Sternoclavicular joint dislocation

1. Sternoclavicular joint dislocation Jason Blackham, MD Clinical Assistant Professor Division of General InternalMedicine University of Iowa Sports Medicine Center

2. History • 17 yo high school quarterback was sacked during a game • Complained of • Right antero-inferior neck pain • Dyspnea • Dysphagia • Unremarkable PMH

4. Physical Exam • RR 20, HR 84 • Normal mentation and no resp distress • Neurological exam normal • Pain with palpation of right clavicle • Loss of fullness of proximal clavicle • No skin tenting

5. Physical Exam • Walked off the field • Postured with head tilted (R), arm at side in IR with elbow at 90 degrees flexion • Off field exam • Trachea midline, no stridor • Breath sounds normal, symmetric, resonant • No cardiac murmer or rub and symmetric pulses • Transported to ED

6. Differential Diagnosis • Shoulder dislocation • Proximal clavicular fracture • Sternoclavicular joint dislocation • Traumatic pneumothorax

9. AF C C BV T BV E BA R

16. Diagnosis • Posterior sternoclavicular joint dislocation with avulsion fracture

17. Closed Reduction

20. Treatment • Reduction under general anesthesia • 4 weeks immobilized in sling • 2 weeks of protected ROM, strengthening • Cornerback for 3 weeks • Returned to quarterback at 9 weeks

21. 40% MVC 21% Sports 39% Other Trauma ~3% of all shoulder girdle injuries > 90% anterior dislocations Epidemiology Clin Sports Med 2003;22:387-405 Phys Sports Med 1999;27(2):105-13

22. Mechanisms

23. Mechanisms of Posterior • Fall on shoulder with arm flexed and adducted • Lateral force to shoulder when shoulder rolled forward • Posterolateral force to shoulder while opposite shoulder on ground • Force to anteromedial clavicle Clin Sports Med 2003;22:387-405 Military Med 2004;169(2):134-6 Rockwood and Green’s Fractures in Adults. 1997

24. Complications of Anterior • SC joint arthritis • Cosmetic appearance • Persistent prominence • Chronic pain • Recurrent instability

25. Complications of Posterior • Pneumothorax • Compression or laceration • Trachea • Esophagus • Artery / Vein • SVC laceration • Brachial plexus injury • Thoracic outlet obstruction J Trauma 1998;44(2):381-3 Clin Sports Med 2003;22:371-85

26. Treatment of Anterior • Anterior Dislocation • Controversial • Majority unstable following reduction • Sling immobilization for 6 weeks • If continued symptoms, surgery

27. Treatment of Posterior • Recommendation is for closed reduction • <48 hrs to <7 days of injury • Sling or figure-of-eight • Single review article & case studies • good results • If unstable or complications, then open Clin Sports Med 2003;22:359-70 Clin Sports Med 2003;22:387-405 Can J Surgery 1986;29(2):104-6 J Trauma 1967;7(3):416-23

28. Return to Play • Sling or figure-eight harness for 4-6 weeks • Return when pain free motion • may require additional 4-8 weeks Military Med 2004;169(2):134-6 Phys Sports Med 1999;27(2):105-13

29. Operative Treatment • Claviculectomy • Resection of medial clavicle • Reconstruction of capsule or ligaments • Not pinning • Migration of transfixion pins

30. Operative Treatment • Capsule repair with tendon graft • Burrow’s procedure • Sublcavius tendon tenodesis • Fascia lata graft • Sternocleidomastoid muscle • Medial clavicle osteotomy

31. Outcome • Completed FB season without pain or instability • Pitched for high school baseball team

32. Summary • Posterior SC dislocations are rare • Potentially severe complications • Closed reduction is preferred • RTP after healing and ROM regained • generally 6-14 weeks