Clinical Outcomes and Complications Following Surgical Management of Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review

Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability: Patient-reported outcomes at a minimum of 2 years

Background

Instability of the sternoclavicular joint (SCJ) is a rare problem that is often treated closed, with few published outcomes of surgical treatment with tendon graft reconstruction.

Methods

We reviewed a consecutive series of patients who underwent tendon graft reconstruction for SCJ instability over a 7-year period. Cases with acute fractures or fewer than 2 years of follow-up were excluded. Pre- and postoperative function and pain were assessed using Single assessment numeric evaluation (SANE), simple shoulder test (SST), and visual analog scale (VAS) outcome measures.

Results

Thirty cases were included, with 27 (90%) available for follow-up at a minimum of 2 years postoperatively. SANE scores improved from a median of 40 to 90. SST scores improved from a median of 3 positive responses to a median of 12 on a 12-point scale. VAS scores decreased from a median of 7 to 0 points. One patient underwent reoperation for recurrent instability and wound dehiscence. Three (11%) patients did not achieve a minimum 30% of maximum possible improvement in SST scores.

Conclusions

Tendon graft reconstruction for SCJ instability is a safe procedure with a low complication rate and statistically and clinically significant improvements in patient-reported outcome measures at 2-year minimum follow-up.

Level of evidence

Level IV: Therapeutic.

Current Concepts in Sternoclavicular Joint Injuries

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Return to Sports After Closed Reduction of Acute Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review

BACKGROUND

Acute traumatic posterior sternoclavicular (SC) joint dislocation is a serious injury given its potential to cause cardiovascular and airway compromise that typically will require emergent closed reduction. There are limited data on the rate of return to sports (RTS) after this injury pattern when treated in a closed fashion.

PURPOSE

To systematically review the literature and evaluate (1) the rate of RTS after closed reduction of posterior SC dislocation and (2) the timeline for RTS after closed reduction of posterior SC dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed using the PubMed, EBSCOhost, and Elsevier databases with the search term "sternoclavicular dislocation." Inclusion criteria were publications reporting successful closed reduction of posterior SC joint dislocation and containing data relevant to the study objectives. Exclusion criteria were cases with unsuccessful closed reduction, open surgical reduction, concomitant fracture, epiphyseal disruption, superior or anterior dislocation, subluxation injury, treatment without reduction, and atraumatic or congenital origins.

RESULTS

Sixteen studies and an additional forthcoming case at the authors' institution were identified to have documented RTS with a total of 31 patients. Of these patients, 23 (74%) in the cohort had full RTS. Eight of the 16 studies plus the additional case reported a timeline for RTS. The mean time to RTS was 3.1 months (range, 1-6 months). Of the 8 patients who did not return to preinjury sports or activity, 12.9% (4/31) reported restrictions with sports or activity, 6.5% (2/31) changed to a sport with less contact, 3.2% (1/31) experienced symptomatic recurrence requiring surgical stabilization, and 3.2% (1/31) quit the sport.

CONCLUSION

Closed reduction of acute traumatic posterior SC joint dislocations provides high RTS rates with low rates of secondary surgical stabilization. The mean time to RTS at the preinjury activity level was 3.1 months.

Incidence of sports-related sternoclavicular joint dislocations in the United States over the last two decades

BACKGROUND

Epidemiological understanding of acute sternoclavicular (SC) dislocations secondary to sports across the United States is poorly defined.

AIM

To identify and assess epidemiological trends of SC dislocations occurring secondary to sports-related mechanisms across United States over the past two decades.

METHODS

This cross-sectional, descriptive epidemiological study evaluates epidemiological trends of SC dislocations from sports that present to emergency departments (EDs) across the United States. Data were obtained from the National Electronic Injury Surveillance System database spanning two decades. Data on incidence, patient demographics, mechanisms of injury, dislocation types, incident locales, and patient dispositions were collected.

RESULTS

1622 SC dislocations occurred nationwide from 2001 to 2020 [incidence = 0.262/1000000 people, confidence interval (CI) = 0.250-0.275], comprising 0.1% of shoulder/upper trunk dislocations. Most patients were male (91%, n = 1480) and aged 5-17 (61%, n = 982). Football, wrestling, and biking were the most frequently implicated sports, with contact sports responsible for 59% of athletic injuries (n = 961). Recreational vehicle-related sports injuries, such as all-terrain vehicles, dirt bikes, and mopeds accounted for 7.8% of all injuries (n = 126), with dirt bikes specifically comprising 3.7% (n = 61). Ultimately, 82% were discharged from the ED (n = 1337), 12% were admitted (n = 194), and 6% were transferred (n = 90). All recorded posterior dislocations were admitted or transferred from the ED. Patients sustaining SC dislocations from contact sports had a significantly increased risk of hospital admission or transfer rather than discharge from the ED as compared to patients whose injuries were from non-contact sports (incidence rate ratio = 1.46, CI: = 1.32-1.61, P < 0.001).

CONCLUSION

SC dislocations from sports continue to be rare with a stably low incidence over the past two decades, likely comprising a smaller proportion of shoulder dislocations than previously thought. Contact sports are a frequent source of injury, especially among school-aged and teenage males. Most patients are discharged directly from the ED; however, a substantial number are hospitalized, many of which had documented posterior dislocations. Ultimately, understanding the epidemiology and mechanism-related trends of acute SC dislocations is important given the potential severity of these injuries, concentration in a specific population, and uncertainty linked to rare presentation.

The Floating Clavicle: Surgical Technique for Management of an Ipsilateral Acromioclavicular and Sternoclavicular Joint Dislocation

Bipolar "floating" clavicle injuries are infrequent upper-extremity injuries that occur secondary to a high-energy trauma, which can cause dislocation at the sternoclavicular (SC) and acromioclavicular joints. Given the rarity of this injury, there is not a consensus regarding clinical management. Although anterior dislocations can be managed nonoperatively, posterior dislocations may pose a threat to chest-wall structures and typically are managed surgically. Here, we present our preferred technique for concomitant management of a locked posterior SC joint dislocation with associated grade 3 acromioclavicular joint dislocation. Reconstruction of both ends of the clavicle was performed in this case, using a figure-of-8 gracilis allograft and nonabsorbable suture reconstruction for the SC joint, and an anatomic acromioclavicular joint and coracoclavicular ligament reconstruction with semitendinosus allograft and nonabsorbable suture.

Clinical Outcomes and Return to Sports After Open Reduction and Hamstring Tendon Autograft Reconstruction in Patients With Acute Traumatic First-Time Posterior Dislocation of the Sternoclavicular Joint

BACKGROUND

Traumatic posterior dislocations of the sternoclavicular joint (SCJ) are rare. Multiple case reports, case series, and systematic reviews have been published on the treatment of posterior SCJ dislocations. However, they have usually been of small numbers, described a variety of surgical techniques on a mixture of acute and chronic dislocations, and have not focused on functional recovery or return to sports.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the clinical outcomes and return to sports after SCJ open reduction and reconstruction using a hamstring tendon autograft in patients with an acute first-time traumatic posterior dislocation of the SCJ. We hypothesized that SCJ open reduction and reconstruction would result in high survivorship, good clinical outcomes, and a high rate of return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study included all patients who underwent SCJ open reduction and reconstruction within 14 days of sustaining a first-time traumatic posteriorly dislocated SCJ, with a minimum 3-year follow-up. Patient-reported outcomes were assessed by the following scores: short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Rockwood SCJ, modified Constant, and Single Assessment Numeric Evaluation (SANE). Survivorship was defined as no clinical failure, such as instability or recurrent dislocation, and no revision surgery. Return to sports was assessed using a customized questionnaire.

RESULTS

A total of 19 patients who underwent surgery were included, with a mean age of 30.8 years (range, 18-52 years). Seventeen patients were available at final follow-up at a mean 94.5 months (range, 37-155 months). At final follow-up, the mean scores were as follows: QuickDASH, 4.3 (range, 0-20.4); Rockwood, 13.9 (range, 12-15); modified Constant, 94.4 (range, 71-100); and SANE, 92.1 (range, 70-100). The construct survivorship was 96%. Of the 14 patients who participated in sports, 12 (86%) returned to their preinjury levels.

CONCLUSION

After an acute first-time traumatic posterior SCJ dislocation, open reduction and stabilization with a hamstring tendon autograft, undertaken within 14 days of injury, provides good clinical outcomes and high rates of survivorship and return to sports.

Successful Nonsurgical Management of a Posteriorly Displaced Medial Clavicular Physeal Fracture in an Adolescent Athlete: A Case Report

Traumatic and sport-related sternoclavicular (SCJ) injuries in adolescent athletes are more commonly physeal fractures rather than true SCJ dislocations. Although rare, posterior displacement of the medial clavicular metaphysis after a physeal fracture necessitates prompt evaluation and treatment. Despite the inherent healing ability of physeal separations, delayed or failed diagnosis has the capacity to cause serious complications or fatality secondary to injury of retrosternal structures. Even with the potential severity, a lack of consensus exists in the literature regarding the most appropriate treatment modality. We report an adolescent football player with a medial clavicular physeal fracture with posterior metaphyseal displacement abutting the left brachiocephalic vein. After nonsurgical management and progression to play, the patient returned to play football. This case not only highlights the diagnostic principles of medial clavicular physeal fractures with posterior metaphyseal displacement but also discusses how these challenging injuries can be managed successfully with conservative treatment.

Acute Dislocations of the Sternoclavicular Joint: A Review Article

Acute dislocations of the sternoclavicular joint are uncommon injuries, and it is difficult for physicians to develop expertise in treating these injuries because of their infrequent nature. No level I evidence currently exists for these injuries, but several retrospective studies and surgical techniques have been described. For acute injuries, current recommendations include early treatment with closed reduction. If unable to attain or maintain reduction after a closed attempt, open management should be considered. Previous reviews have outlined relevant anatomy, physical examination findings, and imaging for these injuries. This article aims to review updated information from the past decade regarding techniques for reduction, outcomes, and complications related to the injury and surgical management.

Complications after sternoclavicular surgery

BACKGROUND

Sternoclavicular joint (SCJ) pathologies such as instability are rare; therefore, SCJ surgery is performed infrequently. Complications of these surgeries can be devastating. This study evaluated complications, and particularly infections, after SCJ surgery.

METHODS

A retrospective cohort of 68 patients who underwent SCJ surgery with a minimum follow-up of 1 year was reviewed. Patients' characteristics, intraoperative, and postoperative complications were retrieved. In case of a reoperation, relevant data from the reoperation and microbiological findings were collected.

RESULTS

Twenty-two men and 46 women with a mean age of 37.5 years (range, 13-70 years) were analyzed. A complication occurred in 26 of 68 patients (38.2%). In 16 patients (23.5%), this was an infection. Cutibacterium acnes was the pathogen in 14 of these infections. Infection occurred more often in men than in women (P = .02). A total of 26 reoperations were performed in our cohort: 14 due to clinical signs of infection, 9 due to instability, 1 due to complaints of SCJ osteoarthritis, and 2 due to other causes.

CONCLUSION

Complications after SCJ surgery occur more often than previously described. C. acnes infections are often seen. When left untreated, these complications can lead to persistent complaints or recurrent instability due to failure of reconstruction. Therefore, it is of utmost importance to identify infections at an early stage, or better, to prevent them. The use of benzoyl peroxide gel preoperatively seems effective in reducing early C. acnes infections in this type of surgery.

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study

BACKGROUND

Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment.

METHODS

Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging.

RESULTS

Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention.

CONCLUSIONS

In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD.

LEVEL OF EVIDENCE

Level III-therapeutic case control study.

Outcomes After Surgical Fixation of Posterior Sternoclavicular Physeal Fractures and Dislocations in Children

BACKGROUND

Acute sternoclavicular fractures and dislocations (SCFDs) are a rare but important injury in pediatric patients. SCFDs are either true dislocations, or more commonly, physeal fractures in children. The reduction is advised given the proximity to surrounding vascular structures, and some authors advocate for routine fixation given rates of redisplacement after closed reduction. The purpose of the current study was to provide validated long-term functional outcome data following open reduction and surgical fixation of pediatric SCFDs, as well as provide injury and demographic information.

METHODS

This is a retrospective observational study with a subset of patients reporting functional outcomes. Patients under the age of 18 that had surgically managed acute posterior SCFD from 1990 to 2018 were included. A retrospective chart review was performed to obtain demographic, clinical, and surgical details. Patients with a minimum of 6-month follow-up were contacted to assess outcomes. Functional outcomes of interest included QuickDash, Visual Analog Scale pain rating, Single Assessment Numeric Evaluation of shoulder function, and PROMIS Upper Extremity questionnaire. Statistical analysis included descriptive statistics.

RESULTS

A total of 37 patients that sustained an acute posterior SCFD during the study period were included. The average age at the time of injury was 15.2±2.1 years and 89% were male. Patient-reported outcomes were obtained for 14 patients with a mean follow-up of 4.5 years. The mean QuickDash score was 5.1/100 with 0 being normal, and the mean Visual Analog Scale pain rating was 0.7/10. The mean Single Assessment Numeric Evaluation score was 96% with 100% being completely normal. The mean PROMIS score was 55 with 50 being the mean of the relevant reference population. Approximately 29% (4/14 patients) stated that their injury negatively affected their ability to participate in sports.

CONCLUSIONS

There is a paucity of literature on functional outcomes after surgical management of pediatric acute posterior SCFD. Functional outcomes after surgery were satisfactory in this cohort with most patients being able to perform major activities of daily living. Additional future studies with larger cohorts and comparative groups are needed to better understand outcomes in this population.

LEVEL OF EVIDENCE

Level IV.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

Single loop allograft reconstruction for sternoclavicular joint instability

Background

Various surgical strategies have been used for the treatment of sternoclavicular joint instability with variable results. The purpose of this study was to report the clinical results of patients who underwent single-loop allograft reconstruction for sternoclavicular joint instability.

Methods

A total of 10 patients underwent single-loop allograft reconstruction for sternoclavicular joint instability from June 2012 to August 2014 by a single surgeon. All patients had a history of instability of the sternoclavicular joint with persistent chronic subluxation of the joint, magnetic resonance imaging disruption of the sternoclavicular ligaments, and persistent symptoms of pain and instability. Regarding the surgical technique, a single 5.5 mm drill hole was placed in the sternum and a second was placed in the medial aspect of the clavicle. A semitendinosus hamstring allograft was looped between the 2 holes and then tied in a square knot anteriorly. A #5 high-strength suture was used as cerclage as well. Nine of 10 patients (90% follow-up) were available at an average of 3.3 ± 0.84 years postoperatively. The average age of patients at the time of surgery was 42 years (range, 20-73 years). Patients were evaluated postoperatively with outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test), a question regarding tenderness at the sternoclavicular joint, and a question regarding residual instability and overall patient satisfaction (yes/no).

Results

The average functional outcome scores for the Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons score were 11.8, 0.9, and 94.8, respectively. Three of 9 patients reported some residual tenderness located to the sternoclavicular joint. No patients reported any residual instability of the sternoclavicular joint. Eight of 9 patients reported that they were satisfied with the procedure. No patients required reoperation, and there were no complications.

Conclusion

Single-loop allograft reconstruction of the sternoclavicular joint provides reliable pain relief, functional improvement, and joint stability for patients with chronic sternoclavicular joint instability. The simplicity of the procedure eliminates the need for small, multiple drill holes that may lead to fracture between tunnels or the use of a small, thin graft.

Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study

Patients suffering from extremely medial clavicle fractures combined with distinct displacement generally need surgical intervention. Double-plate fixation is a widely applied technique in the treatment of distal radius fracture, which has been reported to fix lateral clavicle fracture as well. This study reveals the effect of double-plate fixation as an innovative procedure in the treatment of extremely medial clavicle fractures for the first time.Nine patients complaint of extremely medial clavicle fracture were enrolled in this research from May 2017 to March 2019. Patients were operated with an open reduction and internal fixation using the double-plate technique. Postoperative x-ray was taken regularly to observe the fracture healing at each visit, and the related complications were also recorded. The rating score systems of Constant Murley score of treated shoulder and contralateral shoulder, ROWE score as well as American Shoulder and Elbow Surgeons (ASES) were evaluated to comment on the postoperative shoulder joint function.All patients achieved postoperative fracture healing with no complications. Only 1 patient complained of slight restriction, 2 patients complained of pain during overhead work, and another patient was found with plate breakage. Meanwhile, the Constant Murley scores of treated and contralateral shoulder were 94.1 and 98.5 points, respectively, indicating the similar shoulder function. Furthermore, the ROWE and ASES scores of the involved shoulder were 96.7 and 96.3 points at average, respectively.It is the first time to introduce the surgical technique of vertical double-plate fixation implied in stable fixation of extremely medial clavicle fractures, which could provide the surgeons with an alternative method for this type of fracture.

Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights From a National Sample

OBJECTIVES

To describe the incidence of and risk factors for vascular injury associated with P-SCD.

METHODS

We used data from the HCUP-NIS from 2015 to 2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics, and injury severity score in this cohort.

RESULTS

Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, <2% of patients had a vascular injury, all of whom had an injury severity score ≥15, independent of the vascular injury itself. Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD.

CONCLUSIONS

Here, we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.