Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

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Injuries of the Clavicle, Acromioclavicular Joint
and Sternoclavicular Joint

• Andrew H. Schmidt, M.D.
• T.J. McElroy
• Created March 2004 Revised January 2007

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Clavicle

• S-shaped bone
• Medial - sternoclavicular joint
• Lateral - acromioclavicular joint and
  coracoclavicular ligaments
• Muscle attachments
• Medial sternocleidomastoid
• Lateral Trapezius, pectoralis major

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AC Joint

• Diarthrodial joint between medial facet of
  acromion and the lateral (distal) clavicle.
• Contains intra-articular disk of variable size.
• Thin capsule stabilized by ligaments on all
  sides
• AC ligaments control horizontal (anteroposterior
  ) displacement
• Superior AC ligament most important

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Distal Clavicle

• Coracoclavicular ligaments
• Suspensory ligaments of the upper extremity
• Two components
• Trapezoid
• Conoid
• Stronger than AC ligaments
• Provide vertical stability to AC joint

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Mechanism of Injury

• Moderate or high-energy traumatic impacts to the
  shoulder
• Fall from height
• Motor vehicle accident
• Sports injury
• Blow to the point of the shoulder
• Rarely a direct injury to the clavicle

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Physical Examination

• Inspection
• Evaluate deformity and/or displacement
• Beware of rare inferior or posterior displacement
  of distal or medial ends of clavicle
• Compare to opposite side.

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Physical Examination

• Palpation
• Evaluate pain
• Look for instability with stress

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Physical Examination

• Neurovascular examination
• Evaluate upper extremity motor and sensation
• Measure shoulder range-of-motion

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Radiographic Evaluationof the Clavicle

• Anteroposterior View
• 30-degree Cephalic Tilt View

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Radiographic Evaluation of the Clavicle

• Quesana View
• 45-degree angle superiorly and a 45-degree angle
  inferiorly
• Provide better assessment of the extent of
  displacement

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Radiographic Evaluationof the AC Joint

• Zanca View
• AP view centered at AC joint with 10 degree
  cephalic tilt
• Less voltage than used for AP shoulder

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Stress Views of the Distal Clavicle AC Joint

• Rationale will demonstrate instability and
  differentiate grade III AC separations from
  partial Grade I-II injuries
• Performed by having patient hold 10 weight with
  injured arm
• Rarely used today, since most AC joint injuries
  treated the same, and management of distal
  clavicle fractures depends on initial
  displacement and location of fracture.

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Radiographic Evaluation of the Medial One Third

• X-ray Cephalic tilt view of 40 to 45 degrees
• CT scan usually indicated to best assess degree
  and direction of displacement

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Clavicle Fractures
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Classification ofClavicle Fractures

• Group I Middle third
• Most common (80 of clavicle fractures)
• Group II Distal third
• 10-15 of clavicle injuries
• Group III Medial third
• Least common (approx. 5)

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Treatment Options

• Nonoperative
• Sling
• Brace
• Surgical
• Plate Fixation
• Screw or Pin Fixation

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Nonoperative Treatment

• Standard of Care for most clavicle fractures.
• Continued questions about the need to wear a
  specialized brace.

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Simple Sling vs.Figure-of-8 Bandage

• Prospective randomized trial of 61 patients
• Simple sling
• Less discomfort
• Functional and cosmetic results identical
• Alignment of healed fractures unchanged from the
  initial displacement in both groups

Andersen et al., Acta Orthop Scand 58 71-4, 1987.
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Nonoperative Treatment

• It is difficult to reduce clavicle fractures by
  closed means.
• Most clavicle fractures unite rapidly despite
  displacement
• Significantly displaced mid-shaft and
  distal-third injuries have a higher incidence of
  nonunion.

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Nonoperative Treatment

• There is new evidence that the outcome of
  nonoperative management of displaced middle-third
  clavicle fractures is not as good as
  traditionally thought, with many patients having
  significant functional problems.

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Deficits following nonoperative treatment of
displaced midshaft clavicular fractures

• A patient-based outcome questionnaire and
  muscle-strength testing were used to evaluate 30
  patients after nonoperative care of a displaced
  midshaft fracture of the clavicle.
• At a minimum of twelve months (mean 55 mos),
  outcomes were measured with the Constant shoulder
  score and the DASH patient questionnaire. In
  addition, shoulder muscle-strength testing was
  performed with the Baltimore Therapeutic
  Equipment Work Simulator, with the uninjured arm
  serving as a control.

McKee et al. J Bone Joint Surg Am 200688-A35-40.
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Deficits following nonoperative treatment of
displaced midshaft clavicular fractures

• The strength of the injured shoulder was 81 for
  maximum flexion, 75 for endurance of flexion,
  82 for maximum abduction, 67 for endurance of
  abduction, 81 for maximum external rotation, 82
  for endurance of external rotation, 85 for
  maximum internal rotation, and 78 for endurance
  of internal rotation (p lt 0.05 for all).
• The mean Constant score was 71 points, and the
  mean DASH score was 24.6 points, indicating
  substantial residual disability.

McKee et al. J Bone Joint Surg Am 200688-A35-40.
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• Displaced midshaft clavicle fractures can cause
  significant, persistent disability, even if they
  heal uneventfully.

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Definite Indications for Surgical Treatment of
Clavicle Fractures

• 1) Open fractures
• 2) Associated neurovascular injury

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Relative Indications for Acute Treatment of
Clavicle Fractures

• 1) Widely displaced fractures
• 2) Multiple trauma
• 3) Displaced distal-third fractures

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Relative Indications for Acute Treatment of
Clavicle Fractures

• 4) Floating shoulder
• 5) Seizure disorder
• 6) Cosmetic deformity
• 7) Earlier return to work.

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Clavicular Displacement

• lt 5 mm shortening acceptable results at 5 years
  (Nordqvist et al, Acta Orthop Scand
  199768349-51.
• gt 20 mm shortening associated with increased risk
  of nonunion and poor functional outcome at 3
  years (Hill et al, JBJS 199779B 537-9)

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Plate Fixation

• Traditional means of ORIF
• Plate applied superiorly or inferiorly
• Inferior plating associated with lower risk of
  hardware prominence
• Used for acute displaced fractures and nonunions.

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Intramedullary Fixation

• Large threaded cannulated screws
• Flexible elastic nails
• K-wires
• Associated with risk of migration
• Useful when plate fixation contra-indicated
• Bad skin
• Severe osteopenia
• Fixation less secure

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Complications of Clavicular Fractures and its
Treatment

• Nonunion
• Malunion
• Neurovascular Sequelae
• Post-Traumatic Arthritis

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Risk Factors for the Development of Clavicular
Nonunions

• Location of Fracture
• (outer third)
• Degree of Displacement
• (marked displacement)
• Primary Open Reduction

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Principles for the Treatment of Clavicular
Nonunions

• Restore length of clavicle
• May need intercalary bone graft
• Rigid internal fixation, usually with a plate
• Iliac crest bone graft
• Role of bone-graft substitutes not yet defined.

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Correction of symptomatic nonunion with IM screw
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Clavicular Malunion

• Symptoms of pain, fatigue, cosmetic deformity.
• Initially treat with strengthening, especially of
  scapulothoracic stabilizers.
• Consider osteotomy, internal fixation in rare
  cases in which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx
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Neurologic Sequelae

• Occasionally, fracture fragments or abundant
  callus can cause brachial plexus symptoms.
• Treatment is reduction and fixation of the
  fracture, or resection of callus with or without
  osteotomy and fixation for malunions.

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Osteotomy for Clavicular Malunion

• 15 patients with malunion after nonoperative
  treatment of a displaced midshaft clavicle
  fracture of the clavicle. Average clavicular
  shortening was 2.9 cm (range, 1.6 to 4.0 cm).
• Mean time from the injury to presentation was
  three years (range, 1 to 15 years).
• Outcome scores revealed major functional
  deficits.
• All patients underwent corrective osteotomy of
  the malunion through the original fracture line
  and internal fixation.

McKee MD, et al. J Bone Joint Surg Am
200385-A(5)790-7
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Osteotomy forClavicular Malunion

• At follow-up (mean 20 months postoperatively) the
  osteotomy site had united in 14 of 15 patients.
• All 14 patients satisfied with the result.
• Mean DASH score for all 15 patients improved from
  32 points preoperatively to 12 points at the time
  of follow-up (p 0.001).
• Mean shortening of the clavicle improved from 2.9
  to 0.4 cm (p 0.01).
• There was 1 nonunion, and 2 patients had elective
  removal of the plate.

McKee MD, et al. J Bone Joint Surg Am
200385-A(5)790-7
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Distal Third Clavicle Fractures
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Classification of Distal Clavicular
Fractures(Group II Clavicle Fractures)

• Type I-nondisplaced
• Between the CC and AC ligaments with ligament
  still intact

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Classification of Distal Clavicular Fractures

• Type II
• Typically displaced secondary to a fracture
  medial to the coracoclavicular ligaments, keeping
  the distal fragment reduced while allowing the
  medial fragmetn to displace superiorly
• Highest rate of nonunion (up to 30)
• Two Types

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Type IIA

• A. Conoid and trapezoid attached to distal
  fragment

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type IIB

• Type IIB Conoid torn, trapezoid attached

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Classification of Distal Clavicular Fractures

• Type IIIarticular fractures

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Treatment of Distal-Third (Type II) Clavicle
Fractures

• Nonoperative treatment
• 22 to 33 failed to unite
• 45 to 67 took more than three months to heal
• Operative treatment
• 100 of fractures healed within 6 to 10 weeks
  after surgery

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• Displaced Type II fractures of the distal
  clavicle are often treated more aggressively
  because of the increased risk of nonunion with
  nonoperative treatment

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Techniques for Acute Operative Treatment of
Distal Clavicle Fractures

• Kirschner wires inserted into the distal fragment
• Dorsal plate fixation
• CC screw fixation
• Tension-band wire or suture
• Transfer of coracoid process to the clavicle
• Clavicular Hook Plate

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• For most techniques of clavicular fixation,
  coracoclavicular fixation is also needed to
  prevent redisplacement of the medial clavicle.

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• The Hook Plate (Synthes USA, Paoli, PA) was
  specifically designed to avoid this problem of
  redisplacement.

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Hook Plate - Results

• Recent series of distal clavicle fractuers
  treated with the Hook Plate document high union
  rates of 88 - 100. Complications are rare but
  potentially significant, including new fracture
  about the implant, rotator cuff tear, and
  frequent subacromial impingement.

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Preferred Technique for Fixation of Acute Distal
ThirdClavicle Fractures

• Horizontal incision
• Manual reduction of fracture
• Dorsal tension band suture and reconstruction/augm
  entation of coracoclavicular ligaments.

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Indications for Late Surgery for Distal Clavicle
Fractures

• Pain
• Weakness
• Deformity

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Techniques for Late Surgery for Distal Clavicle
Fractures

• Excision of distal clavicle
• With or without reconstruction of
  coracoclavicular ligaments (Modified Weaver-Dunn
  procedure)
• Reduction and fixation of fracture

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Case Example
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Case Example
Medial Clavicle
Distal Clavicle
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Case Example
Fixation to Acromion
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Acromioclavicular Joint
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Radiographic Evaluation of the Acromioclavicular
Joint

• Proper exposure of the AC joint requires
  one-third to one-half the x-ray penetration of
  routine shoulder views
• Initial Views
• Anteroposterior view
• Zanca view (15 degree cephalic tilt)
• Other views
• Axillary demonstrates anterior-posterior
  displacement
• Stress views not generally relevant for
  treatment decisions.

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Classification for Acromioclavicular Joint
Injuries

• Initially classified by both Allman and Tossy et
  al. into three types (I, II, and III).
• Rockwood later added types IV, V, and VI, so
  that now six types are recognized.
• Classified depending on the degree and direction
  of displacement of the distal clavicle.

Allman FL Jr. Fractures and ligamentous injuries
of the clavicle and its articulation. JBJS 49A
774-784, 1967. Rockwood CA Jr and Young DC.
Disorders of the acromioclavicular joint, In
Rockwood CA, Matsen FA III The Shoulder,
Philadelphia, WB Saunders, 1990, pp. 413-476.
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Type I

• Sprain of acromioclavicular ligament
• AC joint intact
• Coracoclavicular ligaments intact
• Deltoid and trapezius muscles intact

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type II

• AC joint disrupted
• lt 50 Vertical displacement
• Sprain of the coracoclavicular ligaments
• CC ligaments intact
• Deltoid and trapezius muscles intact

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type III

• AC ligaments and CC ligaments all disrupted
• AC joint dislocated and the shoulder complex
  displaced inferiorly
• CC interspace greater than the normal
  shoulder(25-100)
• Deltoid and trapezius muscles usually detached
  from the distal clavicle

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type III Variants

• Pseudodislocation through an intact periosteal
  sleeve
• Physeal injury
• Coracoid process fracture

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Type IV

• AC and CC ligaments disrupted
• AC joint dislocated and clavicle displaced
  posteriorly into or through the trapezius muscle
• Deltoid and trapezius muscles detached from the
  distal clavicle

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type V

• AC ligaments disrupted
• CC ligaments disrupted
• AC joint dislocated and gross disparity between
  the clavicle and the scapula (100-300)
• Deltoid and trapezius muscles detached from the
  distal half of clavicle

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Type VI

• AC joint dislocated and clavicle displaced
  inferior to the acromion or the coracoid process
• AC and CC ligaments disrupted
• Deltoid and trapezius muscles detached from the
  distal clavicle

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Treatment Options for Types I - II
Acromioclavicular Joint Injuries

• Nonoperative Ice and protection until pain
  subsides (7 to 10 days).
• Return to sports as pain allows (1-2 weeks)
• No apparent benefit to the use of specialized
  braces.

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• Type II operative treatment
• Generally reserved only for the patient with
  chronic pain.
• Treatment is resection of the distal clavicle and
  reconstruction of the coracoclavicular ligaments.

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Treatment Options for Type III-VI
Acromioclavicular Joint Injuries

• Nonoperative treatment
• Closed reduction and application of a sling and
  harness to maintain reduction of the clavicle
• Short-term sling and early range of motion
• Operative treatment
• Primary AC joint fixation
• Primary CC ligament fixation
• Excision of the distal clavicle
• Dynamic muscle transfers

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• Type III Injuries Need for acute surgical
  treatment remains very controversial.
• Most surgeons recommend conservative treatment
  except in the throwing athlete or overhead
  worker.
• Repair generally avoided in contact athletes
  because of the risk of reinjury.

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Indications for Acute Surgical Treatment of
Acromioclavicular Injuries

• Type III injuries in highly active patients
• Type IV, V, and VI injuries

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Surgical Options for AC Joint Instability

• Coracoid process transfer to distal transfer
  (Dynamic muscle transfer)
• Primary AC joint fixation
• Primary Coracoclavicular Fixation
• Distal Clavicle Excision with CC ligament
  reconstruction.

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Weaver-Dunn Procedure

• The distal clavicle is excised.
• The CA ligament is transferred to the distal
  clavicle.
• The CC ligaments are repaired and/or augmented
  with a coracoclavicular screw or suture.
• Repair of deltotrapezial fascia

From Nuber GW and Bowen MK, JAAOS, 511, 1997
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Indications for Late Surgical Treatment of
Acromioclavicular Injuries

• Pain
• Weakness
• Deformity

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Techniques for Late Surgical Treatment of
Acromioclavicular Injuries

• Reduction of AC joint and repair of AC and CC
  ligaments
• Resection of distal clavicle and reconstruction
  of CC ligaments (Weaver-Dunn Procedure)

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Case Example
AP View
Zanca View
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Case Example
After Weaver-Dunn procedure
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Sternoclavicular Joint
From Wirth MA and Rockwood CA, JAAOS, 4268, 1996
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The Anatomy of the Sternoclavicular Joint

• Diarthrodial Joint
• Saddle shaped
• Poor congruence
• Intra-articular disc ligament. Divides SC joint
  into two separate joint spaces.
• Costoclavicular ligament- (rhomboid ligament)
  Short and strong and consist of an anterior and
  posterior fasciculus

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• Interclavicular ligament- Connects the
  superomedial aspects of each clavicle with the
  capsular ligaments and the upper sternum
• Capsular ligament- Covers the anterior and
  posterior aspects of the joint and represents
  thickenings of the joint capsule. The anterior
  portion of the ligament is heavier and stronger
  than the posterior portion.

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Epiphysis of the Medial Clavicle

• Medial Physis- Last of the ossification centers
  to appear in the body and the last epiphysis to
  close.
• Does not ossify until 18th to 20th year
• Does not unite with the clavicle until the 23rd
  to 25th year

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Radiographic Techniques for Assessing
Sternoclavicular Injuries

• 40-degree cephalic tilt view
• CT scan- Best technique for sternoclavicular
  joint problems

From Wirth MA and Rockwood CA, JAAOS, 4268, 1996
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Injuries Associated with Sternoclavicular Joint
Dislocations

• Mediastinal Compression
• Pneumothorax
• Laceration of the superior vena cava
• Tracheal erosion

From Wirth MA and Rockwood CA, JAAOS, 4268, 1996
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Treatment of Anterior Sternoclavicular
Dislocations

• Nonoperative treatment
• Analgesics and immobilization
• Functional outcome usually good
• Closed reduction
• Often not successful
• Direct pressure over the medial end of the
  clavicle may reduce the joint

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Treatment of Posterior Sternoclavicular
Dislocations

• Careful examination of the patient is extremely
  important to rule out vascular compromise.
• Consider CT to rule out mediastinal compression
• Attempt closed reduction - it is often successful
  and remains stable.

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Closed Reduction Techniques

• Abduction traction
• Adduction traction
• Towel Clip - anterior force applied to clavicle
  by percutaneously applied towel clip

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Operative Techniques

• Resection arthroplasty
• May result in instability of remaining clavicle
  unless stabilization is done.
• Suggest minimal resection of bone and fixation of
  medial clavicle to first rib.
• Sternoclavicular reconstruction with suture,
  tendon graft.

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