Traumatic sternoclavicular joint dislocation - A case series and discussion of methods of management

VN Ravish; TS Channappa; G Bharath Raju; Manju Jayaram; CL Karan

doi:10.4103/jodp.jodp_35_22

CASE SERIES

Year : 2022 | Volume : 5 | Issue : 3 | Page : 190-194

Traumatic sternoclavicular joint dislocation - A case series and discussion of methods of management

VN Ravish, TS Channappa, G Bharath Raju, Manju Jayaram, CL Karan
Department of Orthopaedics, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Date of Submission	06-Apr-2022
Date of Decision	20-Apr-2022
Date of Acceptance	22-Apr-2022
Date of Web Publication	1-Sep-2022

Correspondence Address:
C L Karan
Department of Orthopaedics, Kempegowda Institute of Medical Sciences, Bengaluru - 560 004, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_35_22

Abstract

Traumatic sternoclavicular (SC) joint injuries account for <3% of all traumatic joint injuries. Instability of the SC joint (SCJ) is a difficult problem to treat and can present with gross limitations in activities. Prompt diagnosis and intervention are imperative in the management of these fracture dislocations. We present three cases of posttraumatic SCJ dislocation treated conservatively and two cases treated with open reduction and internal fixation with reconstruction plate and its functional outcome and discuss the various modes of management of these dislocations.

Keywords: Dislocation, sternoclavicular joint, traumatic joint injuries

How to cite this article:
Ravish V N, Channappa T S, Raju G B, Jayaram M, Karan C L. Traumatic sternoclavicular joint dislocation - A case series and discussion of methods of management. J Orthop Dis Traumatol 2022;5:190-4

How to cite this URL:
Ravish V N, Channappa T S, Raju G B, Jayaram M, Karan C L. Traumatic sternoclavicular joint dislocation - A case series and discussion of methods of management. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 6];5:190-4. Available from: https://jodt.org/text.asp?2022/5/3/190/355246

Introduction

Traumatic sternoclavicular (SC) joint injuries are uncommon and account for <3% of all traumatic joint injuries. The dislocations can be traumatic or atraumatic. Traumatic dislocations can be anterior or posterior depending on the displacement of the medial end of clavicle in relation to the margin of the sternum. Forces which retract and depress the clavicle cause dislocation anteriorly and posterior dislocation is either due to direct force on the medial end of the clavicle or to a force acting on the posterolateral aspect of the shoulder.^[1] Anterior dislocations are more common and the posterior dislocations are associated with severe intrathoracic injuries. They require accurate diagnosis and management to avoid complications.^[2]

Anterior SC joint (SCJ) dislocation is primarily treated conservatively with a high risk of persistent instability. Posterior dislocation is treated by closed or open reduction. Various operative procedures have been described to treat SCJ dislocations, which include resection of the medial end of the clavicle, fixation with sutures, stabilization with K-wires or plates, and reconstruction with allograft tendon or tenodesis.^[3] We present three cases of acute anterior dislocation of SCJ following trauma treated by open reduction and internal fixation with reconstruction plate.

Case Reports

Case 1

A 27-year-old male patient came with a history of fall from his vehicle complaining of pain in the right side of the chest during movements of the right shoulder. On examination, a bony swelling was noted in the medial end of the right clavicle. Chest X-ray suggested anterior dislocation of the right SCJ. Closed reduction was done by giving traction to the abducted shoulder and pressing on the medial end of the right clavicle. The reduction was satisfactory and the limb was immobilized for 4 weeks in a shoulder immobilizer. At the end of 4 weeks, the reduction was found to be stable and physiotherapy exercises were started.

Case 2

A 45-year-old male patient who works as a manual labor presented to our hospital 3 days after injury with a history of self-fall from about 8 feet height and sustained injury to the right shoulder and right side of the chest. The patient complained of pain in the right shoulder and chest and limitation to do activities of daily living. On examination, a swelling was noted in the medial end of the right clavicle [Figure 1]. There was local tenderness along with the tenderness of 2^nd, 3^rd, and 4^th ribs. There was restriction of movements at the right shoulder due to pain. Chest anteroposterior and sternal views showed anterior dislocation of the right SCJ [Figure 2],[Figure 3].

Figure 1: Clinical photograph (case 2)

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Figure 2: Preoperative radiograph showing dislocation of sternoclavicular joint (case 2)

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Figure 3: CT images showing dislocation (case 2). CT: Computed tomography

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Closed reduction was done which was noticed to be unstable and the patient was taken up for surgery 7 days after the initial injury. The patient was operated with open reduction and internal fixation with reconstruction plate. A curvilinear incision of about 10 cm is made over the right clavicle from the SCJ. The dislocation was reduced and fixed with a 12-hole reconstruction plate with 5 screws in the clavicle and 5 in the sternum [Figure 4],[Figure 5]. Care should be taken while inserting the screws to the sternum, and smallest screws are used so as to avoid injuring the retrosternal structures. The screws are positioned under direct visualization and confirmed by fluoroscopic guidance in anterior-posterior and sternal views. Intraoperatively, there was excellent stability of the fracture and restoration of the articular surface.

Figure 4: Intraoperative photograph showing reduction (case 2)

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Figure 5: Intraoperative fixation with reconstruction plate and screws (case 2)

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The shoulder was immobilized for 3 weeks in a shoulder immobilizer. The postoperative radiographs showed acceptable reduction with plate and screws in situ [Figure 6]. Physiotherapy exercises were started. The patient was followed up and at 3 months demonstrated good functional range of motion of right shoulder and returned to all previous activities. Implant removal was done after 1 year.

Figure 6: Postoperative AP and sternal views with plate and screws in situ (case 2). AP: Anterior-Posterior

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Case 3

A 55-year-old male patient who works as a manual labor presented with a history of self-fall from 1^st floor height and sustained injury to the right shoulder and left chest. On examination, a swelling was noted over the lateral end of right clavicle associated with local tenderness and crepitus and a swelling was noted in the medial end of left clavicle [Figure 7]. Anteroposterior and serendipity view of the chest showed anterior dislocation of the left SCJ with fracture of lateral end of the right clavicle. The patient underwent surgery for the right clavicle 3 days later. The patient was operated with open reduction and internal fixation with lateral clavicle Locking compression plate (LCP) to the right clavicle. Closed reduction was done for the right SC dislocation and the arm was immobilized. The patient complained of sudden onset of pain 10 days later and on examination, a swelling and deformity were noted in the left SCJ. The patient was noted to have a redislocation. The patient was taken up for surgical management with open reduction and internal fixation to the left sternoclavicular joint fixed. A 8 hole reconstruction plate with 4 screws to the manubrium and 3 screws to left clavicle was placed [Figure 8]. The reduction was satisfactory and articular surface was restored. The postoperative radiographs showed acceptable reduction [Figure 9]. Physiotherapy exercises were started for rehabilitation, and the patient was followed up. At the end of 3 months, the patient had returned to his activities of daily living.

Figure 7: Clinical photograph (case 3)

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Figure 8: Intraoperative fixation with reconstruction plate and screws (case 3)

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Figure 9: Postoperative AP, sternal, and serendipity views with plate and screws in situ (case 3). AP: Anterior-Posterior

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Discussion

The SCJ is a diarthrodial joint. It is an articulation of the upper limb girdle to the axial skeleton providing load bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The articular surface of the clavicle is much bigger than that of the sternum, which makes it inherently unstable due to its osseous geometry. The joint contains a well-developed and tough intra-articular fibrocartilaginous disc. The integrity of the SCJ comes from the surrounding ligaments, the costoclavicular (CCL), interclavicular (extrinsic), and capsular (intrinsic) ligaments.^[4]

Closed reduction

Acute anterior SCJ dislocations can be reduced by closed reduction method with sedation. In this method, the patient lies supine with a bolster placed between the shoulders. A downward pressure is applied on both the shoulders by an assistant, a gentle traction is applied with the upper limb in 90° of abduction, and the medial end of clavicle is pushed backward. Following the reduction, the arm is immobilized for 4–6 weeks. The advantage of this method is that it is easy to achieve. However, in most cases, the reduction is unstable and re-dislocation occurs.

According to Savastano and Stutz,^[1] the stability of the SCJ is not necessary to ensure the normal function of the involved limb, and residual prominence of the medial portion of the clavicle does not interfere with the function. The cosmesis is improved if closed reduction is successful.^[5] Eskola^[6] treated eight cases with closed reduction and reported re-dislocation in five cases and two of these cases were operated on with good results. Primary open reduction was done in four cases with good results.

Féry and Sommelet^[7] observed 49 SCJ dislocations, 40 of which were anterior treated by either closed reduction, operative treatment, or left untreated. They found out that unreduced dislocations accounted for most of the unsatisfactory results and operative treatment gave 66% of excellent results. Ferrandez et al.^[8] studied 14 anterior SCJ dislocations and proposed conservative management for subluxations and operative management in case of total dislocations.

In acute anterior SCJ dislocations, studies suggest that an initial closed reduction should be performed. The patient should be explained about the chances of re-dislocation and risk of persistent instability.

Operative treatment

In cases where the closed reduction is not possible or there is a symptomatic persistent instability, open reduction should be carried out. There are several procedures described in literature. A surgical strategy can be designed by dividing these into either tissue procedures or stabilization procedures. Tissue procedures include local ligaments and capsule, tendon transfers, or grafts. Stabilization can be to the first rib, the manubrium or both using soft-tissue tensioning, sutures, wires, or plates.

The variety of ligament reconstructive procedures has been described. They include reconstruction of either SC ligament, coracoclavicular (CC) ligament, or both. Different autografts have been proposed in literature. Spencer and Kuhn^[9] evaluated three different reconstruction techniques and found that a figure of 8 semitendinosus technique had superior biomechanical results compared to those of the intramedullary ligament reconstruction and subclavius tendon reconstruction techniques. This technique has been used in young adults with persistent instability and described as a viable alternative with good results.^[10],[11]

Sternocleidomastoid transfer has been used in many forms. It has been used with success to recreate the anterior SC or CC ligaments. Booth and Roper^[12] described a successful technique in 5 SCJ dislocations by transferring the sternal head around the first rib and clavicle and sutured back to itself. Brown.^[13] described a similar technique with clavicular head as the anterior sling and augmented with pins. They have been done in a small group of patients with favorable results.

Suture anchors have been a popular technique in the recent times, by avoiding the need for autografts. The technique involves placing a suture anchor in the manubrium and passing them through drill holes in the medial end of clavicle. Abiddin et al.^[14] performed this technique in eight cases and reported good results. Rotini et al.^[15] described a hybrid fixation technique in a young adult with traumatic anterior SCJ dislocation with good results.

Another option is the resection of medial end of clavicle. It was reported by Rockwood et al. that those with a ruptured CCL requiring reconstruction then excision of the medial clavicle were unsatisfactory.^[16] Cases of persistent instability following the resection have been reported.^[17]

K-wires have been used in the stabilization of SC dislocations, but several disadvantages have been reported. Chen et al.^[18] described a technique of tension band wiring and K-wire fixation with good results in eight patients. The complications are serious and can be life-threatening due to breakage or displacement into the mediastinum and injuring heart, lungs, or major vessels.^[19]

While fixation with pins and wires is not preferred, the use of metal implants is considered with excellent results. Franck et al.^[20] used a Balser plate in 6 cases with acute anterior SCJ dislocations and achieved good results. The plate is contoured medially to match the clavicle with a hook for sternal fixation. The disadvantage is the need for implant removal later.

In this case report, both the patients were middle-aged male who engaged in manual work; we used a reconstruction plate for fixation of the SCJ dislocation after open reduction, immobilized the shoulder for 4 weeks to allow the surrounding soft tissues to heal, and later started physiotherapy exercises to regain good functional outcome at 3-month follow-up. We found this technique of open reduction for a traumatic anterior SCJ dislocation to be simple and cost-effective with good functional outcomes.

Conclusion

Traumatic sternoclavicular joint dislocations are uncommon injuries. They require accurate diagnosis and management to avoid complications. A closed or open reduction of the dislocation can be carried out. Closed reduction is simple to carry out but has a high chance of redislocation, leading to persistent instability. There are various methods of open reduction described in literature. The surgeon should be familiar with the complex anatomy, and a plan of management can be made based on the occupational needs and affordability of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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