Rockwood Children CH19

750

SECTION TWO • Upper Extremity

A

B

Figure 19-18.  A: CT scan showing a posterior dislocation of the right sternoclavicular joint. B: Three-dimensional reconstruction makes the injury more apparent.

and sternohyoid muscles. The ligamentous structures include anterior and posterior sternoclavicular ligaments which rein- force the joint capsule as well as the interclavicular (connects both medial ends of the clavicle) and costoclavicular ligaments (between the inferior aspect of the clavicle and the superior costal cartilage of the adjacent rib). In addition, there is an intra-articular disk that is attached to the superior-posterior part of the clavicular articular surface and inferiorly to the costocartilaginous junction of the first rib (Fig. 19-19). The greatest amount of stability with regard to anterior translation is provided by the posterior capsule and sternoclavicular liga- ments. The greatest stability with regard to posterior transla- tion is provided by the posterior capsule. 138,139 The medial epiphysis of the clavicle does not ossify until approximately 18 to 20 years of age, and closes between 22 and 25 years of age. Therefore, sternoclavicular injuries occur- ring in pediatric and adolescent patients are difficult to discern radiographically between fractures and dislocations. Operative treatment of posterior sternoclavicular injuries has taught us that dislocations and physeal fractures have near equivalent incidence rather than the previous teaching that most posterior sternoclavicular injuries were physeal fractures. Although the medial physis contributes approximately 80% of longitudinal growth of the clavicle, the degree of remodeling possible from a physeal fracture is uncertain. Clearly remodeling cannot occur with a dislocation.

TREATMENT OPTIONS FOR STERNOCLAVICULAR FRACTURE–DISLOCATIONS

NONOPERATIVE TREATMENT OF STERNOCLAVICULAR DISLOCATIONS Indications/Contraindications Nonoperative Treatment of Sternoclavicular Fracture– Dislocations: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications • Atraumatic anterior dislocations • Acute posterior dislocations with An atraumatic anterior dislocation should be treated nonop- eratively. Some have advocated closed reduction maneuvers be performed for acute posterior fracture–dislocations due to potential stability of reduction and/or remodeling of the medial clavicle. 85,158 Acute posterior dislocations with associ- ated neurovascular injury, dyspnea, dysphagia, odynophagia, or hoarseness should clearly be treated with open reduction. associated neurovascular injury, dyspnea, dysphagia, odynophagia, or hoarseness

Interclavicular ligament

Sternoclavicular ligament

Articular disk

Costoclavicular ligament

Subclavius

Figure 19-19.  Schematic drawing of the sterno- clavicular joint. Note the numerous ligamentous structures that provide stability. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2012.)

First rib

Manubrium

Cartilage, first rib