ORIGINAL ARTICLE
Chronic Posterior Sternoclavicular Joint Fracture Dislocations in Children and Young Adults: Results of Surgical Management Beverlie L. Ting, MD,* Donald S. Bae, MD,w and Peter M. Waters, MDw
Background: Posterior sternoclavicular joint (SCJ) fracture dislocations in children and young adults can be missed on initial examination or could fail closed treatment. We hypothesize that surgical interventions (open reduction and ligamentous reconstruction or medial clavicle resection depending on the clinical scenario) are safe treatment options in patients with symptomatic chronic posteriorly displaced SCJ injuries. Methods: A retrospective review was conducted of all patients younger than 25 years of age who underwent surgical treatment for chronic posteriorly displaced SCJ injuries at our institution from January 1, 1999 to December 31, 2011. Chronic injuries were defined as those presenting and/or treated at a minimum of 6 weeks from the causative injury. Indications for surgery included symptomatic posterior SCJ dislocations or posteriorly angulated physeal fractures that did not remodel and were refractory to nonoperative treatment. Subjective patient outcomes were obtained by mailed survey and telephone contact. Outcomes included a Disabilities of the Arm, Shoulder and Hand score, patient-rated levels of pain and/or disability, SCJ stability, and symptom improvement. Results: Seven patients met the inclusion criteria and all patients reported postoperative improvement or complete resolution of pain at last clinical follow-up (mean, 13 mo). At average 5.5 years follow-up, all respondents (n = 4) reported that their injury did not interfere with normal social activities or daily activities. No patients reported difficulty with employment; however, all patients reported mild difficulty with return to their level of athletic activity before SCJ fracture dislocation. Patients rated their level of pain or disability as 1.5 on a 10-point scale. Conclusions: Surgical intervention can reliably provide pain relief and facilitate successful return to activities including work in patients with symptomatic chronic posterior SCJ fracture dislocations. However, patients must be counseled that they may experience persistent symptoms with return to their previous level of sport performance.
From the *Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital; and wDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. None of the authors received financial support for this study. The authors declare no conflict of interest. Reprints: Peter M. Waters, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
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Level of Evidence: Therapeutic Study—Investigating the Results of Treatment: Level IV. Key Words: sternum, clavicle, sternoclavicular, fracture, dislocation, open reduction, reconstruction, resection, pediatric, chronic injury (J Pediatr Orthop 2014;34:542–547)
S
ternoclavicular joint (SCJ) fracture dislocations account for 6 weeks
from injury. Indications for surgery included symptomatic posterior SCJ dislocations or posteriorly angulated physeal fractures that did not remodel refractory to nonoperative treatment, including physical therapy and activity modification. During the study period, our institution evaluated 57 patients with posterior SCJ injuries. Seven patients with chronic posterior SCJ injuries met the inclusion criteria and were treated by 2 primary surgeons (P.M.W., D.S.B.) (Table 1). At the time of surgery, 5 patients had true posterior SCJ dislocations, whereas 2 patients had posterior fracture malunions. One patient had an associated acute glenohumeral dislocation closed reduced at the time of injury and another had an associated acute acromioclavicular joint injury treated nonoperatively. The average age at time of surgery was 17 years (range, 15 to 22 y), and the average clinical follow-up was 13 months (range, 17 d to 37 mo). Mechanisms of injury included fall during an athletic activity (n = 3), collision during rough play (n = 1), and motor vehicle accident (n = 1). In 2 cases, a patient with a history of acute lymphoblastic leukemia in remission and prior sternal biopsy and an athletic patient, there was no clear history of injury.
FIGURE 2. Three-dimensional computed tomography reconstructions demonstrating chronic posterior sternoclavicular joint dislocation with moderate mass effect on the left brachiocephalic vein.
FIGURE 3. Preoperative axial computed tomography images demonstrating chronic posterior dislocation of the sternoclavicular joint with medial clavicle dysplasia and bony overgrowth.
METHODS
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TABLE 1. Patient Data
Patient Number Sex
Age at Time of Surgery (y)
Duration of Symptoms (mo) Side
Mechanism
1
M
16
7
R
Atraumatic
2
M
15
19
R
Sports (unknown)
3
F
16
25
L
4
M
16
2
L
5
F
22
3
L
6
M
15
10
L
7
F
17
28
R
Symptoms Pain, dysphagia
Pain, numbness, hand swelling, radial pulse obliterates with abduction/ external rotation Sports (soccer) Pain Miscellaneous (play) MVA Sports (snowboarding) Atraumatic
Pain
Intraoperative Diagnosis Dislocation Dislocation Fracture dislocation Dislocation
Pain, dysphagia, hoarseness
Fracture dislocation
Pain
Dislocation
Pain
Dislocation
Procedure Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization and gracilis tendon allograft Reconstruction of sternoclavicular joint using sternocleidomastoid tendon Reconstruction of sternoclavicular joint using sternocleidomastoid tendon
MVA indicates motor vehicle accident.
Preoperatively, all patients complained of functionally limiting pain. Three of these patients had symptoms of mediastinal compression: trouble swallowing, hoarseness, intermittent hand swelling, and numbness of the injured extremity. Of the 5 patients with known trauma, only 2 were diagnosed at the time of injury: 1 patient underwent closed reduction before presentation to us in a chronic dislocated state and the other was initially treated conservatively because of lack of any apparent neurovascular injury but subsequently developed symptoms of neurovascular compromise. The average time from injury to operative intervention was 14 months (range, 2 to 26 mo). Four patients underwent resection of the medial clavicle and suture repair/reconstruction of the costoclavicular and sternoclavicular ligaments; one patient underwent medial clavicle resection and SCJ reconstruction with a gracilis allograft; and the remaining 2 patients underwent open joint reduction and SCJ reconstruction with sternocleidomastoid autograft.3,4,18–20
Surgical Technique A general surgeon was available throughout the surgery in a nearby operating room, given the potential risk of compromise to nearby mediastinal structures. Patients were positioned in a beach-chair position, and the injured SCJ, ipsilateral chest, and upper extremity were prepared and draped into the surgical field. An extensile transverse incision was made from the diaphysis of the medial clavicle across the SCJ.4,18–21 Soft tissue dissection was carried out through the skin and subcutaneous tissue, protecting the supraclavicular nerves. The platysma was incised. To expose the medial clavicle and SCJ, a sleeve of periosteum, including the sternocleidomastoid and pectoralis muscle attachments, was elevated
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anteriorly. With the posterior periosteum left intact, the displaced medial clavicle was followed lateral to medial and dissected carefully off the posterior sternum. This is a very delicate maneuver as the deformed medial clavicle is often adherent to the posterior sternum. Meticulous care was taken not to penetrate the protective posterior periosteal sleeve during dissection. If the medial clavicle could be elevated out of the mediastinal region atraumatically, it was brought up into the wound with gentle traction using a bone reduction clamp. The articular surface of the medial clavicle was inspected to assess if joint reduction and reconstruction would be feasible. In 2 of the dislocation patients, there was no articular damage and thus the medial clavicle was stably reduced into the SCJ. Drill holes were then made in the medial clavicle and in the sternum approximately 1.5 cm away from the SCJ articular surface. Nonabsorbable braided polyester suture (Ethibond, Ethicon, Somerville, NJ) was passed in a figure-of-eight manner through the drill holes with the sutures parallel posteriorly and crossing anteriorly.21 The periosteal sleeve with the attached sternoclavicular and costoclavicular ligaments were repaired. In these 2 cases, the medial half of the adjacent sternocleidomastoid tendon was detached from its musculotendinous junction proximally and passed underneath the remainder of the sternocleidomastoid muscle. Its attachment to the manubrium and sternum was left intact. A weave technique was used to pass the tendon through the periosteum directly adjacent to the sternum anteriorly. The tendon was then either passed through drill holes made in the medial clavicle or it was looped around the inferior portion of the clavicle as a sling and secured with a suture anchor. In 5 patients, the articular cartilage was thin or eroded, and the medial clavicle was deformed. In the r
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judgment of the surgeon, reduction and reconstruction would not have alleviated and may have potentially worsened the patient’s pain. Therefore, a medial clavicle resection was performed using both an oscillating saw and an osteotome. Retractors were used to protect the posterior neurovascular structures, and the periosteal sleeve was left intact. Approximately 1 to 2 cm of medial clavicle was resected. Intraoperative cross-body adduction testing was performed to be certain there was no impingement and an adequate excision performed. There were 2 cases where the bulbous deformity of the medial clavicle and its adherence to the posterior sternum raised concern for iatrogenic injury to mediastinal structures with traction reduction. Therefore, the medial clavicle was transected carefully at the metaphyseal-diaphyseal junction while still dislocated and then carefully extracted. Subsequent soft tissue reconstruction was performed as noted above. A gracilis tendon allograft was used in one case because of incompetent costoclavicular ligaments. The allograft was passed in a figure-of-eight manner through drills holes in the sternum and medial clavicle 1.5 cm from the SCJ.21 An additional nonabsorbable braided ultra–high-molecular weight polyethylene and polyester suture (FiberWire, Arthrex, Naples, FL) was passed through the region of the costoclavicular ligament through one of these drill holes to supplement the repair. The capsule and periosteum surrounding the clavicle were then reapproximated with nonabsorbable braided polyester suture (Ethibond, Ethicon, Somerville, NJ). Stability and range of motion was tested after ligament reconstruction and periosteal closure. All patients were placed into a sling and swathe for 4 weeks, followed by a sling for an additional 2 weeks. This period of relative immobilization was followed by 6 weeks of progressive gentle passive and active range of motion with physical therapy. Patients were instructed to avoid competitive sports and rigorous activities for minimum of 12 weeks. Clinical follow-up data was obtained from medical records. The integrity of the repair or reconstruction was assessed using 1-month and 3-month follow-up plain radiographs and, subsequently, patients were evaluated based on clinical examination (lack of gross deformity, stability of the SCJ with shoulder motion, lack of SCJ tenderness) and improvement of preoperative symptoms. In 1 patient, a postoperative CT scan demonstrated SCJ reduction following reconstruction (Fig. 4). Subjective patient outcomes were obtained by mailed survey. All patients were mailed a Disabilities of the Arm, Shoulder and Hand (DASH) survey. The DASH is a validated 30-item questionnaire outcome measure that can be used to evaluate disability for any region of the upper limb using a 5-point scale.18 Outcomes are often reported using the DASH disability/symptom score determined by the following formula: [(Sum of n responses [graded 1 to 5] divided by n) 1] 25, with a maximum of 100 points (0 is a perfect score) or by simply reporting the overall summative score.22,23 Patients were also asked to rate their current level of pain and/or disability on a scale 1 to 10 (10 reflecting the most severe symptoms) and to grade their sense of SCJ stability on a scale of 1 to 3 (1 = unstable, r
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FIGURE 4. A postoperative computed tomography scan demonstrating sternoclavicular joint reduction following a resection arthroplasty and reconstruction using a gracilis tendon allograft. Drill holes are visualized in the medial clavicle.
2 = moderately stable, 3 = completely stable). Patients who presented with late symptoms, including pain, numbness, trouble swallowing, and hoarseness were asked if these symptoms had improved (1 = resolved entirely, 2 = improved but with residual symptoms, 3 = no improvement). Patients were given the option to respond by mail or a secure online Web site. Those who did not respond within 4 weeks were contacted by telephone. We attempted to locate patients with inaccurate contact information by a previously described Internet search protocol.24
RESULTS At last clinical follow-up (mean, 13 mo), 6 patients reported complete resolution of pain and the remaining patient reported improved pain. Four patients responded to the study survey at an average follow-up of 5.5 years (range, 3.4 to 9.0 y) from the time of surgery. Overall, patients reported an average summative DASH score of 34 (DASH disability/symptom score = 3.33). Normal DASH scores in a young, active population without shoulder symptoms have been reported to be 1.85.25 No patients reported difficulty placing an object on an overhead shelf; with heavy household chores; or managing transportation needs. Two patients reported mild difficulty with recreational activities. All patients reported that their injury did not interfere with their social activities or daily activities. No patient reported feeling less capable, confident, or useful because of injury. Two patients currently employed had no difficulty using their usual work technique and did not feel inhibited by pain. They reported they were performing their work as well as they would like spending their usual amount of time at work. Three patients reported participation in sports including basketball, horseback riding, and golf. Two of www.pedorthopaedics.com |
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these patients reported no difficulty using usual technique; however, 1 patient reported mild difficulty with golfing. All patients reported mild difficulty playing their sport; however, all patients reported spending their usual amount of time practicing or playing. One particular patient described limitations only when performing repetitive activities such as push-ups. Patients rated their current level of pain or disability as 1.5 (range, 1 to 2) on a 10-point scale. Patients reported a sense of moderate (n = 3) or complete (n = 1) SCJ stability. All patients reported that symptoms either resolved entirely (n = 1) or improved but with residual symptoms (n = 3). There were no major surgical complications or need for subsequent surgeries.
DISCUSSION The treatment of posteriorly displaced SCJ injuries in children and young adults is varied. The rationale for acute closed reduction (within 10 days of injury) is that a successful closed reduction will achieve stability and subsequent remodeling of a physeal fracture.6,17,26 Operative management is recommended because of concerns: (1) of recurrent instability after reduction; (2) that true dislocations cannot remodel; (3) that physeal fractures may fail to remodel fully; (4) that chronic displacement will lead to pain; and (5) that acute repair is safe and effective,4 Of note, we advocate open reduction and stabilization of acute injuries. Chronic injuries are a rare but difficult clinical problem. Patients who have initially unrecognized injuries or who fail nonoperative treatment may present with persistent pain or late complications. Although medial clavicle resection and SCJ repair or reconstruction has been recommended in cases presenting with late complications, the information on results of surgical intervention is limited. One case series of adult patients examined operative and nonoperative treatment of acute and chronic posterior SCJ dislocations with an average 5-year follow-up.3 Thirteen operative candidates (9 chronic injuries) underwent medial clavicle resection and reapproximation of the periosteum. Five patients reported an excellent result, whereas 6 reported a good result. Most patients (n = 11) reported only occasional or no pain. Seven patients reported normal function with activities of daily living, work, and sports; however, 6 patients reported restriction with overhead activities, including one who had to change his vocation to reduce his overhead activity. Another recent case series of 6 patients (mean age, 22 y; range, 15 to 46 y) with chronic anterior or posterior sternoclavicular (n = 2) instability described a figure-ofeight reconstructive technique using autologous hamstrings and reported 22-month outcomes.18 DASH scores improved from 54.3 points to 28.8 points postoperatively, and all patients returned to full activity without limitations. Overall, our patients reported an average summative DASH score in the same range as these previously
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reported postoperative DASH scores. A case report also demonstrated encouraging outcomes after SCJ reconstruction using a gracilis tendon, reporting no residual pain or disability at 1-year follow-up.27 We investigated functional outcomes after surgical treatment for chronic posterior SCJ fracture dislocations in adolescents and young adults using subjective data, as well as validated outcome measures. Overall, our patients reported a low level of pain or disability and a sense of moderate or complete SCJ stability. All patients reported either partial or complete symptom improvement postoperatively. Specifically, patients were able to return to work without inhibition and return to sport with only mild difficulty playing their sport at their desired level. All patients reported that their injury did not interfere with social activities or daily activities. No patient reported feeling less capable, confident, or useful at follow-up. There were no major complications from surgery, and no patient required subsequent revision surgery. Despite the very challenging anatomic region, only 2 intraoperative complications, cardiac tamponade secondary to brachiocephalic vessel injury, and a pericardial tear have previously been described and both occurred in the setting of wire fixation.28,29 This study had several limitations. Because of the rarity of posteriorly displaced SCJ injuries, the study population is small. Furthermore, the majority of posteriorly displaced SCJ fracture dislocations that initially present to our institution are treated with acute surgical intervention. Our study population has inherent selection bias as only patients with symptomatic chronic posterior SCJ instability were referred to our tertiary care center. The natural history of nonoperatively treated chronic posteriorly displaced SCJ injuries remains unclear, as an unknown number of these patients may be asymptomatic and never seek medical attention. The study is retrospective and there were no preoperative DASH scores available for comparison. Despite these limitations, however, this investigation provides valuable insight into the successful management of symptomatic chronic posterior SCJ instability. Our results support surgical treatment for chronic symptomatic posterior SCJ instability. In our study, patients were treated with either medial clavicle resection and suture repair/reconstruction of costoclavicular and sternoclavicular ligaments, medial clavicle resection and SCJ reconstruction with a gracilis allograft, or SCJ reconstruction with sternocleidomastoid autograft. Alternative surgical techniques described in the literature include suture anchors, plate fixation, subclavius tenodesis, and fascia lata graft.30 Surgical intervention can reliably provide pain relief. Patients should expect full return to normal, social, and regular daily activities but should be counseled that they may experience some persistent symptoms with return to their previous level of sport performance.
REFERENCES 1. Massachusetts General Hospital. Fracture Clinic. Cave EF. Fractures and Other Injuries. Chicago: Year Book Publishers; 1958. r
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2. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med. 1996;30:71. 3. Groh GI, Wirth MA, Rockwood CA Jr. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg. 2011;20:107–113. 4. Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracturedislocations in children and adolescents. J Pediatr Orthop. 2003;23:464–469. 5. Mirza AH, Alam K, Ali A. Posterior sternoclavicular dislocation in a rugby player as a cause of silent vascular compromise: a case report. Br J Sports Med. 2005;39:e28. 6. Luhmann JD, Bassett GS. Posterior sternoclavicular epiphyseal separation presenting with hoarseness: a case report and discussion. Pediatr Emerg Care. 1998;14:130–132. 7. Laffosse J-M, Espie´ A, Bonnevialle N, et al. Posterior dislocation of the sternoclavicular joint and epiphyseal disruption of the medial clavicle with posterior displacement in sports participants. J Bone Joint Surg Br. 2010;92:103–109. 8. Keating M, Von Ungern-Sternberg BS. Compression of the common carotid artery following clavicle fracture in a twelve-yearold. Anaesth Intensive Care. 2010;38:759–760. 9. Jougon JB, Lepront DJ, Dromer CE. Posterior dislocation of the sternoclavicular joint leading to mediastinal compression. Ann Thorac Surg. 1996;61:711–713. 10. Fenig M, Lowman R, Thompson BP, et al. Fatal posterior sternoclavicular joint dislocation due to occult trauma. Am J Emerg Med. 2010;28:385.e5–385.e8. 11. Noda M, Shiraishi H, Mizuno K. Chronic posterior sternoclavicular dislocation causing compression of a subclavian artery. J Shoulder Elbow Surg. 1997;6:564–569. 12. Nakayama E, Tanaka T, Noguchi T, et al. Tracheal stenosis caused by retrosternal dislocation of the right clavicle. Ann Thorac Surg. 2007;83:685–687. 13. Jain S, Monbaliu D, Thompson JF. Thoracic outlet syndrome caused by chronic retrosternal dislocation of the clavicle. Successful treatment by transaxillary resection of the first rib. J Bone Joint Surg Br. 2002;84:116–118. 14. Rayan GM. Compression brachial plexopathy caused by chronic posterior dislocation of the sternoclavicular joint. J Okla State Med Assoc. 1994;87:7–9. 15. Volker R, Emby DJ. Dislocation of the sternoclavicular joint: delayed diagnosis with an unusual complication. Continuing Medical Education. 2008;24:45.
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16. Wasylenko MJ, Busse EF. Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula. Can J Surg. 1981;24: 626–627. 17. Rockwood CA. The Shoulder. 4th ed. Philadelphia, PA: Saunders/ Elsevier; 2009. 18. Singer G, Ferlic P, Kraus T, et al. Reconstruction of the sternoclavicular joint in active patients with the figure-of-eight technique using hamstrings. J Shoulder Elbow Surg. 2012;22:64–69. 19. Armstrong AL, Dias JJ. Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle. J Bone Joint Surg Br. 2008;90:610–613. 20. Rockwood J, Groh GI, Wirth MA, et al. Resection arthroplasty of the sternoclavicular joint*. J Bone Joint Surg Am. 1997;79: 387–393. 21. SpencerJr. EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am. 2004;86:98–105. 22. Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146. 23. Smith MV, Calfee RP, Baumgarten KM, et al. Upper extremityspecific measures of disability and outcomes in orthopaedic surgery. J Bone Joint Surg Am. 2012;94:277–285. 24. Louie DL, Earp BE, Blazar PE. Finding orthopedic patients lost to follow-up for long-term outcomes research using the internet: an update for 2012. Orthopedics. 2012;35:595–599. 25. Clarke MG, Dewing CB, Schroder DT, et al. Normal shoulder outcome score values in the young, active adult. J Shoulder Elbow Surg. 2009;18:424–428. 26. Wirth MA, Rockwood CA. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg. 1996;4:268–278. 27. Martı´ nez A´, Rodrı´ guez A, Gonza´lez G, et al. Atraumatic spontaneous posterior subluxation of the sternoclavicular joint. Arch Orth Traum Surg. 1999;119:344–346. 28. Bensafi H, Laffosse J-M, Taam SA, et al. Tamponade following sternoclavicular dislocation surgical fixation. Orthop Traumatol Surg Res. 2010;96:314–318. 29. Smolle-Juettner FM, Hofer PH, Pinter H, et al. Intracardiac malpositioning of a sternoclavicular fixation wire. J Orthop Trauma. 1992;6:102–105. 30. Sewell MD, Al-Hadithy N, Le Leu A, et al. Instability of the sternoclavicular joint: current concepts in classification, treatment and outcomes. Bone Joint J. 2013;95-B:721–731.
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Chronic Posterior Sternoclavicular Joint Fracture Dislocations in Children and Young Adults: Results of Surgical Management Beverlie L. Ting, MD,* Donald S. Bae, MD,w and Peter M. Waters, MDw
Background: Posterior sternoclavicular joint (SCJ) fracture dislocations in children and young adults can be missed on initial examination or could fail closed treatment. We hypothesize that surgical interventions (open reduction and ligamentous reconstruction or medial clavicle resection depending on the clinical scenario) are safe treatment options in patients with symptomatic chronic posteriorly displaced SCJ injuries. Methods: A retrospective review was conducted of all patients younger than 25 years of age who underwent surgical treatment for chronic posteriorly displaced SCJ injuries at our institution from January 1, 1999 to December 31, 2011. Chronic injuries were defined as those presenting and/or treated at a minimum of 6 weeks from the causative injury. Indications for surgery included symptomatic posterior SCJ dislocations or posteriorly angulated physeal fractures that did not remodel and were refractory to nonoperative treatment. Subjective patient outcomes were obtained by mailed survey and telephone contact. Outcomes included a Disabilities of the Arm, Shoulder and Hand score, patient-rated levels of pain and/or disability, SCJ stability, and symptom improvement. Results: Seven patients met the inclusion criteria and all patients reported postoperative improvement or complete resolution of pain at last clinical follow-up (mean, 13 mo). At average 5.5 years follow-up, all respondents (n = 4) reported that their injury did not interfere with normal social activities or daily activities. No patients reported difficulty with employment; however, all patients reported mild difficulty with return to their level of athletic activity before SCJ fracture dislocation. Patients rated their level of pain or disability as 1.5 on a 10-point scale. Conclusions: Surgical intervention can reliably provide pain relief and facilitate successful return to activities including work in patients with symptomatic chronic posterior SCJ fracture dislocations. However, patients must be counseled that they may experience persistent symptoms with return to their previous level of sport performance.
From the *Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital; and wDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. None of the authors received financial support for this study. The authors declare no conflict of interest. Reprints: Peter M. Waters, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
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Level of Evidence: Therapeutic Study—Investigating the Results of Treatment: Level IV. Key Words: sternum, clavicle, sternoclavicular, fracture, dislocation, open reduction, reconstruction, resection, pediatric, chronic injury (J Pediatr Orthop 2014;34:542–547)
S
ternoclavicular joint (SCJ) fracture dislocations account for 6 weeks
from injury. Indications for surgery included symptomatic posterior SCJ dislocations or posteriorly angulated physeal fractures that did not remodel refractory to nonoperative treatment, including physical therapy and activity modification. During the study period, our institution evaluated 57 patients with posterior SCJ injuries. Seven patients with chronic posterior SCJ injuries met the inclusion criteria and were treated by 2 primary surgeons (P.M.W., D.S.B.) (Table 1). At the time of surgery, 5 patients had true posterior SCJ dislocations, whereas 2 patients had posterior fracture malunions. One patient had an associated acute glenohumeral dislocation closed reduced at the time of injury and another had an associated acute acromioclavicular joint injury treated nonoperatively. The average age at time of surgery was 17 years (range, 15 to 22 y), and the average clinical follow-up was 13 months (range, 17 d to 37 mo). Mechanisms of injury included fall during an athletic activity (n = 3), collision during rough play (n = 1), and motor vehicle accident (n = 1). In 2 cases, a patient with a history of acute lymphoblastic leukemia in remission and prior sternal biopsy and an athletic patient, there was no clear history of injury.
FIGURE 2. Three-dimensional computed tomography reconstructions demonstrating chronic posterior sternoclavicular joint dislocation with moderate mass effect on the left brachiocephalic vein.
FIGURE 3. Preoperative axial computed tomography images demonstrating chronic posterior dislocation of the sternoclavicular joint with medial clavicle dysplasia and bony overgrowth.
METHODS
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TABLE 1. Patient Data
Patient Number Sex
Age at Time of Surgery (y)
Duration of Symptoms (mo) Side
Mechanism
1
M
16
7
R
Atraumatic
2
M
15
19
R
Sports (unknown)
3
F
16
25
L
4
M
16
2
L
5
F
22
3
L
6
M
15
10
L
7
F
17
28
R
Symptoms Pain, dysphagia
Pain, numbness, hand swelling, radial pulse obliterates with abduction/ external rotation Sports (soccer) Pain Miscellaneous (play) MVA Sports (snowboarding) Atraumatic
Pain
Intraoperative Diagnosis Dislocation Dislocation Fracture dislocation Dislocation
Pain, dysphagia, hoarseness
Fracture dislocation
Pain
Dislocation
Pain
Dislocation
Procedure Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization Medial clavicle resection with suture stabilization and gracilis tendon allograft Reconstruction of sternoclavicular joint using sternocleidomastoid tendon Reconstruction of sternoclavicular joint using sternocleidomastoid tendon
MVA indicates motor vehicle accident.
Preoperatively, all patients complained of functionally limiting pain. Three of these patients had symptoms of mediastinal compression: trouble swallowing, hoarseness, intermittent hand swelling, and numbness of the injured extremity. Of the 5 patients with known trauma, only 2 were diagnosed at the time of injury: 1 patient underwent closed reduction before presentation to us in a chronic dislocated state and the other was initially treated conservatively because of lack of any apparent neurovascular injury but subsequently developed symptoms of neurovascular compromise. The average time from injury to operative intervention was 14 months (range, 2 to 26 mo). Four patients underwent resection of the medial clavicle and suture repair/reconstruction of the costoclavicular and sternoclavicular ligaments; one patient underwent medial clavicle resection and SCJ reconstruction with a gracilis allograft; and the remaining 2 patients underwent open joint reduction and SCJ reconstruction with sternocleidomastoid autograft.3,4,18–20
Surgical Technique A general surgeon was available throughout the surgery in a nearby operating room, given the potential risk of compromise to nearby mediastinal structures. Patients were positioned in a beach-chair position, and the injured SCJ, ipsilateral chest, and upper extremity were prepared and draped into the surgical field. An extensile transverse incision was made from the diaphysis of the medial clavicle across the SCJ.4,18–21 Soft tissue dissection was carried out through the skin and subcutaneous tissue, protecting the supraclavicular nerves. The platysma was incised. To expose the medial clavicle and SCJ, a sleeve of periosteum, including the sternocleidomastoid and pectoralis muscle attachments, was elevated
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anteriorly. With the posterior periosteum left intact, the displaced medial clavicle was followed lateral to medial and dissected carefully off the posterior sternum. This is a very delicate maneuver as the deformed medial clavicle is often adherent to the posterior sternum. Meticulous care was taken not to penetrate the protective posterior periosteal sleeve during dissection. If the medial clavicle could be elevated out of the mediastinal region atraumatically, it was brought up into the wound with gentle traction using a bone reduction clamp. The articular surface of the medial clavicle was inspected to assess if joint reduction and reconstruction would be feasible. In 2 of the dislocation patients, there was no articular damage and thus the medial clavicle was stably reduced into the SCJ. Drill holes were then made in the medial clavicle and in the sternum approximately 1.5 cm away from the SCJ articular surface. Nonabsorbable braided polyester suture (Ethibond, Ethicon, Somerville, NJ) was passed in a figure-of-eight manner through the drill holes with the sutures parallel posteriorly and crossing anteriorly.21 The periosteal sleeve with the attached sternoclavicular and costoclavicular ligaments were repaired. In these 2 cases, the medial half of the adjacent sternocleidomastoid tendon was detached from its musculotendinous junction proximally and passed underneath the remainder of the sternocleidomastoid muscle. Its attachment to the manubrium and sternum was left intact. A weave technique was used to pass the tendon through the periosteum directly adjacent to the sternum anteriorly. The tendon was then either passed through drill holes made in the medial clavicle or it was looped around the inferior portion of the clavicle as a sling and secured with a suture anchor. In 5 patients, the articular cartilage was thin or eroded, and the medial clavicle was deformed. In the r
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judgment of the surgeon, reduction and reconstruction would not have alleviated and may have potentially worsened the patient’s pain. Therefore, a medial clavicle resection was performed using both an oscillating saw and an osteotome. Retractors were used to protect the posterior neurovascular structures, and the periosteal sleeve was left intact. Approximately 1 to 2 cm of medial clavicle was resected. Intraoperative cross-body adduction testing was performed to be certain there was no impingement and an adequate excision performed. There were 2 cases where the bulbous deformity of the medial clavicle and its adherence to the posterior sternum raised concern for iatrogenic injury to mediastinal structures with traction reduction. Therefore, the medial clavicle was transected carefully at the metaphyseal-diaphyseal junction while still dislocated and then carefully extracted. Subsequent soft tissue reconstruction was performed as noted above. A gracilis tendon allograft was used in one case because of incompetent costoclavicular ligaments. The allograft was passed in a figure-of-eight manner through drills holes in the sternum and medial clavicle 1.5 cm from the SCJ.21 An additional nonabsorbable braided ultra–high-molecular weight polyethylene and polyester suture (FiberWire, Arthrex, Naples, FL) was passed through the region of the costoclavicular ligament through one of these drill holes to supplement the repair. The capsule and periosteum surrounding the clavicle were then reapproximated with nonabsorbable braided polyester suture (Ethibond, Ethicon, Somerville, NJ). Stability and range of motion was tested after ligament reconstruction and periosteal closure. All patients were placed into a sling and swathe for 4 weeks, followed by a sling for an additional 2 weeks. This period of relative immobilization was followed by 6 weeks of progressive gentle passive and active range of motion with physical therapy. Patients were instructed to avoid competitive sports and rigorous activities for minimum of 12 weeks. Clinical follow-up data was obtained from medical records. The integrity of the repair or reconstruction was assessed using 1-month and 3-month follow-up plain radiographs and, subsequently, patients were evaluated based on clinical examination (lack of gross deformity, stability of the SCJ with shoulder motion, lack of SCJ tenderness) and improvement of preoperative symptoms. In 1 patient, a postoperative CT scan demonstrated SCJ reduction following reconstruction (Fig. 4). Subjective patient outcomes were obtained by mailed survey. All patients were mailed a Disabilities of the Arm, Shoulder and Hand (DASH) survey. The DASH is a validated 30-item questionnaire outcome measure that can be used to evaluate disability for any region of the upper limb using a 5-point scale.18 Outcomes are often reported using the DASH disability/symptom score determined by the following formula: [(Sum of n responses [graded 1 to 5] divided by n) 1] 25, with a maximum of 100 points (0 is a perfect score) or by simply reporting the overall summative score.22,23 Patients were also asked to rate their current level of pain and/or disability on a scale 1 to 10 (10 reflecting the most severe symptoms) and to grade their sense of SCJ stability on a scale of 1 to 3 (1 = unstable, r
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FIGURE 4. A postoperative computed tomography scan demonstrating sternoclavicular joint reduction following a resection arthroplasty and reconstruction using a gracilis tendon allograft. Drill holes are visualized in the medial clavicle.
2 = moderately stable, 3 = completely stable). Patients who presented with late symptoms, including pain, numbness, trouble swallowing, and hoarseness were asked if these symptoms had improved (1 = resolved entirely, 2 = improved but with residual symptoms, 3 = no improvement). Patients were given the option to respond by mail or a secure online Web site. Those who did not respond within 4 weeks were contacted by telephone. We attempted to locate patients with inaccurate contact information by a previously described Internet search protocol.24
RESULTS At last clinical follow-up (mean, 13 mo), 6 patients reported complete resolution of pain and the remaining patient reported improved pain. Four patients responded to the study survey at an average follow-up of 5.5 years (range, 3.4 to 9.0 y) from the time of surgery. Overall, patients reported an average summative DASH score of 34 (DASH disability/symptom score = 3.33). Normal DASH scores in a young, active population without shoulder symptoms have been reported to be 1.85.25 No patients reported difficulty placing an object on an overhead shelf; with heavy household chores; or managing transportation needs. Two patients reported mild difficulty with recreational activities. All patients reported that their injury did not interfere with their social activities or daily activities. No patient reported feeling less capable, confident, or useful because of injury. Two patients currently employed had no difficulty using their usual work technique and did not feel inhibited by pain. They reported they were performing their work as well as they would like spending their usual amount of time at work. Three patients reported participation in sports including basketball, horseback riding, and golf. Two of www.pedorthopaedics.com |
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these patients reported no difficulty using usual technique; however, 1 patient reported mild difficulty with golfing. All patients reported mild difficulty playing their sport; however, all patients reported spending their usual amount of time practicing or playing. One particular patient described limitations only when performing repetitive activities such as push-ups. Patients rated their current level of pain or disability as 1.5 (range, 1 to 2) on a 10-point scale. Patients reported a sense of moderate (n = 3) or complete (n = 1) SCJ stability. All patients reported that symptoms either resolved entirely (n = 1) or improved but with residual symptoms (n = 3). There were no major surgical complications or need for subsequent surgeries.
DISCUSSION The treatment of posteriorly displaced SCJ injuries in children and young adults is varied. The rationale for acute closed reduction (within 10 days of injury) is that a successful closed reduction will achieve stability and subsequent remodeling of a physeal fracture.6,17,26 Operative management is recommended because of concerns: (1) of recurrent instability after reduction; (2) that true dislocations cannot remodel; (3) that physeal fractures may fail to remodel fully; (4) that chronic displacement will lead to pain; and (5) that acute repair is safe and effective,4 Of note, we advocate open reduction and stabilization of acute injuries. Chronic injuries are a rare but difficult clinical problem. Patients who have initially unrecognized injuries or who fail nonoperative treatment may present with persistent pain or late complications. Although medial clavicle resection and SCJ repair or reconstruction has been recommended in cases presenting with late complications, the information on results of surgical intervention is limited. One case series of adult patients examined operative and nonoperative treatment of acute and chronic posterior SCJ dislocations with an average 5-year follow-up.3 Thirteen operative candidates (9 chronic injuries) underwent medial clavicle resection and reapproximation of the periosteum. Five patients reported an excellent result, whereas 6 reported a good result. Most patients (n = 11) reported only occasional or no pain. Seven patients reported normal function with activities of daily living, work, and sports; however, 6 patients reported restriction with overhead activities, including one who had to change his vocation to reduce his overhead activity. Another recent case series of 6 patients (mean age, 22 y; range, 15 to 46 y) with chronic anterior or posterior sternoclavicular (n = 2) instability described a figure-ofeight reconstructive technique using autologous hamstrings and reported 22-month outcomes.18 DASH scores improved from 54.3 points to 28.8 points postoperatively, and all patients returned to full activity without limitations. Overall, our patients reported an average summative DASH score in the same range as these previously
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reported postoperative DASH scores. A case report also demonstrated encouraging outcomes after SCJ reconstruction using a gracilis tendon, reporting no residual pain or disability at 1-year follow-up.27 We investigated functional outcomes after surgical treatment for chronic posterior SCJ fracture dislocations in adolescents and young adults using subjective data, as well as validated outcome measures. Overall, our patients reported a low level of pain or disability and a sense of moderate or complete SCJ stability. All patients reported either partial or complete symptom improvement postoperatively. Specifically, patients were able to return to work without inhibition and return to sport with only mild difficulty playing their sport at their desired level. All patients reported that their injury did not interfere with social activities or daily activities. No patient reported feeling less capable, confident, or useful at follow-up. There were no major complications from surgery, and no patient required subsequent revision surgery. Despite the very challenging anatomic region, only 2 intraoperative complications, cardiac tamponade secondary to brachiocephalic vessel injury, and a pericardial tear have previously been described and both occurred in the setting of wire fixation.28,29 This study had several limitations. Because of the rarity of posteriorly displaced SCJ injuries, the study population is small. Furthermore, the majority of posteriorly displaced SCJ fracture dislocations that initially present to our institution are treated with acute surgical intervention. Our study population has inherent selection bias as only patients with symptomatic chronic posterior SCJ instability were referred to our tertiary care center. The natural history of nonoperatively treated chronic posteriorly displaced SCJ injuries remains unclear, as an unknown number of these patients may be asymptomatic and never seek medical attention. The study is retrospective and there were no preoperative DASH scores available for comparison. Despite these limitations, however, this investigation provides valuable insight into the successful management of symptomatic chronic posterior SCJ instability. Our results support surgical treatment for chronic symptomatic posterior SCJ instability. In our study, patients were treated with either medial clavicle resection and suture repair/reconstruction of costoclavicular and sternoclavicular ligaments, medial clavicle resection and SCJ reconstruction with a gracilis allograft, or SCJ reconstruction with sternocleidomastoid autograft. Alternative surgical techniques described in the literature include suture anchors, plate fixation, subclavius tenodesis, and fascia lata graft.30 Surgical intervention can reliably provide pain relief. Patients should expect full return to normal, social, and regular daily activities but should be counseled that they may experience some persistent symptoms with return to their previous level of sport performance.
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2. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med. 1996;30:71. 3. Groh GI, Wirth MA, Rockwood CA Jr. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg. 2011;20:107–113. 4. Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracturedislocations in children and adolescents. J Pediatr Orthop. 2003;23:464–469. 5. Mirza AH, Alam K, Ali A. Posterior sternoclavicular dislocation in a rugby player as a cause of silent vascular compromise: a case report. Br J Sports Med. 2005;39:e28. 6. Luhmann JD, Bassett GS. Posterior sternoclavicular epiphyseal separation presenting with hoarseness: a case report and discussion. Pediatr Emerg Care. 1998;14:130–132. 7. Laffosse J-M, Espie´ A, Bonnevialle N, et al. Posterior dislocation of the sternoclavicular joint and epiphyseal disruption of the medial clavicle with posterior displacement in sports participants. J Bone Joint Surg Br. 2010;92:103–109. 8. Keating M, Von Ungern-Sternberg BS. Compression of the common carotid artery following clavicle fracture in a twelve-yearold. Anaesth Intensive Care. 2010;38:759–760. 9. Jougon JB, Lepront DJ, Dromer CE. Posterior dislocation of the sternoclavicular joint leading to mediastinal compression. Ann Thorac Surg. 1996;61:711–713. 10. Fenig M, Lowman R, Thompson BP, et al. Fatal posterior sternoclavicular joint dislocation due to occult trauma. Am J Emerg Med. 2010;28:385.e5–385.e8. 11. Noda M, Shiraishi H, Mizuno K. Chronic posterior sternoclavicular dislocation causing compression of a subclavian artery. J Shoulder Elbow Surg. 1997;6:564–569. 12. Nakayama E, Tanaka T, Noguchi T, et al. Tracheal stenosis caused by retrosternal dislocation of the right clavicle. Ann Thorac Surg. 2007;83:685–687. 13. Jain S, Monbaliu D, Thompson JF. Thoracic outlet syndrome caused by chronic retrosternal dislocation of the clavicle. Successful treatment by transaxillary resection of the first rib. J Bone Joint Surg Br. 2002;84:116–118. 14. Rayan GM. Compression brachial plexopathy caused by chronic posterior dislocation of the sternoclavicular joint. J Okla State Med Assoc. 1994;87:7–9. 15. Volker R, Emby DJ. Dislocation of the sternoclavicular joint: delayed diagnosis with an unusual complication. Continuing Medical Education. 2008;24:45.
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