An 18-year-old male presented to his family physician approximately 45 minutes after sustaining an injury to his right shoulder. He was tackled by another player while playing football. He noted a "pop" at his right sternoclavicular joint (SCJ), and resultant difficulty moving the right arm secondary to pain and a reproducible popping sensation of the clavicle. He denied numbness or tingling, shortness of breath, neck pain, jaw pain, or facial swelling, but noted mild difficulty swallowing. The patient's past medical history was unremarkable.
On physical examination, there was asymmetric swelling at the right SCJ. His skin was intact. Range of motion and strength was limited by pain. Tenderness to palpation was present at the right SCJ, and shoulder motion produced a palpable clavicular "clunk." The neurovascular exam of the right upper extremity was unremarkable. The patient's arm was placed in a sling, and an emergent CT scan was obtained after x-rays revealed an asymmetry of the SC joints (Fig. 1). The patient's arm was placed in a sling, and an emergent CT scan was then obtained (Figure 2, Figure 3).
The orthopedic team on call was notified. Given the patient's stable examination, he was discharged home with a referral to the shoulder and elbow clinic for management.
He was seen the following day in the shoulder clinic. His exam was unchanged. His diagnosis was posterior sternoclavicular fracture-dislocation, with fracture through the medial clavicular physis (Salter-Harris I). Risks and benefits of surgical reduction and stabilization were discussed with the patient and his father. They elected to proceed with surgery. Arrangements were made with a vascular surgeon for assistance if needed. The patient was taken to the operating room one week after injury for open reduction and internal fixation.
Following routine preoperative procedure, the patient was carefully positioned in the supine attitude with a rolled towel between the shoulder blades.
Under general anesthesia, and after administration of 2 grams of Ancef, a 5-cm necklace incision was made overlying the medial clavicle onto the manubrium. Meticulous dissection and hemostasis then followed to expose the periosteum on the clavicle. The two heads of the sternocleidomastoid were identified and protected throughout the case. The epiphysis was noted to be still attached to the articular disk and in appropriate orientation with the manubrium; however, the medial clavicle had dislocated posteriorly through the physis (Figure 4, Figure 5).
Following debridement, the clavicle was atraumatically reduced using a point-to-point clamp. The medial clavicle was then sewn back to the epiphysis with transosseous and transepiphyseal #2 FiberWire sutures (Arthrex, Naples, FL), with excellent stability achieved to the repair (Figure 6, Figure 7). The periosteum was oversewn, and this was reefed back to the surrounding sternoclavicular ligament and articular disk medially. Excellent fixation was achieved. The shoulder was taken through a full range of motion, and no motion was appreciated at the fracture site. The wound was copiously irrigated and closed in layers. The arm was put into an UltraSling. The patient was observed overnight and discharged one day after surgery.
The right shoulder was kept immobilized in a sling for four weeks to allow for fracture healing. Elbow and wrist range-of-motion and grip exercises for the hand were started immediately after surgery without restriction. At his two-week postoperative followup, the patient reported resolution of his dysphagia and was relatively painfree. His incision was healing appropriately, without evidence of infection or complication. He was instructed to continue with sling wear, removing it frequently for Codman, elbow, wrist, and hand exercises. He was not allowed to participate in contact sports for 6 months. A postoperative CT scan demonstrated near-anatomic reduction of the SCJ fracture-dislocation (Figure 8, Figure 9).