Management of Traumatic Sternoclavicular Joint Injuries

Review Article Management of Traumatic Sternoclavicular Joint Injuries

Abstract Gordon I. Groh, MD Traumatic sternoclavicular joint injuries account for <3% of all Michael A. Wirth, MD traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classiﬁed according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. From the Blue Ridge Bone and Joint MRI is useful in differentiating physeal injury from sternoclavicular Clinic, Asheville, NC (Dr. Groh), and dislocation in patients aged <23 years. the Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX (Dr. Wirth).

Dr. Groh or an immediate family ternoclavicular joint injury has the medial end of the clavicle is the member has received royalties from Sbeen reported to account for only last of the long bones to appear and Encore Medical; is a member of a 3% of all shoulder girdle injuries.1 is the last epiphysis to close. It does speakers’ bureau or has made paid Some orthopaedic surgeons will not ossify until age 18 to 20 years. presentations on behalf of ArthroCare, DePuy, and DJO; never see or treat a sternoclavicular The epiphysis does not fuse with the serves as a paid consultant to or is dislocation during their entire ca- shaft of the clavicle until age 23 to an employee of ArthroCare, DePuy, reers. Although rare, sternoclavicular 25 years.2 The sternoclavicular joint Ascension Orthopedics, UPex, and DJO; has received research or dislocations are associated with sev- is freely mobile, and it functions in institutional support from Ascension eral life-threatening complications almost all planes, including the Orthopaedics and DePuy; and has because of the close proximity of the transverse (ie, in rotation). This stock or stock options held in UPex. small, diarthrodial joint is the only Dr. Wirth or an immediate family hilar structures. These structures in- member serves as a board member, clude the trachea, esophagus, and true articulation between the upper owner, officer, or committee member lungs, any of which may be damaged extremity and the axial skeleton. The of the American Shoulder and Elbow in traumatic injury. Systematic evalu- ligamentous supporting structure, Surgeons; has received royalties which comprises the intra-articular from DePuy; is a member of a ation and treatment is essential to speakers’ bureau or has made paid successful management of traumatic disk, costoclavicular, capsular, and presentations on behalf of and sternoclavicular joint injuries. interclavicular ligaments, yields a serves as a paid consultant to or is strength that can withstand the an employee of DePuy and Tornier; and has stock or stock options held forces directed at the joint and ac- in Tornier. Anatomy counts for a low dislocation rate (Figure 1, A). The costoclavicular J Am Acad Orthop Surg 2011;19:1-7 The clavicle is the first long bone to (rhomboid) ligament is the strongest Copyright 2011 by the American ossify and does so by intrauterine supporting ligament and is made up Academy of Orthopaedic Surgeons. week 5. However, the epiphysis at of two separate bands, which give it

January 2011, Vol 19, No 1 1 Management of Traumatic Sternoclavicular Joint Injuries

Figure 1 cation 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. Poste- rior 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 A, The articular disk ligament (held by forceps) attached to the right medial the medial clavicle is displaced poste- clavicle appears normal after removal of the capsular ligaments. B, Left 7 medial clavicle demonstrating the anterior sternoclavicular capsular ligament riorly. However, swelling may pre- (arrow) and the rhomboid appearance of the costoclavicular ligament clude an accurate clinical assessment (arrowhead). (Reproduced with permission from Wirth MA, Rockwood CA Jr: of injury. Patients with posterior dis- Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III, placement may report shortness of Wirth MA, Lippitt SB, Fehringer EV, Sperling JW, eds: The Shoulder,ed3. Philadelphia, PA, WB Saunders, 2009, pp 527-558.) breath or difficulty breathing because of compression of the trachea or pneumothorax. Similarly, compression of the esophagus may result a twisted appearance. These separate in dysphagia. Compression of the fibers provide critical resistance to Clinical Indications posterior vascular structures can re- both anterior and posterior rotation sult in decreased circulation to the forces of the medial clavicle3 (Figure Sprain and Subluxation ipsilateral extremity or venous con- 1, B). The capsular ligaments also In a mild sprain, the ligaments of the gestion in the extremity or neck. provide anteroposterior and rota- sternoclavicular joint remain intact. Tingling or numbness may be the tional stability.4 The patient reports pain and tender- predominant complaint with com- ness with palpation over the joint. pression of the brachial plexus. Pos- Swelling may be present, but no in- terior sternoclavicular dislocation or Mechanism of Injury stability is noted. Swelling and pain associated injuries may render the become more pronounced as the lig- patient medically unstable. Given the strong support provided to aments are stretched, which results the sternoclavicular joint by the sur- in subluxation of the joint. Pain is rounding ligaments, dislocation re- Radiographic Evaluation marked with motion of the ipsilat- quires tremendous force. Direct an- eral extremity. Laxity of the joint teromedial force to the joint typically In general, routine radiographic may be apparent compared with the results in the clavicle being pushed studies of the sternoclavicular joint contralateral joint. posteriorly behind the sternum into are difficult to interpret due to the mediastinum. Examples of this overlap of the medial clavicle, ribs, mechanism of injury include an ath- Dislocation sternum, and vertebrae. However, lete’s being jumped on while lying Severe pain and deformity accom- Wirth and Rockwood10 developed an supine or a kick delivered to the pany dislocations of the sternoclavic- oblique view of the sternoclavicular front of the medial clavicle. By com- ular joint. Surprisingly, clinical ex- joint, called the serendipity view, parison, indirect force, (eg, motor ve- amination to determine the direction that permits comparison of the in- hicle accidents) the most common of the dislocation may be inconclu- jured clavicle to the normal clavicle. mechanism of injury, may result in sive because of swelling. In addition The serendipity view is obtained by either anterior or posterior force to swelling, compression of the vital pointing the radiographic beam at a across the sternoclavicular joint.5,6 structures posterior to the joint may 40° angle tilted cephalically with the Motor vehicle accidents and athletic occur with dislocation injuries. The beam centered on the sternoclavicu- injuries account for >80% of injuries orthopaedic surgeon should keep lar joint. The technique is best suited to this joint.7-9 this potential life-threatening compli- for isolated sternoclavicular injuries.

2 Journal of the American Academy of Orthopaedic Surgeons Gordon I. Groh, MD, and Michael A. Wirth, MD

CT is more effective than radiogra- Figure 2 phy for evaluation of sternoclavicular injury because sprains, dislocations, and medial clavicle fractures are easily distinguishable (Figure 2). To facilitate an accurate diagnosis, the patient’s history and the mechanism of injury should be communi- cated to the radiologist, and a CT scan of the chest should be obtained to identify injuries to the structures that surround the sternoclavicular joint. The scan also should include both medial clavicles so that the in- jured joint can be compared with the contralateral joint. In children and young adults, MRI may also be used to distinguish a dis- Axial CT scan demonstrating a right posterior sternoclavicular dislocation location of the sternoclavicular joint (arrow). (Reproduced with permission from Rockwood CA Jr, Wirth MA: from a physeal injury. MRI displays Injuries to the sternoclavicular joint, in Rockwood CA Jr, Green DP, Bucholz RW, et al, eds: Rockwood and Green’s Fractures in Adults,ed4. soft tissue and allows assessment of Philadelphia, PA, Lippincott-Raven, 1996, vol 2, p 1439.) the trachea, esophagus, and great vessels as well as the integrity of the costoclavicular ligament and attach- controversy regarding management be- history and physical examination. ments of the intra-articular disk. cause good long-term results have been Dyspnea, choking, or hoarseness is in- However, CT is the preferred imag- reported with nonsurgical manage- dicative of pressure on the mediasti- 12 ing modality in the setting of acute ment. Closed reduction can be per- num. Mediastinal involvement requires injury because of its speed, availabil- formed with the patient under sedation prompt consultation with a thoracic or ity, and ability to delineate soft-tissue or local or general anesthesia. The pa- cardiothoracic surgeon. and bony injuries. tient is placed supine on a table with a 3-inch pad placed between the shoul- Closed Reduction ders. Pressure on the medial clavicle is Open techniques are typically not re- Management applied in a posterior direction. If the quired to reduce acute posterior ster- joint remains reduced, the ipsilateral noclavicular injuries. Furthermore, Anterior Strain and extremity is immobilized with a figure- once the reduction is achieved by Subluxation of-8 or Velpeau-type sling for 6 weeks closed reduction, it is typically sta- Ice and analgesics are used in the ini- to promote healing. ble.16,17 We recommend having a tho- tial treatment of anterior strain and Most anterior sternoclavicular dis- racic surgeon available during closed subluxation of the sternoclavicular locations are unstable after closed re- reductions in the event of mediasti- joint. Subluxation can be reduced by duction, but closed reduction is per- nal involvement. directing the shoulders posteriorly formed because, when successful, it The patient is placed supine on the and medially. A clavicle strap or a results in improved cosmesis. Nu- operating table while under sedation sling and swathe can then be used to merous methods of open reduction or general anesthesia. A 3- to 4-inch- 13-15 support the injury. The patient is have been described; however, the thick bolster is placed between the protected from further injury by im- authors do not recommend open re- scapulae to extend the shoulders. mobilizing the ipsilateral extremity duction for these unstable injuries The ipsilateral extremity is posi- for 6 weeks. because the potential complications tioned near the edge of the table, al- may outweigh the end results. lowing the arm to be extended and Anterior Dislocation abducted (Figure 3). Initially, gentle Closed reduction of anterior disloca- Posterior Dislocation traction is applied to the abducted tion is the current treatment of Management of these injuries requires extremity in line with the clavicle choice,11 although there is still some radiographic evaluation and a careful while countertraction is applied by

January 2011, Vol 19, No 1 3 Management of Traumatic Sternoclavicular Joint Injuries

Figure 3 Figure 4

Intraoperative photograph demonstrating closed reduction of a posterior sternoclavicular dislocation. A sandbag or bolster is placed between the shoulders, and lateral traction is applied to the arm against countertraction as the arm is brought into extension. Drawings demonstrating drill holes placed in the clavicle and manubrium. The semitendinosus an assistant, who steadies the pa- icle strap or sling for 4 weeks to pro- graft is weaved through the holes tient. Traction on the arm is slowly mote soft-tissue healing. in a ﬁgure-of-8 fashion and sutured into position, which provides increased while the arm is brought stability comparable to that of an into extension. If this reduction tech- Open Reduction intact sternoclavicular joint. nique is unsuccessful,18 traction may When closed reduction fails in pa- (Reproduced with permission from Spencer EE Jr, Kuhn JE: be applied to the arm in adduction tients with a closed physis, open re- Biomechanical analysis of while posterior pressure is applied to duction is indicated. Management is reconstructions for sternoclavicular the shoulder to lever the clavicle over required because unreduced poste- joint instability. J Bone Joint Surg the first rib. rior dislocations are associated with Am 2004;86[1]:98-105.) If the traction techniques are un- numerous complications, including successful, an assistant grasps the thoracic outlet syndrome, vascular medial clavicle and extends over the medial clavicle and pushes down in compromise, and erosion of the sternum. One goal of exposure is an effort to dislodge it from the ster- medial clavicle into vital posterior preservation of as much anterior num. In some cases, it may be impos- structures. These potentially life- capsular structure as possible. Fol- sible to grasp the medial clavicle be- threatening complications may arise lowing exposure, reduction can be cause of swelling. The skin is then acutely or from chronic posterior achieved with a combination of surgically prepped, and a sterile dislocations. Open reduction of the traction/countertraction and lifting towel clip is used to grasp the clavi- sternoclavicular joint always should anteriorly on the medial clavicle. The cle percutaneously. The clip should be performed with a thoracic sur- reduction will be stable if the ante- not penetrate the dense cortical bone geon assisting or immediately avail- rior capsule is undamaged by the ini- of the clavicle but should be used to able. tial injury or when enough of the an- grasp completely around the clavicle. Once the patient is placed under terior capsule has been preserved Applying traction through the af- general anesthesia, he or she is during exposure. Instability of the fected limb and lifting anteriorly on placed supine with a bolster between medial clavicle can be addressed by a the clavicle usually reduces the dislo- the scapulae. The involved extremity variety of surgical techniques.13-15 In cation. The reduction may be accom- is draped free to allow the intraoper- a biomechanical study, Spencer and panied by an audible snap and can ative use of traction. A folded sheet Kuhn4 described a figure-of-8 recon- be noted visually or by palpation. around the thorax can be used to struction using a semitendinosus The reduction should be confirmed provide countertraction. A 5- to graft that provided stability close to with intraoperative radiographs. We 7-cm incision is made that runs par- that of the intact sternoclavicular recommend use of a figure-of-8 clav- allel to the superior border of the joint (Figure 4).

4 Journal of the American Academy of Orthopaedic Surgeons Gordon I. Groh, MD, and Michael A. Wirth, MD

Figure 5

Drawings demonstrating resection of the medial clavicle. A, Subperiosteal exposure of the medial end of the clavicle. B, Excision of the medial clavicle is facilitated by drilling holes at the intended site of the osteotomy. Note preservation of the capsular ligament (arrow). C, The capsular ligament is secured to the medial clavicle with sutures exiting the superior cortex of the clavicle. Closure of the periosteal sleeve and ﬁxation of these structures to the costoclavicular ligaments is accomplished with multiple 1-mm Dacron sutures. (Reproduced with permission from Rockwood CA Jr, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt SB, Fehringer EV, Sperling JW, eds: The Shoulder, ed 3. Philadelphia, PA, WB Saunders, 2009, pp 527-558.)

We have achieved good to excel- through the medullary canal and ing. However, we do not recommend lent stability by resecting the medial through the drill holes to accept the su- that patients return to heavy labor clavicle.19 The medial clavicle is re- tures from the ligament transfer (Fig- activities when they have undergone sected and the residual clavicle se- ure 5, C). The sutures are then used to medial clavicle resection. cured anatomically to the periosteum secure the transferred ligament into the of the first rib with 1-mm Dacron clavicle while the clavicle is held in a re- tape. After the medial clavicle is ex- duced position. Physeal Injuries of the posed subperiosteally, the remnants The procedure is completed by pass- Medial Clavicle of the intra-articular or capsular liga- ing multiple 1-mm sutures around the The closed reduction maneuvers previ- ments are identified and preserved reflected periosteal tube, clavicle, and ously described are performed for an- (Figure 5, A). These structures are any residual costoclavicular ligament. terior or posterior injury (Figure 6). tagged with a 1-mm Dacron suture, These sutures restore the normal space Open reduction of the physeal injury is with the suture exiting the avulsed between the clavicle and first rib. If the seldom indicated, except for an irreduc- free end of the ligament. The medial repair is tenuous, it may be augmented ible posterior displacement with symp- clavicle is then resected while the by the reconstruction method described toms of compression of mediastinal posterior vascular structures are pro- by Spencer and Kuhn.4 Typically, the structures. After reduction, a figure-of-8 tected with a curved Crego or ribbon clavicular head of the sternocleido- splint is used for 4 weeks. retractor. The resection includes 1 mastoid is detached because it is a cm of clavicle inferiorly and curves superior deforming force on the me- laterally to include 2 cm (Figure 5, dial clavicle. Complications of Surgical B). Care must be taken not to dam- A figure-of-8 clavicle splint is used Management age the remaining costoclavicular for 4 weeks after open reduction or (rhomboid) ligament. resection. A sling is used for an addi- Complications of surgical manage- The medullary canal of the clavicle is tional 6 to 8 weeks. Patients should ment include postoperative infection, then drilled and curetted to receive the not elevate the arm ≥60° during this loss of reduction, and posttraumatic transferred disk and capsular ligaments. time and should use the extremity arthritis.8,20-22 The most serious com- Two superior holes are drilled in the only for hygiene. After 12 weeks, pa- plications arise from the use of pins clavicle 1 cm lateral to the resection. tients may gradually increase the use that cross the sternoclavicular joint. The free sutures are then shuttled of the arm for activities of daily liv- The torque applied to these pins can

January 2011, Vol 19, No 1 5 Management of Traumatic Sternoclavicular Joint Injuries

Figure 6 tula, stridor, and dysphagia. Careful analysis of reconstructions for physical examination is required to sternoclavicular joint instability. J Bone Joint Surg Am 2004;86(1):98-105. detect these complications in the pa- 5. Mehta JC, Sachdev A, Collins JJ: tient with a sternoclavicular joint in- Retrosternal dislocation of the clavicle. jury. Injury 1973;5(1):79-83. Radiography has largely been sup- 6. Hening CF: Retrosternal dislocation of planted by CT examination for view- the clavicle: Early recognition, xray diagnosis and management. J Bone Joint ing bony detail. In the nonacute Surg Am 1968;50:830. setting, MRI may be helpful in differ- 7. Nettles JL, Linscheid RL: entiating a physeal injury from a Sternoclavicular dislocations. J Trauma sternoclavicular dislocation in a pa- 1968;8(2):158-164. tient aged <23 years. Physeal injuries 8. Waskowitz WJ: Disruption of the Axial CT scan obtained 3 months can typically be managed with closed sternoclavicular joint: An analysis and after closed reduction of a posterior review. Am J Orthop 1961;3:176-179. left sternoclavicular dislocation in reduction alone; these injuries rarely an 18-year-old patient. New bone require open reduction except for ir- 9. Omer GE Jr: Osteotomy of the clavicle in surgical reduction of anterior formation (arrow) is readily reducible posterior dislocations in apparent within the periosteal sternoclavicular dislocation. J Trauma 1967;7(4):584-590. sleeve of the medial clavicle. the setting of mediastinal compression. 10. Wirth MA, Rockwood CA: Disorders of In contrast to anterior dislocations, the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt acute posterior dislocations are typi- SB, eds: The Shoulder, ed 4. Philadelphia, cause migration and fatigue failure cally amenable to closed reduction PA, Saunders, 2009, pp 527-560. of the hardware. Reports of migra- and are stable after reduction. Be- 11. Féry A, Sommelet J: Sternoclavicular tion of intact or broken pins and cause of the possibility of late onset dislocations: Observations on the wires into the heart, pulmonary ar- treatment and result of 49 cases of life-threatening complications, all [French]. Int Orthop 1988;12(3):187- tery, subclavian artery, innominate unreduced posterior dislocations 195. artery, and aorta are common in the should be surgically reduced with a 12. de Jong KP, Sukul DM: Anterior literature.20,23-37 No transfixing de- thoracic surgeon present. Resection sternoclavicular dislocation: A long-term vice, regardless of diameter, should follow-up study. J Orthop Trauma 1990; of the medial clavicle and reconstruc- 4(4):420-423. be used across the sternoclavicular tion of the costoclavicular ligaments joint. 13. Bankart AS: An operation for recurrent have yielded good results. Transfix- dislocation (subluxation) of the ing pins should never be used at the sternoclavicular joint. Br J Surg 1938;26: 320-323. sternoclavicular joint because of the Summary 14. Key JA, Conwell HE, eds: The risk of hardware failure and migra- Management of Fracture, Dislocations, Sternoclavicular injuries are rare but tion. and Sprains, ed 5. St. Louis, MO, CV can be associated with serious short- Mosby, 1951, pp 458-461. and long-term complications. Ante- 15. Burrows HJ: Tenodesis of subclavius in References the treatment of recurrent dislocation of rior injuries are typically unstable the sterno-clavicular joint. J Bone Joint even after reduction but are well tol- Surg Br 1951;33(2):240-243. Citation numbers printed in bold type erated by patients. Few patients may 16. Wirth MA, Rockwood CA: develop late degenerative changes af- indicate references published within Complications following repair of the the past 5 years. sternoclavicular joint, in Bigliani LU, ed: ter anterior dislocation; they can be Complications of the Shoulder. treated with medial clavicle excision 1. Cave EF, ed: Fractures and Other Baltimore, MD, Williams & Wilkins, and ligament reconstruction. Injuries. Chicago, IL, Year Book 1993, pp 139-153. Publishers, 1958. Posterior sternoclavicular disloca- 17. Groh GI, Wirth MA, Rockwood CA Jr: tions can be immediately associated 2. Webb PA, Suchey JM: Epiphyseal union Treatment of traumatic posterior of the anterior iliac crest and medial sternoclavicular joint dislocations. with pneumothorax, laceration or clavicle in a modern multiracial sample J Shoulder Elbow Surg 2010;Jun 23: occlusion of the great vessels, rup- of American males and females. Am J [Epub ahead of print]. 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6 Journal of the American Academy of Orthopaedic Surgeons Gordon I. Groh, MD, and Michael A. Wirth, MD

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