Sternoclavicular Sternoclavicular joint dislocationjoint dislocation

Jason Blackham, MDJason Blackham, MDClinical Assistant Professor Clinical Assistant Professor

Division of General InternalDivision of General Internal MedicineMedicine

University of Iowa Sports Medicine University of Iowa Sports Medicine CenterCenter

HistoryHistory 17 yo high school quarterback was 17 yo high school quarterback was

sacked during a gamesacked during a game Complained ofComplained of

Right antero-inferior neck painRight antero-inferior neck pain DyspneaDyspnea DysphagiaDysphagia

Unremarkable PMHUnremarkable PMH

Physical ExamPhysical Exam RR 20, HR 84RR 20, HR 84

Normal mentation and no resp Normal mentation and no resp

distressdistress

Neurological exam normalNeurological exam normal

Pain with palpation of right claviclePain with palpation of right clavicle Loss of fullness of proximal clavicleLoss of fullness of proximal clavicle No skin tentingNo skin tenting

Physical ExamPhysical Exam Walked off the fieldWalked off the field

Postured with head tilted (R), arm at side Postured with head tilted (R), arm at side in IR with elbow at 90 degrees flexionin IR with elbow at 90 degrees flexion

Off field examOff field exam Trachea midline, no stridorTrachea midline, no stridor Breath sounds normal, symmetric, Breath sounds normal, symmetric,

resonantresonant No cardiac murmer or rub and symmetric No cardiac murmer or rub and symmetric

pulsespulses Transported to EDTransported to ED

Differential Differential DiagnosisDiagnosis

Shoulder dislocationShoulder dislocation

Proximal clavicular Proximal clavicular

fracturefracture

Sternoclavicular joint Sternoclavicular joint

dislocationdislocation

Traumatic pneumothoraxTraumatic pneumothorax

T

CC

AF

R

BV BAE

BV

DiagnosisDiagnosis Posterior Posterior

sternoclavicular sternoclavicular joint dislocation joint dislocation with avulsion with avulsion fracturefracture

Closed ReductionClosed Reduction

TreatmentTreatment Reduction under general anesthesiaReduction under general anesthesia

4 weeks immobilized in sling4 weeks immobilized in sling

2 weeks of protected ROM, 2 weeks of protected ROM,

strengtheningstrengthening

Cornerback for 3 weeksCornerback for 3 weeks

Returned to quarterback at 9 weeksReturned to quarterback at 9 weeks

EpidemiologyEpidemiology

40% MVC40% MVC

21% Sports21% Sports

39% Other 39% Other

TraumaTrauma

~~3% of all 3% of all

shoulder girdle shoulder girdle

injuriesinjuries

> 90% anterior > 90% anterior

dislocationsdislocationsClin Sports Med 2003;22:387-405Clin Sports Med 2003;22:387-405Phys Sports Med 1999;27(2):105-13Phys Sports Med 1999;27(2):105-13

MechanismsMechanisms

Mechanisms of PosteriorMechanisms of Posterior

Fall on shoulder with arm flexed and Fall on shoulder with arm flexed and adductedadducted Lateral force to shoulder when shoulder Lateral force to shoulder when shoulder

rolled forwardrolled forward Posterolateral force to shoulder while Posterolateral force to shoulder while

opposite shoulder on groundopposite shoulder on ground Force to anteromedial clavicleForce to anteromedial clavicle

Clin Sports Med 2003;22:387-405Clin Sports Med 2003;22:387-405Military Med 2004;169(2):134-6Military Med 2004;169(2):134-6Rockwood and Green’s Fractures in Adults. 1997Rockwood and Green’s Fractures in Adults. 1997

Complications of Complications of AnteriorAnterior

SC joint arthritisSC joint arthritis Cosmetic Cosmetic

appearanceappearance Persistent Persistent

prominenceprominence Chronic painChronic pain Recurrent Recurrent

instabilityinstability

Complications of Complications of PosteriorPosterior

PneumothoraxPneumothorax Compression or lacerationCompression or laceration

TracheaTrachea EsophagusEsophagus Artery / VeinArtery / Vein

SVC lacerationSVC laceration Brachial plexus injuryBrachial plexus injury Thoracic outlet obstructionThoracic outlet obstruction

J Trauma 1998;44(2):381-3J Trauma 1998;44(2):381-3Clin Sports Med 2003;22:371-85Clin Sports Med 2003;22:371-85

Treatment of AnteriorTreatment of Anterior

Anterior DislocationAnterior Dislocation ControversialControversial Majority unstable Majority unstable

following reductionfollowing reduction Sling Sling

immobilization for immobilization for 6 weeks 6 weeks

If continued If continued symptoms, symptoms, surgerysurgery

Treatment of PosteriorTreatment of Posterior

Recommendation is for closed Recommendation is for closed reductionreduction <48 hrs to <7 days of injury<48 hrs to <7 days of injury

Sling or figure-of-eightSling or figure-of-eight Single review article & case studiesSingle review article & case studies

good resultsgood results If unstable or complications, then openIf unstable or complications, then open

Clin Sports Med 2003;22:359-70Clin Sports Med 2003;22:359-70Clin Sports Med 2003;22:387-405 Clin Sports Med 2003;22:387-405 Can J Surgery 1986;29(2):104-6Can J Surgery 1986;29(2):104-6J Trauma 1967;7(3):416-23J Trauma 1967;7(3):416-23

Return to PlayReturn to Play

Sling or figure-eight harness for Sling or figure-eight harness for

4-6 weeks4-6 weeks

Return when pain free motionReturn when pain free motion

may require additional 4-8 may require additional 4-8

weeksweeks

Military Med 2004;169(2):134-6Military Med 2004;169(2):134-6Phys Sports Med 1999;27(2):105-13Phys Sports Med 1999;27(2):105-13

Operative TreatmentOperative Treatment

ClaviculectomyClaviculectomy Resection of medial clavicleResection of medial clavicle Reconstruction of capsule or Reconstruction of capsule or

ligamentsligaments Not pinningNot pinning

Migration of transfixion pinsMigration of transfixion pins

Operative TreatmentOperative Treatment

Capsule repair with tendon graftCapsule repair with tendon graft Burrow’s procedureBurrow’s procedure

Sublcavius tendon tenodesisSublcavius tendon tenodesis Fascia lata graftFascia lata graft Sternocleidomastoid muscleSternocleidomastoid muscle Medial clavicle osteotomyMedial clavicle osteotomy

OutcomeOutcome Completed FB season without pain or Completed FB season without pain or

instabilityinstability

Pitched for high school baseball teamPitched for high school baseball team

SummarySummary Posterior SC dislocations are rarePosterior SC dislocations are rare

Potentially severe complicationsPotentially severe complications

Closed reduction is preferredClosed reduction is preferred

RTP after healing and ROM RTP after healing and ROM

regainedregained generally 6-14 weeksgenerally 6-14 weeks