Educational video describing dislocation of the sternoclavicular joint – review.
The proximal (medial) clavicle physis is the last to close between 23-25 years of age. CT scan is the study of choice. Serendipity view x-ray is not frequently used: 40° cephalic tilt view.
Atraumatic ligamentous laxity
•Will give subluxation (treated conservatively)
Anterior dislocation of the sternoclavicular joint
•Patient will have an anterior bump
•The deformity is usually acceptable
•It is usually unstable with reduction yet asymptomatic
•Patients with anterior sternoclavicular joint dislocation usually do very well
•Some patients will progress to chronic instability which could be associated with pain and decreased activity.
•Nonoperative treatment – immobilization with a sling
oOften not successful
oAchieved by direct pressure over the medial end of the clavicle
oUse figure 8 sling and immobilize for 6 weeks
•Surgery for chronic anterior sternoclavicular dislocation
oSternoclavicular joint reconstruction & medial clavicle resection
oMost of the time a tendon graft from the palmaris longus tendon is used (use figure 8 technique)
Posterior dislocation of the sternoclavicular joint
•This condition is not common and is dangerous
•Dislocation may compress the trachea, esophagus and the great vessels
•May cause dyspnea, stridor, dysphagia or tachypnea
Rule out physeal injury
•Rule out proximal physeal injury of the clavicle in young patients
•Fracture is through the medial physis and the clavicle shaft may sublux or dislocate anteriorly or posteriorly, leaving the epiphysis attached to the sternum
oReduction is done under general anesthesia with abduction and extension of the shoulder
oHave thoracic surgeon back up
oTowel clip may be placed percutaneously on the medial end of the clavicle
oUsually stable after reduction
What if the proximal clavicle becomes unstable? Do soft tissue surgery stabilization. Some prefer to do resection of the medial clavicle but do not resect more than 1.5 cm in order to avoid injury to the costoclavicular ligament.
What if the posterior dislocation is late? Avoid closed reduction due to adhesions in the retrosternal area.
What if the patient is young? It is probably not a dislocation and is a medial clavicle physeal fracture especially if the patient is younger than 25 years old (it is probably Salter-Harris Type I or Type II fracture). If the clavicle is dislocated posterior you will need to reduce it.
What if a closed reduction cannot be done? If the patient is asymptomatic leave it alone and observe the patient, even if it is a posterior displaced physeal fracture. If the patient is symptomatic, do open reduction with thoracic surgeon backup.
•Anterior dislocation of the sternoclavicular – leave it alone
•Subluxation of the sternoclavicular joint is usually ligamentous laxity – leave it alone
•Posterior dislocation of the sternoclavicular joint is dangerous – get the dislocation out
oHave a backup thoracic surgeon present
oUsually the reduction is stable
oIf reduction turns out to be unstable, do soft tissue procedure for surgical stabilization (resect medial clavicle no more than 1.5 cm and avoid injury to the costoclavicular ligament).
•Posterior dislocation that is old – leave it alone
•Physeal injury in young patient that is posteriorly displaced
oDo closed reduction – leave it alone if closed reduction cannot be done and the patient is asymptomatic
oDo open reduction – if patient is symptomatic, do open reduction with thoracic surgeon backup
•Symptomatic patient – reduce the posterior dislocation – get it out!
•Asymptomatic patient – if dislocation is chronic and asymptomatic – leave it alone.
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