CHAPTER 46 • STERNOCLAVICULAR, CLAVICULAR, AND ACROMIOCLAVICULAR INJURIES 275STERNOCLAVICULAR JOINT
TREATMENT
- Anterior and posterior dislocations are best reduced
within the first 7 days of the injury. - Unfortunately, anterior dislocations typically are not
well maintained after a closed reduction. They are
best treated postreduction with a figure of eight har-
ness as a standard sling can put a medially directed
load on the SC joint. - Posterior dislocations must be treated as soon as possi-
ble. Failure to do so can result in compromise of the
trachea and mediastinal structures. A very thorough
physical examination and prereduction radiographic
evaluation is mandatory. Assuming there is no involve-
ment of the underlying structures, they can be managed
with a closed reduction, if seen within the first 7 days
postinjury, followed by immobilization for 6–10 weeks.
If an adequate closed reduction is not obtained, an open
reduction and stabilization must be performed. - Chronic anterior dislocations should be treated with
activity modification and support treatment for 6–
12 months as most of these become less symptomatic
with time. If still symptomatic, they can be treated
with a resectional arthroplasty and stabilization. - Chronic posterior dislocations also require a very
thorough radiographic evaluation to determine com-
promise of the underlying soft tissues. If it has been
longer than 7–10 days since the original injury, an
open reduction and resectional arthroplasty of the
medial clavicle is usually required. - As the medial physis does not close till 23–25 years of
age, anterior and posterior dislocations under that age
are typically physeal injuries and are best managed
with observation as the deformity can remodel.
•Degenerative arthritis of the SC joint can typically be
managed with supportive measures such as activity
modification and anti-inflammatory drugs. If the
patient continues to have symptoms for more than
6–12 months, and the symptoms can be alleviated
with an injection in the SC joint, they can be consid-
ered for a resectional arthroplasty and stabilization
(Rockwood and Young, 1990). - Under no circumstances should hardware, especially
smooth pins, be used to stabilize the medial clavicle
as numerous cases of hardware migration have been
reported in which some resulted in death.
RETURN TO PLAY CRITERIA
•For a mild sprain of the SC joint, the patient can be
treated with ice, rest, and a sling for 4–5 days. Activity
can then be advanced as tolerated.
•For a more severe sprain or subluxation, that is not a
true dislocation, ice and rest should be used; however,
the involved extremity should be immobilized in a
sling or figure of eight harness for 6–8 weeks before
resuming activity. The patient should have full, pain-
free motion before returning to sports, particularly
overhead sports. This may take up to 3 months.- In the case of a true dislocation, a closed reduction
maneuver should be made and the extremity immobi-
lized in a sling or figure of eight harness for 6–8
weeks. That extremity should be protected for an
additional 2 weeks before resumption of strenuous
activity and then only advanced as tolerated. Again,
the return to play criteria is full, pain-free range of
motion.
CLAVICLE FACTS- The clavicle is the first bone to ossify and the last to
finish growing. The physes of the clavicle do not close
till approximately 23–25 years of age. Prior to this
time, most injuries actually represent physeal injuries.
The clavicle grows through intramembranous ossifi-
cation much like the flat bones of the body such as the
pelvis and skull and the medial physis accounts for
approximately 80% of the growth. - The middle third of the clavicle has poor muscle cov-
erage much like the mid-tibia, which may contribute
to healing problems. - There does not appear to be an intraosseous blood
supply to the clavicle, unlike most bones. All of its
blood is supplied through the periosteum.
CLAVICLE FRACTURES•Clavicle fractures are very common, accounting for
5–15% of all fractures and nearly half of all shoulder
fractures.- Middle third fractures are by far the most common,
accounting for 80% of all clavicle fractures with lat-
eral third fractures accounting for about 10–15% and
medial third fractures accounting for about 5%. - Although commonly thought to be a result of a direct
blow, the clavicle is typically fractured by a fall on to
the lateral aspect of the shoulder; however, it can also
be fractured by a direct blow as seen in seat belt frac-
tures or in sports such as lacrosse. There are reported
cases of stress fractures of the clavicle, typically in
overhead athletes (Taft, Wilson, and Oglesby, 1987).
•Midshaft clavicle fractures tend to occur in younger
individuals while lateral third fractures tend to occur
in older individuals.