SternoclavicularSternoclavicular joint joint dislocationdislocation

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HistoryHistory17 17 yoyo high school quarterback was sacked high school quarterback was sacked during a gameduring a gameComplained ofComplained of

Right Right anteroantero--inferior neck paininferior neck painDyspneaDyspneaDysphagiaDysphagia

Unremarkable PMHUnremarkable PMH

Physical ExamPhysical ExamRR 20, HR 84RR 20, HR 84

Normal Normal mentationmentation and no and no respresp distressdistress

Neurological exam normalNeurological exam normal

Pain with palpation of right claviclePain with palpation of right clavicleLoss of fullness of proximal clavicleLoss of fullness of proximal clavicle

No skin tentingNo skin tenting

Physical ExamPhysical ExamWalked off the fieldWalked off the field

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

Off field examOff field examTrachea midline, no Trachea midline, no stridorstridorBreath sounds normal, symmetric, resonantBreath sounds normal, symmetric, resonantNo cardiac No cardiac murmermurmer or rub and symmetric or rub and symmetric pulsespulses

Transported to EDTransported to ED

Differential DiagnosisDifferential DiagnosisShoulder dislocationShoulder dislocation

Proximal Proximal clavicularclavicular fracturefracture

SternoclavicularSternoclavicular joint joint

dislocationdislocation

Traumatic Traumatic pneumothoraxpneumothorax

T

CCAF

R

BV BAE

BV

DiagnosisDiagnosisPosterior Posterior sternoclavicularsternoclavicular joint joint dislocation dislocation with with avulsion fractureavulsion fracture

Closed ReductionClosed Reduction

TreatmentTreatmentReduction under general anesthesiaReduction under general anesthesia

4 weeks immobilized in sling4 weeks immobilized in sling

2 weeks of protected ROM, strengthening2 weeks of protected ROM, strengthening

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 Trauma39% Other Trauma

~~3% of all shoulder 3% of all shoulder

girdle injuriesgirdle injuries

> 90% anterior > 90% anterior

dislocationsdislocations

ClinClin Sports Med 2003;22:387Sports Med 2003;22:387--405405Phys Sports Med 1999;27(2):105Phys Sports Med 1999;27(2):105--1313

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 rolled Lateral force to shoulder when shoulder rolled forwardforward

PosterolateralPosterolateral force to shoulder while force to shoulder while opposite shoulder on groundopposite shoulder on groundForce to Force to anteromedialanteromedial clavicleclavicle

ClinClin Sports Med 2003;22:387Sports Med 2003;22:387--405405Military Med 2004;169(2):134Military Med 2004;169(2):134--66Rockwood and GreenRockwood and Green’’s Fractures in Adults. 1997s Fractures in Adults. 1997

Complications of AnteriorComplications of Anterior

SC joint arthritisSC joint arthritisCosmetic Cosmetic appearanceappearance

Persistent Persistent prominenceprominence

Chronic painChronic painRecurrent Recurrent instabilityinstability

Complications of PosteriorComplications of Posterior

PneumothoraxPneumothoraxCompression or lacerationCompression or laceration

TracheaTracheaEsophagusEsophagusArtery / VeinArtery / Vein

SVC lacerationSVC lacerationBrachial plexus injuryBrachial plexus injuryThoracic outlet obstructionThoracic outlet obstruction

J Trauma 1998;44(2):381J Trauma 1998;44(2):381--33ClinClin Sports Med 2003;22:371Sports Med 2003;22:371--8585

Treatment of AnteriorTreatment of Anterior

Anterior DislocationAnterior DislocationControversialControversialMajority unstable Majority unstable following reductionfollowing reductionSling Sling immobilization for 6 immobilization for 6 weeks weeks If continued If continued symptoms, surgerysymptoms, surgery

Treatment of PosteriorTreatment of Posterior

Recommendation is for closed reductionRecommendation is for closed reduction

<48 hrs to <7 days of injury<48 hrs to <7 days of injury

Sling or figureSling or figure--ofof--eighteight

Single review article & case studiesSingle review article & case studies

good resultsgood resultsIf unstable or complications, then openIf unstable or complications, then open

ClinClin Sports Med 2003;22:359Sports Med 2003;22:359--7070ClinClin Sports Med 2003;22:387Sports Med 2003;22:387--405 405 Can J Surgery 1986;29(2):104Can J Surgery 1986;29(2):104--66J Trauma 1967;7(3):416J Trauma 1967;7(3):416--2323

Return to PlayReturn to Play

Sling or figureSling or figure--eight harness for 4eight harness for 4--6 6 weeksweeks

Return when pain free motionReturn when pain free motion

may require additional 4may require additional 4--8 weeks8 weeks

Military Med 2004;169(2):134Military Med 2004;169(2):134--66Phys Sports Med 1999;27(2):105Phys Sports Med 1999;27(2):105--1313

Operative TreatmentOperative Treatment

ClaviculectomyClaviculectomyResection of medial clavicleResection of medial clavicleReconstruction of capsule or ligamentsReconstruction of capsule or ligamentsNot pinningNot pinning

Migration of transfixion pinsMigration of transfixion pins

Operative TreatmentOperative Treatment

Capsule repair with tendon graftCapsule repair with tendon graftBurrowBurrow’’s procedures procedure

SublcaviusSublcavius tendon tendon tenodesistenodesis

Fascia Fascia latalata graftgraftSternocleidomastoidSternocleidomastoid musclemuscleMedial clavicle Medial clavicle osteotomyosteotomy

OutcomeOutcomeCompleted 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 regainedRTP after healing and ROM regainedgenerally 6generally 6--14 weeks14 weeks