Most patients seek medical treatment because of initial pain and concern regarding the potential harm of the condition. In a review of 37 patients with spontaneous anterior subluxation of the sternoclavicular joint [11], subluxations were reproducible and painless in 29 patients. Eighty percent of the patients demonstrated evidence of generalized ligamentous laxity. Twenty-nine patients were treated nonsurgically with strengthening exercises and advancement to unrestricted activity as tolerated. Although many patients subsequently reported intermittent episodes, few reported discomfort, and most were able to participate successfully in athletics.

The most common reason for surgery was the failure of a previous attempt at reconstruction. Surgery is rarely indicated. Nonsurgical management, including patient education of the benign nature of the condition, is recommended [11]. For patients with continued symptoms in spite of physical therapy, sternoclavicular joint reconstruction with a figure-of-eight graft may be indicated. Short- and intermediate-term clinical results of this reconstruction [12] have shown promise. However, longer term studies are currently lacking regarding the durability of results. The surgical technique is described in the following section outlining anterior SC dislocation.

In a mild sprain , the ligaments of the sternoclavicular joint remain intact. The patient reports pain and tenderness with palpation over the joint. Swelling may be present, but no instability is noted. Swelling and pain become more pronounced as the ligaments are stretched, which results in subluxation of the joint. Pain is marked with motion of the ipsilateral extremity. Laxity of the joint may be apparent compared with the contralateral joint.

Severe pain and deformity accompany dislocations of the sternoclavicular joint. Surprisingly, clinical examination to determine the direction of the dislocation may be inconclusive because of swelling. In addition to swelling, compression of the vital structures posterior to the joint may occur with dislocation injuries. The orthopedic surgeon should keep this potential life-threatening complication in mind while performing the clinical evaluation.

Anterior sternoclavicular injuries may exhibit prominence of the medial clavicle. This prominence is more easily appreciated while the patient is in the supine position. Posterior dislocation is less common than anterior dislocation. Patients with posterior dislocation demonstrate a higher level of pain, and the corner of the sternum may be discerned as the medial clavicle is displaced posteriorly [7]. However, swelling may preclude an accurate clinical assessment of injury.

Patients with posterior displacement may report shortness of breath or difficulty breathing Because of compression of the trachea or pneumothorax. Similarly, compression of the esophagus may result in dysphagia. Compression of the posterior vascular structures can result in decreased circulation to the ipsilateral extremity or venous congestion in the extremity or neck. Tingling or numbness may be the predominant complaint with compression of the brachial plexus. Posterior sternoclavicular dislocation or associated injuries may render the patient medically unstable.

The utilization of ice and analgesics in the initial treatment of these injuries is advocated. Subluxations may be reduced by directing the shoulders posterior and medial. Support of the injury by utilization of a clavicle strap or sling and swath is typically useful. The patient is protected from injury using immobilization for 6 weeks after injury.

Closed reduction of anterior dislocation is the current treatment of choice although there is still some controversy regarding management [13, 14]. Closed reduction may be accomplished with sedation, local or general anesthesia. The patient is placed supine on a table with a 3 in. pad between the shoulders. Pressure is placed posteriorly on the medial clavicle. If the joint remains reduced, the patient is immobilized (figure-eight or velpeau type sling) for 6 weeks is utilized to allow healing.

Unfortunately, most anterior sternoclavicular dislocations are unstable after closed reduction, but if successful results in improved cosmesis. Anterior dislocations frequently will remain chronically unstable but generally do not deteriorate to debilitative symptoms [11, 15]. Good results have been shown with nonoperative treatment of asymptomatic anterior instability by physical therapy and activity modification. In rare instances, patients may develop painful crepitus with arm motion and pain that radiates into the neck, altering their ability to work and to participate in athletics [16, 17].

Although numerous methods of open reduction have been described [18–20], most injuries are asymptomatic. Surgical treatment remains controversial as indications and techniques continue to evolve. In 2004, Spencer and Kuhn [21] reported a biomechanical study investigating the strength of a reconstructed sternoclavicular joint utilizing a figure-of-eight semi-tendinosis graft which demonstrated superior biomechanical properties. Multiple clinical studies have demonstrated good results utilizing the technique [22] with minor technical changes incorporated since the initial report including utilization of suture anchors and allograft tissue. Sabatini et al. [12] reported the most recent results of this technique in ten patients with significant improvements in pain scores and ASES scores with a minimum of complications.

The exposure for this technique reported by Sabatini et al. [12] is similar to what has been previously described [23–25] (Fig. 9.5). Briefly, the patient was placed in a supine position and prepared and draped (left shoulder and anterior chest), with the assistance of a cardiothoracic surgeon; a slightly angled transverse incision was made from the medial aspect of the clavicle to the manubrium. This area was then dissected, and the platysma was incised and raised, followed by elevation of periosteum off of the clavicle. The SCJ was visualized and the capsule reflected superiorly and inferiorly, providing room for the reconstruction.

Typically, it is necessary to elevate the soft tissues surrounding the manubrium with removal of the intra-articular disk. Once the approach had been completed and adequate deep visualization of the manubrium and the clavicle was obtained, the allograft was prepared. Typically, a 4.5-mm 25-cm semitendinosus allograft was used with No. 2 polyethylene suture on each end. Four drill holes were placed by a 4.5-mm drill with a cannulated system, 2 in the manubrium and 2 in the distal clavicle.

After this, the graft was shuttled in the sequential fashion from the inferior manubrial drill hole to the inferior clavicle back to the superior manubrial drill hole back to the superior clavicle drill hole.27 With the graft tensioned, two 4.75-mm-diameter 15-mm-length PEEK tenodesis screws (Arthrex, Naples FL, USA) were then placed within the first (inferior manubrium) and fourth (superior clavicle) drill holes to secure the graft. After the placement of the tenodesis screws, two figure-of-eight stitches were placed with No. 2 polyethylene suture to secure the two sides of the graft to one another for additional support without the prominence of a knot of tied tendon. The suture knots were subsequently buried. The sternocleidomastoid, which was initially taken down, was then reapproximated with No. 1 Vicryl. The subcuticular layer was closed with 2-0 Vicryl (Ethicon, Somerville, NJ, USA), and then the skin with staples.

Postoperatively the patient is immobilized in a sling and allowed elbow and hand range of motion immediately postoperatively. Pendulum exercises are instituted within the first 2 weeks after surgery and passive range of motion exercises for the shoulder are continued through the sixth week after surgery. At this point, a gentle strengthening program is instituted and the sling may be discontinued. Activity restriction is typically enforced until 16 weeks after surgery and a return to sport may occur at 6 months postoperatively.

A careful history and physical examination of these injuries and a low threshold for the utilization of CT imaging is recommended. If evaluation reveals dyspnea, choking, or hoarseness, this indicates pressure on the mediastinum. Mediastinal involvement requires prompt consultation with a thoracic or cardiothoracic surgeon in the management of these individuals.