Sternoclavicular Fractures and Dislocations
- Anterior fracture/dislocations more common than posterior and often can be treated nonoperatively.
- Reduction of posterior SC fracture/dislocations requires thoracic surgery on standby.
- Missed diagnosis can end in severe complications
Description:Sternoclavicular (SC) joint dislocations were first described in 1824, with multiple subsequent case reports. Anterior and posterior sternoclavicular dislocations are described based on the position of the clavicle in relationship to the sternum. In pediatric patients, it is more likely a physeal fracture dislocation will occur as the medial clavicular physis appears between 12-19 years of age and fuses around 22-25 years of age. 80% of clavicle growth comes from the medial physis. Salter-Harris 1 and 2 fractures of the medial clavicular physis are most common.
Epidemiology:Most SC dislocations occur from higher energy motor vehicle accidents or sports trauma. Anterior fracture/dislocations are more common than posterior. They account for only 3% of shoulder girdle dislocations (glenohumeral and acromioclavicular being more common).
Clinical Findings:Anterior fracture/dislocations are associated with a prominent and palpable medial clavicle, which can be fixed or mobile. Patients with posterior fracture/dislocations typically have more pain than anterior dislocations and the injury is more likely to get overlooked due to subtle physical exam findings. Posterior dislocation can be associated with dysphagia and respiratory difficulties. Subtle findings such as ipsilateral upper extremity weakness, neck venous engorgement, or a diminished pulse can be seen. Posterior dislocations with severe displacement can present with a pneumothorax or shock from vascular compression.
Imaging Studies:X-rays are difficult to interpret due to penetration and overlying soft tissues. Hobbs, Serendipity, and Heinig views have been described to help in the diagnosis. Axial cut CT scans are considered the gold standard for diagnosis. Intravenous contrast may be administered for evaluation of large vessels and preoperative planning for posterior dislocations (measurement of vessel distance from clavicle can be completed).
Treatment:Given the late physeal closure and high remodeling rate, adolescent patients have been reported to remodel physeal fractures.
Anterior dislocations can be closed reduced, though many are unstable even after reduction. A figure-of-eight brace may be used to hold the reduction. The main stay of treatment for anterior dislocations is nonoperative. Operative interventions have been attempted with varying success. The age of the patient will help predict remodeling potential.
Posterior dislocations are treated urgently in the operating room with thoracic surgery on standby. Vascular injuries have been reported after reduction of the dislocation. In these circumstances, the clavicle injured the vessel then provided a tamponade effect until it was reduced. Closed reduction is typically attempted first if the diagnosis is made within 4-5 days of injury. If unsuccessful, the use of a sterile towel clamp to provide lateral and anterior direction to the medial clavicle can be used. Acute reduction can achieve stability and allow subsequent remodeling. Some authors advocate for acute open reduction and ligament stabilization for SC joint fracture/dislocations.
Open reduction and ligament reconstruction or medial clavicle excision with ligament reconstruction can be performed for chronic, symptomatic dislocations but have had variable success. There are multiple described techniques for this procedure. Free wire pinning should never be done due to hardware migration. Alternatively, medial clavicle resection may be needed for grossly deformed, chronically dislocated medial clavicle dislocations. Arthrodesis of the joint should never be considered due to loss of shoulder range of motion. Post-reduction treatment often includes figure-of-eight bracing for 4-6 weeks.
Complications:Acute complications include great vessel and/or trachea injury, dyspnea, hoarseness, dysphagia. Additionally, traumatic pneumothorax, pneumomediastinum or tracheal stenosis can also occur. A tracheoesophogeal fistula created by a missed posterior SC dislocation has been reported and resulted in death of the patient. Chronic dislocations have caused brachial plexopathies, exertional dyspnea, sepsis, SC joint arthritis, voice changes, and thoracic outlet syndrome. Potential hardware migration is a complication of operative treatment. The most common chronic complication is activity related pain.
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