternum and the upper three ribs. B: Shoulder motion was limited to 90 degrees of flexion and abduction. C: Radiograph after resection of the bony mass and freeing up the medial clavicle. D: The motion of the left shoulder was essentially normal after the elimination of the sternoclavicular arthrodesis.
A: As a result of a military gunshot wound to the left sternoclavicular joint, this patient had a massive bony union of the left medial clavicle to the sternum and the upper three ribs. B: Shoulder motion was limited to 90 degrees of flexion and abduction. C: Radiograph after resection of the bony mass and freeing up the medial clavicle. D: The motion of the left shoulder was essentially normal after the elimination of the sternoclavicular arthrodesis.
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Figure 42-28
The effect of an arthrodesis of the sternoclavicular joint on shoulder function.
A: As a result of a military gunshot wound to the left sternoclavicular joint, this patient had a massive bony union of the left medial clavicle to the sternum and the upper three ribs. B: Shoulder motion was limited to 90 degrees of flexion and abduction. C: Radiograph after resection of the bony mass and freeing up the medial clavicle. D: The motion of the left shoulder was essentially normal after the elimination of the sternoclavicular arthrodesis.
A: As a result of a military gunshot wound to the left sternoclavicular joint, this patient had a massive bony union of the left medial clavicle to the sternum and the upper three ribs. B: Shoulder motion was limited to 90 degrees of flexion and abduction. C: Radiograph after resection of the bony mass and freeing up the medial clavicle. D: The motion of the left shoulder was essentially normal after the elimination of the sternoclavicular arthrodesis.
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Postoperative Care

In most situations, the shoulders are held back with a figure-of-eight bandage for 4 to 6 weeks. When K-wires or Steinmann pins are used, the patient should avoid vigorous activities until the pins are removed. The pins should be carefully monitored with radiographs until they are removed. 

Author’s Preferred Method of Treatment for Sternoclavicular Joint Injuries

 
 
Anterior Sternoclavicular Joint Injuries
 
Atraumatic Instability
 

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.

 
Figure 42-29
Treatment algorithm for traumatic posterior sternoclavicular joint dislocation.
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Subluxation
 

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.

 
Dislocation
 

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.

 
Posterior Sternoclavicular Joint Injuries
 
Subluxation
 

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.

 
Dislocation (Fig. 42-29)
 

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.

 
Table 42-2
Keys to Diagnosis of Posterior Sternoclavicular Dislocation
History of violent injury
Painful sternoclavicular joint
Difficulty in swallowing
Difficulty in breathing
Decreased range of motion of the upper extremity
Palpable step-off of the sternoclavicular joint
Positive “serendipity view”
Posterior displacement on computed tomography
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Closed Reduction
 

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.

 
Open Surgical Procedures
 
Acute Repair of Posterior Dislocation
 

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.

 
Figure 42-30
Initial elevation of periosteum and capsule (held in forceps) and exposure of the medial clavicle (clinical example of right posterior SC joint dislocation; patient’s head at left of image).
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Figure 42-31
Elevation and open reduction of the medial clavicle with clamp (right SC joint, viewed superiorly; patient’s head at bottom right of image).
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Figure 42-32
Grasping suture in the posterior capsule and intra-articular disc ligament.
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Figure 42-33
Drill holes through clavicle for the purpose of transosseous repair.
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Figure 42-34
Repair of the posterior capsule defect with interrupted suture.
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Figure 42-35
Completed repair after transosseous sutures secured.
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Acute Repair with Medial Clavicle Resection (Technique of Rockwood and Wirth)
 

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.

 
Figure 42-36
This postmenopausal, right-handed woman had a resection of the right medial clavicle because of a preoperative diagnosis of “possible tumor.”
 
The postoperative microscopic diagnosis was degenerative arthritis of the right medial clavicle. After surgery, the patient complained of pain and discomfort, marked prominence, and gross instability of the right medial clavicle.
The postoperative microscopic diagnosis was degenerative arthritis of the right medial clavicle. After surgery, the patient complained of pain and discomfort, marked prominence, and gross instability of the right medial clavicle.
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Figure 42-36
This postmenopausal, right-handed woman had a resection of the right medial clavicle because of a preoperative diagnosis of “possible tumor.”
The postoperative microscopic diagnosis was degenerative arthritis of the right medial clavicle. After surgery, the patient complained of pain and discomfort, marked prominence, and gross instability of the right medial clavicle.
The postoperative microscopic diagnosis was degenerative arthritis of the right medial clavicle. After surgery, the patient complained of pain and discomfort, marked prominence, and gross instability of the right medial clavicle.
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Figure 42-37
The proposed skin incision used for open reduction of a posterior sternoclavicular dislocation.
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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.

 
Figure 42-38
Subperiosteal exposure of the medial clavicle.
 
Note the posteriorly displaced medial end of the clavicle.
Note the posteriorly displaced medial end of the clavicle.
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Figure 42-38
Subperiosteal exposure of the medial clavicle.
Note the posteriorly displaced medial end of the clavicle.
Note the posteriorly displaced medial end of the clavicle.
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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.

 
Figure 42-39
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-39
Resection of the right medial clavicle and identification of the intra-articular ligament tagged with suture
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-40
The medullary canal of the medial clavicle is curetted in preparation for receiving the transferred intra-articular ligament.
Rockwood-ch042-image040.png
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Figure 42-41
Drill holes are placed in the superior cortex of the clavicle, approximately 1 cm lateral to the osteotomy site.
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Figure 42-42
The free ends of the suture are passed into the medullary canal and out the two holes in the superior cortex.
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Figure 42-43
Passage of the intra-articular disc ligament into the medullary canal.
 
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-43
Passage of the intra-articular disc ligament into the medullary canal.
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-44
The transferred ligament is secured into the medial clavicle by tying the sutures exiting from the superior cortex of the clavicle.
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Figure 42-45
Passage of sutures through the clavicle and sutures through the periosteal sleeve
 
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-45
Passage of sutures through the clavicle and sutures through the periosteal sleeve
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD).
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Figure 42-46
Closure of the periosteal sleeve around the medial clavicle and secure fixation of these structures to the costoclavicular ligament.
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Figure 42-47
Intraoperative photograph showing Dacron sutures around the reflected periosteal tube, the clavicle, and the residual underlying costoclavicular ligament and periosteum on the dorsal surface of the first rib.
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD.)
(Courtesy of Charles E. Rosipal, MD and R. Michael Gross, MD.)
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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.

 
Open Surgical Reconstruction with Graft (Figure-of-Eight Tendon Graft)
 

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).

 
Figure 42-48
Semitendinosus figure-of-eight reconstruction.
 
A: Drill holes are passed from anterior to posterior through the medial part of the clavicle and the manubrium. B: A free semitendinosus tendon graft is woven through the drill holes such that the tendon strands are parallel to each other posterior to the joint and cross each other anterior to the joint. C: The tendon ends are tied in a square knot and secured with suture. (Redrawn after Spencer EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg 2004;86 A(1):98–105.)
A: Drill holes are passed from anterior to posterior through the medial part of the clavicle and the manubrium. B: A free semitendinosus tendon graft is woven through the drill holes such that the tendon strands are parallel to each other posterior to the joint and cross each other anterior to the joint. C: The tendon ends are tied in a square knot and secured with suture. (Redrawn after Spencer EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg 2004;86 A(1):98–105.)
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Figure 42-48
Semitendinosus figure-of-eight reconstruction.
A: Drill holes are passed from anterior to posterior through the medial part of the clavicle and the manubrium. B: A free semitendinosus tendon graft is woven through the drill holes such that the tendon strands are parallel to each other posterior to the joint and cross each other anterior to the joint. C: The tendon ends are tied in a square knot and secured with suture. (Redrawn after Spencer EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg 2004;86 A(1):98–105.)
A: Drill holes are passed from anterior to posterior through the medial part of the clavicle and the manubrium. B: A free semitendinosus tendon graft is woven through the drill holes such that the tendon strands are parallel to each other posterior to the joint and cross each other anterior to the joint. C: The tendon ends are tied in a square knot and secured with suture. (Redrawn after Spencer EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg 2004;86 A(1):98–105.)
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Figure 42-49
Semitendinosus figure-of-eight reconstruction.
 
A: Reduction of the SC joint (B) passing the tendon graft through bone tunnels with suture passer. C: Tensioning of the graft. D: Completed figure-of-eight construct. (Courtesy Charles E. Rosipal, MD and T. Kevin O’Malley, MD.)
A: Reduction of the SC joint (B) passing the tendon graft through bone tunnels with suture passer. C: Tensioning of the graft. D: Completed figure-of-eight construct. (Courtesy Charles E. Rosipal, MD and T. Kevin O’Malley, MD.)
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Figure 42-49
Semitendinosus figure-of-eight reconstruction.
A: Reduction of the SC joint (B) passing the tendon graft through bone tunnels with suture passer. C: Tensioning of the graft. D: Completed figure-of-eight construct. (Courtesy Charles E. Rosipal, MD and T. Kevin O’Malley, MD.)
A: Reduction of the SC joint (B) passing the tendon graft through bone tunnels with suture passer. C: Tensioning of the graft. D: Completed figure-of-eight construct. (Courtesy Charles E. Rosipal, MD and T. Kevin O’Malley, MD.)
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Postreduction Care of Posterior Dislocations
 

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.

 
Pearls and Pitfalls
 

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.

 
Physeal Injuries of the Medial Clavicle
 

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).

 
Figure 42-50
 
A: A schematic of the healing process with a type II physeal injury of the medial clavicle. The medial clavicle splits out of the periosteal tube, leaving a small fragment (Thurston-Holland sign) behind. The costoclavicular ligament is intact to the inferior periosteal tube. B: Through remodeling from the retained epiphysis and the periosteal tube, the fracture heals. C: A radiograph at 8 days reveals that the right medial clavicle is displaced superiorly from the left clavicle. The inferior medial corner of the clavicle is still located in its normal position adjacent to the epiphysis. D: A radiograph at 6 weeks reveals new bone formation along the inferior periosteal tube. Note the thin epiphyseal plate of the normal left medial clavicle. E, F: Clinically, at 8 weeks the physeal injury has healed and the patient has a full range of motion. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
A: A schematic of the healing process with a type II physeal injury of the medial clavicle. The medial clavicle splits out of the periosteal tube, leaving a small fragment (Thurston-Holland sign) behind. The costoclavicular ligament is intact to the inferior periosteal tube. B: Through remodeling from the retained epiphysis and the periosteal tube, the fracture heals. C: A radiograph at 8 days reveals that the right medial clavicle is displaced superiorly from the left clavicle. The inferior medial corner of the clavicle is still located in its normal position adjacent to the epiphysis. D: A radiograph at 6 weeks reveals new bone formation along the inferior periosteal tube. Note the thin epiphyseal plate of the normal left medial clavicle. E, F: Clinically, at 8 weeks the physeal injury has healed and the patient has a full range of motion. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Figure 42-50
A: A schematic of the healing process with a type II physeal injury of the medial clavicle. The medial clavicle splits out of the periosteal tube, leaving a small fragment (Thurston-Holland sign) behind. The costoclavicular ligament is intact to the inferior periosteal tube. B: Through remodeling from the retained epiphysis and the periosteal tube, the fracture heals. C: A radiograph at 8 days reveals that the right medial clavicle is displaced superiorly from the left clavicle. The inferior medial corner of the clavicle is still located in its normal position adjacent to the epiphysis. D: A radiograph at 6 weeks reveals new bone formation along the inferior periosteal tube. Note the thin epiphyseal plate of the normal left medial clavicle. E, F: Clinically, at 8 weeks the physeal injury has healed and the patient has a full range of motion. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
A: A schematic of the healing process with a type II physeal injury of the medial clavicle. The medial clavicle splits out of the periosteal tube, leaving a small fragment (Thurston-Holland sign) behind. The costoclavicular ligament is intact to the inferior periosteal tube. B: Through remodeling from the retained epiphysis and the periosteal tube, the fracture heals. C: A radiograph at 8 days reveals that the right medial clavicle is displaced superiorly from the left clavicle. The inferior medial corner of the clavicle is still located in its normal position adjacent to the epiphysis. D: A radiograph at 6 weeks reveals new bone formation along the inferior periosteal tube. Note the thin epiphyseal plate of the normal left medial clavicle. E, F: Clinically, at 8 weeks the physeal injury has healed and the patient has a full range of motion. (From: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia, PA: WB Saunders, 1990, with permission.)
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Treatment of Combined SC Injuries
 

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.

Complications in Sternoclavicular Joint Injuries

Nonoperative Complications in Sternoclavicular Joint Injuries

About the only complications that occur with anterior dislocation of the SC joint are cosmetic bumps or late degenerative changes.237239 The serious complications that occur at the time of dislocation of the SC joint are primarily limited to the posterior injuries (Fig. 42-51). Many complications have been reported secondary to the retrosternal dislocation: right pulmonary artery laceration240; transected internal mammary artery and lacerated brachiocephalic vein51; pneumothorax and laceration of the superior vena cava172; tracheal stenosis and respiratory distress161,220; venous congestion in the neck; rupture of the esophagus with abscess and osteomyelitis of the clavicle27; pressure on the subclavian artery in an untreated patient110,164,211; late occlusion of the subclavian artery in an untreated patient211; obstruction of the subclavian vein caused by an unreduced type II Salter–Harris injury of the medial clavicular physis70; compression and thrombosis of the brachiocephalic vein122; myocardial conduction abnormalities220; compression of the right common carotid artery by a fracture-dislocation of the SC joint110; pseudoaneurysm of the right subclavian artery, brachial plexus compression152; hoarseness of the voice, onset of snoring, and voice changes from normal to falsetto with movement of the arm27,118,158,196,225; fatal tracheoesophageal fistula232; mediastinal compression115; and severe thoracic outlet syndrome with swelling and cyanosis of the upper extremity.85,112 
Figure 42-51
 
A: CT scan revealing a posterior fracture-dislocation of the sternoclavicular joint with significant soft tissue swelling and compromise of the hilar structures. B: Duplex ultrasound study revealing a large pseudoaneurysm of the right subclavian artery. Note the large neck of the pseudoaneurysm, which measured approximately 1 cm in diameter (arrow).
A: CT scan revealing a posterior fracture-dislocation of the sternoclavicular joint with significant soft tissue swelling and compromise of the hilar structures. B: Duplex ultrasound study revealing a large pseudoaneurysm of the right subclavian artery. Note the large neck of the pseudoaneurysm, which measured approximately 1 cm in diameter (arrow).
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Figure 42-51
A: CT scan revealing a posterior fracture-dislocation of the sternoclavicular joint with significant soft tissue swelling and compromise of the hilar structures. B: Duplex ultrasound study revealing a large pseudoaneurysm of the right subclavian artery. Note the large neck of the pseudoaneurysm, which measured approximately 1 cm in diameter (arrow).
A: CT scan revealing a posterior fracture-dislocation of the sternoclavicular joint with significant soft tissue swelling and compromise of the hilar structures. B: Duplex ultrasound study revealing a large pseudoaneurysm of the right subclavian artery. Note the large neck of the pseudoaneurysm, which measured approximately 1 cm in diameter (arrow).
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Worman and Leagus,240 in their excellent review of the complications associated with posterior dislocations of the SC joint, reported that 16 of 60 (26.7%) patients reviewed from the literature had suffered complications of the trachea, esophagus, or great vessels.96,118,178 

Complications Following Operative Procedures in Sternoclavicular Joint Injuries

The Use of Pins to Stabilize the Sternoclavicular Joint

There have been numerous reports of deaths and four near deaths from migrations of intact or broken K-wires or Steinmann pins into the heart, pulmonary artery, or aorta.21,48,80,83,89,94,113,116,120,125,126,134,138,163,171,197,206,222 Numerous other authors have reported complications from pin migration into the pulmonary artery,34,134,137 aorta,165 heart,66,114,194,198 subclavian artery,203 mediastinum,75,92,128,229 breast,91 and endopelvic region between the iliac vessels and the right colon.9 
In 1990, Lyons and Rockwood145 published data on the migration of pins from the SC joint in 21 patients. They reported that pins from the SC joint had migrated into the chest, heart, mediastinum, subclavian vein, and lung. They recommended that large, small, smooth, threaded, bent, or straight pins not be used for fixation of the SC joint because of their potential to migrate into vital structures and even cause death. Further, they recommended that anytime pins were used to manage any problems about the shoulder, that is, clavicle fractures or injuries to the AC joint, that the pins be monitored very closely with x-rays and that they should always be removed (Fig. 42-52). 
Figure 42-52
Migration of pins from the sternoclavicular joint.
 
A, B: Migration of Steinmann pin into the spinal canal. C: Migration of Steinmann pin into the mediastinum.
A, B: Migration of Steinmann pin into the spinal canal. C: Migration of Steinmann pin into the mediastinum.
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Figure 42-52
Migration of pins from the sternoclavicular joint.
A, B: Migration of Steinmann pin into the spinal canal. C: Migration of Steinmann pin into the mediastinum.
A, B: Migration of Steinmann pin into the spinal canal. C: Migration of Steinmann pin into the mediastinum.
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Residual Instability.
After reduction of a posterior dislocation, there may be some increased laxity which should normalize with time. A case report of anterior subluxation after closed reduction of a posterior dislocation noted that the residual anterior instability resolved with observation.198 Even with reconstructive procedures, the joint may remain subluxated or subjectively unstable with motion.170 This is particularly true of patients who were treated surgically for atraumatic instability. Excessive resection of the medial clavicle without successful stabilization can create a challenging instability of the residual medial clavicle for which few options exist (Fig. 42-53). In such cases total claviculectomy may be the only option.127 An islandized hemipectoralis muscle flap has also been suggested as a means for filling a large medial clavicular defect and may prove useful in these cases.201 
Figure 42-53
Excessive resection of the right medial clavicle resulting in residual instability of the medial clavicle with adduction.
Rockwood-ch042-image053.png
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The Sternoclavicular Joint Injuries—The Past, Present, and Future

Few surgeons have substantial experience with SC joint injuries as these injuries are rare. As a result, many injuries go unrecognized or are treated inappropriately. Only an occasional publication cites the SC joint and because of the rarity of the problem, it can almost be called the “forgotten joint.” It is one of the strongest and most stable joints and when it dislocates it is difficult to stabilize. It would be helpful if more surgeons report their management of this rare condition to improve the available literature regarding this injury. Despite the years of experience managing this injury, the ultimate stabilizing procedure for dislocations of the SC joint has yet to be published. 
Most surgeons treat anterior SC joint dislocations nonoperatively as patients typically function well despite some instability. The question is—why shouldn’t we be able to reduce and hold the SC joint in place until the ligaments are healed? Presently, it is accepted that these dislocations should not be stabilized with K- wires, Steinman pins, or similar devices. Simple pinning of the joint with or without repairing the ligaments usually results in pin migration to the chest, mediastinum, abdominal organs, or even to the spinal canal. Many deaths have been reported from intracardiac penetration of migrating pins. Recently the use of a combination clavicle plate with intrasternal hook has been reported, but long-term results are needed before this is a commonly accepted procedure. 
Management of posterior dislocations of the SC joint is a challenge. Certainly, we must recognize the condition in adults because the continued displacement of the clavicle can cause erosion into the great vessels and mediastinum and can produce severe complications. If the clavicle is removed from the mediastinum the question is what do you do next? Do you try to stabilize the joint with a plate or do you resect the medial 2 cm and stabilize the residual clavicle to the first rib to prevent anterior/superior and/or continued posterior displacement? 
While dislocations are a problem so are the patients with anterior/posterior spontaneous subluxation of the SC joint. Do you stabilize the joint, excise the medial clavicle or continue to observe the patient? So far, the literature reflects that this condition occurs in young people and the symptoms gradually disappear with aging. Again, if there were more publications on this complex problem then more orthopedists would understand it. 
So what can we look forward to in the diagnosis and treatment of traumatic and atraumatic conditions of the SC joint? Certainly the proliferation of techniques for surgical repair continues. New fixation techniques and new implants are showing efficacy in stabilizing the SC joint with acceptable functional outcomes. The reports of surgical repair must be taken with caution as these studies are rarely prospective or randomized and the concern for overly aggressive surgical treatment must be stated. An area of continued uncertainty remains the management of posterior physeal injuries in adolescents. The exact criteria for open treatment versus closed treatment remains controversial in these patients when they present with no major symptoms. It appears promising that in the future we will see an increase in publications that will educate orthopedic surgeons in the management of problems of the SC joint. 

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