Abstract
Sternoclavicular joint injuries include fractures, sprains, and dislocations. Although most fractures and sprains can be treated nonoperatively, a dislocated sternoclavicular joint should undergo an attempt at closed reduction with the patient under anesthesia. Successful reductions are treated with immobilization and later rehabilitation. Unsuccessfully reduced anterior dislocations could be left in place, and if scar tissue produces stability, need no further treatment. Unsuccessfully reduced posterior dislocations should undergo open reduction with repair of the damaged capsule and/or reconstruction using a tendon graft. Symptomatic chronic anterior dislocation and all chronic posterior dislocations should be treated with open reduction and reconstruction of the joint capsule. The figure-of-eight technique using tendon graft is popular and, in athletes, produces good outcomes with a reasonably high rate of return to play.
Keywords
dislocation, nonoperative treatment, reconstruction, sprain, sternoclavicular joint, surgical treatment
Indications for Surgery
Sternoclavicular joint injuries are rare, and indications for their surgery are also rare. Fractures of the medial end of the clavicle are usually not sports related, are the result of vehicular trauma, and rarely need surgery ( ). Generally, surgery is avoided in atraumatic subluxations of the sternoclavicular joint, because this disorder is generally found in patients with generalized ligamentous laxity and failures after surgery are common ( ).
An acute traumatic anterior or posterior dislocation of the sternoclavicular joint should undergo an attempt at closed reduction in the operating room. Open reduction with repair or reconstruction of the sternoclavicular joint capsule is indicated for irreducible posterior dislocations because a chronically dislocated clavicular head can erode into the mediastinal contents, causing late complications ( ).
For these reasons, a chronic posterior dislocation of the sternoclavicular joint is an indication for open reduction and reconstruction of the stabilizing ligaments. As with most type III acromioclavicular joint dislocations, most chronically displaced anterior dislocations stabilize with scarring and may be minimally symptomatic. Surgery can be entertained in those few patients in whom anterior instability remains symptomatic.
Nonoperative Treatment
Sternoclavicular Joint Sprain
The sternoclavicular joint, like the acromioclavicular joint, is subject to different severities of injury. Sprains of the sternoclavicular joint capsule may occur. The patient with such a sprain has tenderness and pain in extremes of motion but the joint is not dislocated. Sprains can be treated with nonsteroidal antiinflammatory drugs (NSAIDs), ice, and rest. A sling may be used for comfort. Decisions about return to play are based on the patient’s comfort and ability to do sport-specific tasks with comfort. Unlike with the acromioclavicular joint, injecting a sternoclavicular joint to reduce pain and return to play is not recommended.
Sternoclavicular Joint Dislocation
A dislocated sternoclavicular joint should undergo an attempt at closed reduction with the patient under general anesthesia. The patient is placed supine with a rolled towel under the spine. The chest is prepared, and an assistant provides longitudinal traction on the arm of the affected side. A towel clip is placed around the clavicle percutaneously and the clavicle is pulled laterally with pressure toward the operating room table for anterior dislocation, and pulled away toward the ceiling for posterior dislocation ( Fig. 17.1 ). The reduction registers as a large clunk or pop; it is not subtle. If the reduction is not clearly felt, one can assume the attempt was unsuccessful. Post reduction computed tomography (CT) can be used to ensure a successful reduction.
It is important to have a thoracic surgeon available when one is performing a closed reduction of a posterior sternoclavicular joint. There are cases in which the dislocated clavicle has been providing tamponade for an injured great vessel. Upon reduction of the clavicle head, life-threatening hemorrhage is possible. Closed reduction is successful in approximately one-third of patients and is more likely to be successful if performed within 10 days after injury ( ).
Once the dislocated clavicle head is reduced, a standard arm sling for anterior dislocations is applied, and a figure-of-eight brace or pillow sling is used to keep the scapula retracted for 6 weeks. After this time, physical therapy directed toward gradually restoring active motion is employed for 6 weeks; strengthening and sport-specific training can begin at 12 weeks, with return to sport when the patient’s shoulder is ready. It is important to note that there is little data in the literature regarding the treatment of athletes with this condition. One case report of a posterior dislocation in a National Football League (NFL) player allowed return to play after 5 weeks with no apparent complications ( ). In this report the literature was reviewed and summarized; most contact athletes with posterior sternoclavicular joint dislocations required open reduction and surgical repair or fixation ( ).
If the reduction of an anterior dislocation is lost, the clavicular head can be left dislocated, because chronic, stable, anterior dislocations may do well with nonoperative treatment ( ; ). Clinicians should employ the same program for recovery as described for a successful reduction. Surgery should be performed for a failed reduction of a posterior dislocation, for a chronic posterior dislocation, and for a chronic anterior dislocation with symptoms related to instability.
Surgical Treatment
Acute Injuries
If a closed reduction is unsuccessful and an open reduction is required, the torn ligamentous structures, if generally intact, can be repaired primarily. It is important to bring the posterior capsule back to the clavicle—typically using sutures passed through drill holes in the clavicle. Repairing the posterior capsule is of paramount importance because it is the primary restraint to posterior and anterior translation of the sternoclavicular joint ( ). Some writers have recommended using a figure-of-eight suture impregnated with para-aramid synthetic fiber (Kevlar, DuPont USA, Wilmington, DE); however the suture does not deform and could potentially cut through bone if the soft tissues do not heal ( ). Other writers report success using plate fixation ( ), or hook plate fixation ( ); hardware that spans across the joint would require removal, however, as there is a tremendous amount of motion across the sternoclavicular joint. If the soft tissues are inadequate for primary repair, graft reconstruction of the anterior and posterior capsule is typically employed using techniques described here.
Chronic Dislocations
A variety of different techniques are employed to reconstruct the unstable sternoclavicular joint. They include transferring capsule and disk material into the end of the resected clavicle ( ); using the subclavius tendon as described by ; using part of the sternocleidomastoid as local graft ( ); and a variety of subtle variations of the figure-of-eight technique with autograft or allograft. ∗ In a cadaveric biomechanical analysis, the mechanical properties of the figure-of-eight technique were found to be superior to those of the subclavius technique and the disk/capsule stabilization technique ( ). Interestingly, in this cadaver study, the subclavius was found to be of inadequate length in 25% of the specimens ( ). As a result of its better biomechanical properties, the figure-of-eight technique is likely the most popular, and it has been used in more case series in the literature than other techniques ( ; Kusnezov et al, 2015; ).
∗ ; Kusnezov et al, 2015; .
The Figure-of-Eight Graft for Sternoclavicular Joint Instability
The patient is placed prone on a flat operating room table, with a small rolled towel placed behind the spine to allow the shoulders to retract. The patient’s entire chest is prepared and draped. If a semitendinosus autograft is going to be used, the patient’s leg is prepared and draped as well. Generally, the semitendinosus is harvested first through a small incision medial to the tibial tubercle. The tendon is identified and a tendon stripper is used to harvest the tendon after release of any adhesions ( Fig. 17.2 ). Each end of the tendon is cleaned and sutured with #2 permanent suture.
After the bony landmarks of the clavicle, manubrium, sternal notch, and sternocleidomastoid are marked, a curved incision is made following Langer’s lines over the medial clavicle and sternoclavicular joint to the midline over the manubrium ( Fig. 17.3 ). The platysma layer is incised in the same plane and reflected superiorly and inferiorly. The capsule of the sternoclavicular joint is incised and opened by reflection of the superior flap superiorly and the inferior flap inferiorly. It is important to find and protect the sternocleidomastoid muscle. Next any scar tissue in the joint space is removed. A towel clamp is placed on the clavicle, and lateral traction is applied to reduce the joint ( Fig. 17.4 ). It is notable that a lot of force may be required for highly displaced posterior dislocations.
