Reduction of sternoclavicular dislocation

Fractures of the medial clavicle are often a result of a high energy mechanism and associated with a multisystem polytrauma.

Although various techniques for surgical fixation have been reported (eg, suture/wire loop, hook plate, periarticular plate, conventional plate, spanning plate), there is currently no standardized operative procedure for these very rare injuries, which are predominantly treated nonoperatively.

A detailed description of any of these techniques is outside the scope of the surgery reference.

An acute posterior sternoclavicular dislocation can be a life-threatening situation and an immediate closed reduction in the operating room should be undertaken as a potential life-saving procedure.

This 3D CT shows posterior sternoclavicular dislocation.

If a thoracic surgeon is available, he or she should be present from the very beginning of the procedure. Under general anaesthesia with the patient in a supine position, and a bolster between the shoulder blades, the arm is abducted and extended to allow the medial clavicle to reduce.

If this is unsuccessful, a sharp towel clip may be placed percutaneously on the medial end of the clavicle and a very careful reduction maneuver with an anteriorly directed force is attempted.

Once reduced, the sternoclavicular joint is usually stable.

Other dislocations of the medial sternoclavicular joint (eg, anterior, superior, inferior) are non-life-threatening. Although closed reduction maneuvers can be attempted, maintaining stable reduction is usually not possible. Thus, expectant management with reassurance is given with appropriate rehabilitation.

Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.

Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.

Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.

Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

The patient should sleep wearing the sling on his/her back or on the non-injured side.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.

It may be more comfortable sleeping in a sitting or semi reclined position.

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The phases of nonoperative treatment are thus:

• Temporary immobilization
• Passive/assisted range of motion
• Active range of motion
• Progressive resistance exercises

Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.

This is followed by gentle range of motion exercises.

Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.

After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:

• Straightening and flexion of the elbow
• Open and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion
• Movement of an open hand from side to side

• Squeezing the shoulder blades together, while shoulders remain relaxed

Pendular exercises can be started when pain starts to subside.

Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

Activated assisted range of motion exercises are started with:

• External rotation
• Internal rotation

• Flexion with arms on table
• Flexion with ball on wall

Sub-maximal isometric exercises with:

• Internal rotation
• External rotation (1)
• Abduction (2)
• Extension

Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.