Open management of traumatic disorders of the sternoclavicular joint: Indications, techniques, and outcomes

Introduction

Sternoclavicular joint (SCJ) injuries parallel injuries to the acromioclavicular joint in that the severity often predicts the need for surgery. The SCJ can be sprained with no displacement of the joint. Symptoms from a sprain typically resolve in a few weeks. The SCJ can be subluxed; this injury occurs with more energy but often heals without residual symptoms. Alternatively, dislocations of the SCJ typically occur from higher energy injuries and can be displaced anteriorly or posteriorly. Finally, chronic dislocations may be encountered ( Table 29.1 ).

TABLE 29.1

Types of Sternoclavicular Injuries, Findings, and Treatment

Sternoclavicular Joint Injury	Findings	Treatment
Sprain	Tenderness at sternoclavicular joint; no displacement of joint on imaging	Symptomatic; symptoms resolve in a few weeks
Subluxation	Significantly more swelling, slight displacement of joint on imaging	Symptomatic; may require surgery if symptoms persist more than 3 months
Dislocation of clavicle head, anterior	Significant pain, swelling, inability to move arm; anterior displacement of clavicle on imaging	Closed reduction and immobilization; many chronic anterior dislocations will scar and become symptom free (similar to a grade III acromioclavicular separation)
Dislocation of clavicle head, posterior	Significant pain, swelling, inability to move arm; may have mediastinal compression symptoms (dyspnea, dysphagia, vascular compromise), posterior displacement of clavicle on imaging	Closed reduction; if it fails, open reduction and repair/reconstruction of ligaments Chronic posterior dislocation should undergo open reduction and reconstruction of ligaments

Surgical indications

Sprains and mild subluxations can be successfully treated nonoperatively. Acute dislocations should undergo attempts at closed reduction. This is typically done with the patient under general anesthesia and supine. Posterior SCJ dislocations are also associated with thoracic outlet syndrome, mediastinal compression, subclavian artery compression, innominate vein compression, and compression of the brachial plexus (also see Chapter 26 and Box 26.2 ). Case reports have described acute cardiovascular decompensation from a great vessel injury when a posteriorly dislocated clavicle head, which had been providing tamponade, was reduced. ^, In the largest series of posterior SCJ dislocations derived from a large database (N = 140), no vessel injuries and no mortality were noted. Nevertheless, while rare, vascular complications can be fatal. As such, it is recommended that a thoracic surgeon be available when reducing a posterior SCJ dislocation.

With anterior dislocations, if the reduction fails, the clavicle may be left dislocated and allowed to scar in place. Patients with chronically dislocated anterior dislocations may do well as long as there is no gross motion of the clavicle head (similar to a grade III acromioclavicular joint dislocation).

Acute posterior dislocations that cannot be reduced closed should undergo open reduction with repair or reconstruction of the ligaments. Chronic posterior dislocations should undergo open reduction with reconstruction of the ligaments as case reports exist of late erosion of the clavicle head into the great vessels or trachea and esophagus ^, (also see Chapter 26 and Fig. 26.10 ). Symptomatic anterior dislocations with pain and gross motion would be another indication for open reduction and ligament reconstruction ( Table 29.2 ).

TABLE 29.2

Grades of Recommendations for the Treatment of Traumatic Posterior Sternoclavicular Joint Dislocations (Grade III Injuries)

Modified from Kendal JK, Thomas K, Lo IKY, Bois AJ. Clinical outcomes and complications following surgical management of traumatic posterior sternoclavicular joint dislocations: a systematic review. JBJS Rev. 2018;6(11):e2.

Recommendation	Grade ^a
Advanced imaging such as CT or CT angiography should be completed to confirm the direction of dislocation and assess for associated injuries to the mediastinal structures.	C
Closed reduction with or without a sterile clamp used percutaneously should first be considered in acute cases (i.e., within 48 hours from the time of injury) and should be performed in the operating room in the event that open reduction and stabilization are required. The vascular or cardiothoracic surgical team should be notified and on standby prior to bringing the patient to the operating room.	C
When a closed reduction is considered successful, postreduction imaging (CT) should be obtained to confirm reduction of the joint and monitor reduction, especially in cases where symptoms return.	C
Figure-of-eight ligament reconstruction with tendon autograft or allograft is recommended for chronic cases of instability in adults and in select acute cases with significant ligament disruption beyond repair or augmentation using synthetic material.	C
Physeal-sparing primary ligamentous repair or augmentation is recommended in skeletally immature patients with an open medial clavicular physis in the acute setting. Physeal-sparing ligament reconstruction is recommended for chronic cases and in select acute cases with significant ligament disruption beyond repair or augmentation using synthetic material.	C
Medial clavicle resection with soft tissue repair or reconstruction remains an option in the setting of sternoclavicular joint instability combined with significant articular degeneration or osseous destruction of the medial clavicle (secondary to fracture) or in cases where an open reduction is not possible (e.g., chronically fixed or locked dislocations).	C
Open reduction and internal fixation with plate(s) and screws is associated with a high risk of a second surgical procedure for implant removal and is a relative contraindication, except in cases of comminuted fracture-dislocations.	C
The use of smooth or threaded pins, K-wires, or other wire-type constructs (e.g., cerclage) to stabilize the sternoclavicular joint is an absolute contraindication.	C

CT, Computed tomography.

a Grade A = good evidence (level I studies with consistent findings) for or against recommending intervention. Grade B = fair evidence (level II or III studies with consistent findings) for or against recommending intervention. Grade C = conflicting or poor-quality evidence (level IV or V studies) not allowing a recommendation for or against intervention. Grade I = insufficient evidence to make a recommendation.

Techniques

A variety of techniques have been described for treating SCJ instability. Although the use of hardware is concerning because the SCJ is extremely mobile and hardware failure with migration to vital structures has been reported, some authors report good outcomes using plate fixation and hook plate fixation. Patients treated with plate(s) and screws should be informed of the high risk of a second surgical procedure for implant removal. Others report treating chronic anterior instability with an osteotomy of the clavicle.

Soft tissue reconstructions have included the use of the subclavius tendon as described by Burrows (note that in approximately one-third of patients the tendon may be too small to use ), the sternocleidomastoid tendon, and a transfer of the intra-articular disk and capsule into the resected end of the clavicle as described by Rockwood (much like a Weaver Dunn procedure). Alternatively, a variety of methods using autograft or allograft tendons have been described. ^, ^,

The posterior capsule is the most important stabilizing structure of the SCJ; it prevents both anterior and posterior translation. The anterior capsule is important in preventing anterior translation. As such, surgical techniques that reconstruct the anterior and posterior capsule of the SCJ have better biomechanical properties and are more likely to be successful (see Table 29.2 ).

Figure-of-eight sternoclavicular joint reconstruction

This procedure is done under general anesthetic. Patients are positioned supine with a wide surgical preparation in the extremely rare case that a sternotomy would be required to access the great vessels ( Fig. 29.1 ).

A curvilinear incision following Langer’s lines is made over the clavicle, SCJ, and just beyond the mid portion of the manubrium ( Fig. 29.2 ). The platysma is incised in line with the skin incision and reflected superiorly and inferiorly. The joint and both heads of the sternocleidomastoid muscle are identified.

The anterior joint capsule is incised and reflected superiorly and inferiorly ( Fig. 29.3 ). The clavicle head is carefully dissected and reduced to an anatomic position ( Fig. 29.4 ). Chronic posterior dislocations often require extensive careful dissection, and there may be extensive scarring, which must be released to reduce the clavicle.

After the clavicle has been reduced, the approach to the posterior mediastinum is made. An incision is made above the sternal notch and careful dissection is carried out, staying immediately behind the manubrium. A large ribbon retractor is placed to protect the vital structures during drilling of the manubrium and during graft passage ( Fig. 29.5 ).