Chapter 21 Sternoclavicular Fracture Injury

 

R. Jay Lee Afamefuna M. Nduaguba

David A. Spiegel

 

 

DEFINITION

Sternoclavicular fracture-dislocation is an injury to the only bony articulation between the upper extremity and the axial skeleton.

Sternoclavicular fracture-dislocation is reported to be only 3% of upper extremity dislocations, 1% of all joint dislocations.5

Anterior fracture-dislocations are more common, but posterior fracture-dislocations can be associated with life-threatening complications and should be diagnosed promptly.

The majority of the existing literature concerns the adult population, and there are a limited number of studies, mostly case reports, concerning the management in children and adolescents.

 

 

ANATOMY

 

Sternoclavicular joint

 

 

The clavicle is the first bone to ossify at intrauterine week 5. However, the medial epiphysis does not ossify until 18 to 20 years of age and does not fuse until 22 to 25 years of age.22

 

 

 

FIG 1 • A. This preoperative CT that was obtained in the case of a left posterior sternoclavicular fracture-dislocation, note the compression of the branches originating from the aortic arch. B. The three-dimensional (3-D) reconstruction for the same patient. Note the proximity of the underlying neurovascular structures. C. This preoperative CT that was obtained in the case of a right posterior sternoclavicular fracture-dislocation, note the compression on right brachiocephalic vein.

 

 

The sternoclavicular joint is formed by the sternal end of the clavicle, the clavicular notch of the manubrium, and the cartilage of the first rib. Only a small portion of the medial end of the clavicle is covered by articular cartilage, anteriorly and inferiorly, and the majority of the articulation between the medial clavicle and the

manubrium is fibrous.19

 

The primary stabilizers to anterior and posterior translation are the posterior and anterior capsule. The posterior capsule provides the most restraint to both anterior and posterior translation, whereas the anterior

capsule provides additional restraint to anterior translation.18 There is minimal, if any, bony constraint to motion at this articulation.18

 

 

The costoclavicular and interclavicular ligaments do little to limit anterior and posterior translation.18 Mediastinal structures

 

Important mediastinal structures lie in close proximity to the sternoclavicular joint: the trachea, lungs, esophagus, brachiocephalic vein, subclavian artery, and brachial plexus (FIG 1).

 

 

 

PATHOGENESIS

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Sternoclavicular fracture-dislocations can result from direct or indirect force.

 

 

A direct anteromedial force usually results in the clavicle being pushed posteriorly into the sternum and into the mediastinum.

 

An indirect lateral force transmitted along the axis of the clavicle can cause either an anterior or posterior fracture-dislocation, depending on the position of the shoulder relative to the manubrium.12

 

These injuries are often physeal fractures in children rather than pure dislocations. However, these are difficult to distinguish on imaging studies, as the medial epiphysis does not ossify until age 18 to 20 years (FIG 2).

 

NATURAL HISTORY

 

Posteriorly displaced fractures or dislocations can result in life-threatening and other complications:

 

 

Obstruction of the trachea can result in acute airway compromise (FIG 3), and obstruction of the esophagus can result in dysphagia. If untreated, tracheoesophageal fistulas can result.20

 

Obstruction of the underlying brachiocephalic vein or subclavian artery can result in compromised perfusion. If untreated, erosion of the vessels can result.6

 

Impingement of underlying structures can lead to brachial plexopathy17 and thoracic outlet syndrome.7

 

Puncture of the underlying structures can cause pneumomediastinum,13 pneumothorax,20 bleeding, or death.14

PATIENT HISTORY AND PHYSICAL FINDINGS

 

A careful history and physical examination is crucial for identifying this injury. The patient should describe the mechanism of injury and should be asked to point to where the area of maximal discomfort is.

 

 

 

FIG 2 • A. The preoperative CT with three-dimensional (3-D) reconstruction suggests that this injury was a pure sternoclavicular dislocation. B. Intraoperatively, direct inspection demonstrated that it was in fact a physeal fracture of the clavicle.

 

 

 

FIG 3 • A,B. The preoperative CT of the same patient as in FIG 2 shows tracheal compression, which in the endoscopic view is reflected in a narrowed trachea.

 

 

As with all traumas in the acute setting, airway, breathing, and circulation (ABCs) should be assessed first, as posterior sternoclavicular fracture-dislocation can compromise any of them.

 

A careful history may elicit symptoms consistent with obstruction such as dyspnea or dysphagia.

 

Physical examination should include the neck, thorax, and shoulder girdles, with particular attention to the neurovascular examination.

 

In contrast to anterior fracture-dislocations, where pain and sternoclavicular prominence coincide, posterior fracture-dislocations present with pain contralateral to the “prominent” appearing joint.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Sternoclavicular injuries may be missed on standard radiographs. Serendipity views, where the beam centered on the manubrium is aimed 40-degree cephalad, may aid in the diagnosis.

 

Computed tomography (CT) is perhaps the best imaging modality to evaluate the sternoclavicular articulation. Strong consideration should be given to obtain the study with intravenous contrast when such injuries are suspected.

 

Magnetic resonance imaging (MRI) can also demonstrate the pathology well, can provide greater soft tissue detail, and also differentiate between a fracture and a true dislocation. However, obtaining an MRI may not be

practical or achievable in the acute setting. We do not routinely obtain MRI's in our practice.

 

 

DIFFERENTIAL DIAGNOSIS

Clavicular or sternal fracture Sepsis of the sternoclavicular joint

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Sprain of the sternoclavicular joint or surrounding musculature Atraumatic sternoclavicular instability in the setting of generalized laxity

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment may be warranted if fracture displacement or joint subluxation is minimal, and there is no compression of any neurovascular structures.

 

SURGICAL MANAGEMENT

 

Reduction is suggested for those posterior sternoclavicular fractures which are displaced and also those with a true dislocation.

 

Options for reduction include closed and open techniques. Indications for open reduction include fractures or dislocations unable to be reduced by closed means or the inability to maintain a reduction.

 

Given that routine postreduction axial imaging has not been routinely practiced, and the results of a single study in children in which CT scans following closed reduction demonstrated that resubluxation occurred in 3

out of 3 patients initially treated with closed reduction,21 we generally prefer open reduction and internal fixation.

 

Following reduction, especially if an open technique is required, some clinicians prefer to surgically stabilize the fracture or the articulation. Our personal preference has been to perform open reduction and fixation for all displaced posterior fractures and dislocations.

 

Preoperative Planning

 

A careful neurovascular assessment should be documented as a baseline reference.

 

The available literature suggests the importance of having cardiac or thoracic surgical consultants on “standby” during the procedure, in the highly unlikely event that a vascular injury is identified during the reduction.

 

The term standby has not been clearly defined, and it is likely that practice patterns vary between individuals and institutions.

 

We recognize that the likelihood of catastrophic bleeding during reduction or fixation is extremely low, based on just a few anecdotal cases, and that each individual and institution must define how to approach these cases.

 

In our practice, the cardiothoracic surgical service is consulted in advance, and we review the details of the case including the imaging.

 

The consulting team—including the cardiothoracic surgeon and the cardiac anesthesia attending, nursing, and perfusion teams that support the surgeon—is available at the time of the procedure and is generally in

the operating room or just outside when the reduction is performed.

 

If clinical circumstances allow, the patient is admitted and monitored closely and the case scheduled electively to allow for the necessary planning and coordination.

 

The patient has two large bore intravenous catheters placed; several units of blood and a sternotomy tray are kept available in the room.

 

The patient is prepped and draped to allow access for bypass if necessary, and the cardiopulmonary bypass machine is readied outside the room.

 

Thus, at our institution, a “team” of individuals is sequestered during a limited period of time around the open reduction, and this does require advanced planning. We have not had the occasion to perform a truly emergent open reduction and have thus far had the time to coordinate these efforts.

 

Positioning

 

The patient is supine on a radiolucent table.

 

 

A 3- to 4-inch bump is placed between shoulders. A Foley catheter may be placed for fluid monitoring.

 

We prefer to prep and drape the involved upper extremity as well as the entire chest, abdomen, and both groin regions to allow the cardiothoracic team easy access if emergent intervention is required (FIG 4).

 

Approach

 

A direct anterior approach is taken to the clavicle.

 

 

 

 

FIG 4 • Draping the patient with access for both orthopaedic and cardiothoracic intervention, with the involved upper extremity, as well as the entire chest, abdomen, and both groin regions in the field.

 

 

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TECHNIQUES

 

• Closed Reduction

   

  The patient is positioned supine, with the shoulder of the injured side near the edge of the table for accessibility.

   

  A bump, 3 or 4 inches thick, is placed between the shoulders. This serves to position the shoulders posterior to the manubrium to aid in reduction.

   

  The ipsilateral shoulder is abducted and extended.

   

   

  Lateral traction is then applied while an assistant places counter-traction to stabilize the patient. The shoulder is gradually brought back into extension.10

   

  An alternative method is caudal traction of the adducted shoulder while posterior pressure is applied to

  the shoulder.4

   

  Both of these reduction methods can be supplemented by manipulation of the clavicle with percutaneous insertion of a towel clip to aid with control of the clavicle.

• Open Reduction

Exposure

 

Mark out a transverse incision starting laterally over the medial most area of the clavicle that is palpable. Extend this medially across the sternoclavicular joint and onto the manubrium.

 

Alternatively, the incision can be made just superior to this to avoid placing the scar over a prominent area on the skin.

 

An incision of the skin is followed by cautery dissection of the subcutaneous tissue, down to the platysma.

 

Care should be taken during dissection, recognizing the underlying structures may be more anterior than normal, relative to the posteriorly displaced clavicle.

 

The platysma should be incised in line with skin incision, allowing identification of the periosteum overlying the clavicle.

Mobilizing the Clavicle

 

The clavicle is first identified laterally, outside the zone of injury, where the anatomy is more undisturbed and the periosteum incised (go from “known to unknown”).

 

The subperiosteal exposure is continued more medially where the soft tissue anatomy is more distorted, although the periosteum may have already been disrupted by the injury (TECH FIG 1).

Reduction

 

The lateral portion of the exposed clavicle is grasped with a non-pointed or blunt bone-holding clamp, and the medial end is extracted cautiously.

 

Typically, lateral translation either directly through the clamp or indirectly through manipulation of the ipsilateral arm is required initially to “clear” the epiphyseal fragment (or manubrium in the case of a dislocation) before anterior translation of the medial clavicle to complete the reduction (TECH FIG 2).

 

 

 

TECH FIG 1 • A direct anterior approach, with a subperiosteal exposure of the clavicle.

 

 

 

TECH FIG 2 • Lateral placement of the clamp and provisional suture passage in anticipation of placing a figure-of-eight stitch.

 

 

Direct inspection aids in determining whether the injury is a physeal fracture or a dislocation, which will later dictate method of fixation.

 

The adequacy of reduction is assessed.

 

This is easier in the case of a fracture, in which the exposed surface is brought in line with the surface of the epiphyseal fragment. In a dislocation, be mindful that the clavicle sits slightly superiorly and anteriorly relative to the manubrium.19

 

It is useful to compare the surface anatomy with the contralateral joint because this area has been prepped and is available for inspection.

Fixation

 

Many different techniques have been described for stabilizing the sternoclavicular joint, in the setting of both acute and chronic instability, in both pediatric and adult patients. These include suture repair,

stabilization with suture anchors,1 allograft reconstruction, and stabilization with a plate and screws.11 We prefer the use of a larger gauge nonabsorbable suture (no. 1 or 2).

 

During drilling and passage of sutures, carefully protect the underlying structures against posterior penetration by using a malleable retractor blunt instrument.

 

For a physeal fracture, the medial metaphysis of the clavicle may be sutured to the epiphyseal fragment in a figure-of-eight fashion. Unicortical drill holes are placed anteriorly into the

 

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metaphyseal and epiphyseal fragments to allow passage of suture (TECH FIG 3A,B).

 

 

 

 

TECH FIG 3 • A. In a sternoclavicular fracture, anterior unicortical drill holes are placed into the medial metaphysis for suture passage while an assistant holds the reduction with the clamp placed laterally. B. A figure-of-eight stitch placed through the metaphyseal and epiphyseal fragments. C. A figure-of-eight stitch placed through unicortical anterior drill holes in the medial clavicle (arrow at left) and manubrium in this case supplementing a suture from the metaphysis through the epiphysis.

 

 

For a pure dislocation, the end of the clavicle may be sutured to the manubrium using a figure-of-eight technique.

 

Two anterior drill holes are placed in the medial clavicle, and two unicortical drill holes are placed in anterior cortex of the manubrium (TECH FIG 3C).

 

This fixation is not rigid, and the goal is to prevent posterior translation during the healing process.

 

It may be desirable to slightly overreduce the fragment when tying down the suture as slight posterior settling can be seen.

Closure

The stability of the reconstruction is verified with gentle stress.

Irrigation of the surgical site is followed by reapproximation of the periosteal sleeve and the accessible capsule and ligaments.

Sequentially, the platysma, subcutaneous tissues, and skin are closed.

 

 

PEARLS AND PITFALLS

Diagnosis

• A careful history and physical examination is crucial for identifying this injury.

• On x-ray, a sternoclavicular fracture or dislocation may be missed or difficult to interpret. A CT with intravenous contrast better evaluates the articulation and compression of the underlying structures.

Preoperative ▪ Prior consultation and having cardiac or thoracic surgical consultants on standby

planning during the procedure may be beneficial in unlikely event that a vascular injury is identified during the reduction.

Exposure

• The local anatomy may be distorted in the zone of injury. Work lateral to medial,

from the known to the unknown.

Reduction

• Remember that the distal fragment will be medially translated in addition to being

posteriorly displaced, and that translation must be corrected before bringing the clavicle anteriorly in order to clear the manubrium and/or the epiphysis.

Fixation

• Heavy gauge nonabsorbable sutures through drill holes

 

 

 

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POSTOPERATIVE CARE

 

We generally admit the patients overnight for observation.

 

 

Our preference is to keep the patient in a shoulder immobilizer for 6 weeks, followed by a course of physical therapy. We allow our patients to return to all activities 3 months after surgery if they are asymptomatic.

 

Others have reported an immobilizer for 4 to 8 weeks, or a sling for 2 weeks, followed by physical therapy at 6 to 12 weeks, and typically 12 weeks of activity restriction.10, 21

 

OUTCOMES

Outcomes studies specific to the pediatric population are limited.

Early closed reduction of both anterior and posterior dislocations is successful in 50% to 88% of cases,9, 15, 16 and when closed reduction is successful, there has been favorable outcomes for both posterior and

 

anterior dislocations. In a systematic review, Glass et al9 reported no functional limitations in the patients who had successful closed reduction for posterior dislocation and limitations in only 15% of anterior dislocations at 45 months follow-up.

Open reduction is generally successful for (92% to 100%) both anterior and posterior dislocations.8, 9, 21

Waters et al21 reviewed 13 children treated with open reduction for posterior dislocations and reported full return to activities in all patients at 22 months follow-up.

 

 

COMPLICATIONS

Respiratory compromise

Hemorrhage which can be life threatening

Injury to mediastinal structures including the great vessels, esophagus, and trachea Loss of reduction

Persistent instability or malalignment

Intrathoracic migration if wires and pins are used2, 3

Sternoclavicular arthritis10

 

 

ACKNOWLEDGMENT

 

We thank Ammie M. White, MD, for her assistance in creating the radiographic images for this chapter.

 

REFERENCES

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