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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

intervention. 13 Therefore, the majority of patients with acute trau- matic posterior sternoclavicular fracture–dislocations are currently treated operatively. Operative intervention provides symptomatic relief, restores anatomy, and decreases the chance of late compli- cations including recurrent instability and degenerative arthritis. 155 Additional indications for operative treatment include patients with symptomatic acute or chronic anterior disloca- tions who have failed conservative measures and symptomatic patients with chronic posterior dislocations. Contraindications to operative intervention include those patients with asymp- tomatic anterior dislocations or patients with atraumatic recur- rent anterior instability. Open Reduction and Internal Fixation Preoperative Planning ✔ ✔ ORIF of Sternoclavicular Fracture–Dislocations: PREOPERATIVE PLANNING CHECKLIST

We advocate that all posterior fracture–dislocations should be treated operatively. Techniques Closed treatment of a nondisplaced injury consists of sling immobilization for approximately 3 weeks followed by grad- ual return to activities. Attempted closed reduction of anterior dislocations can be performed by placing a posteriorly directed force over the medial clavicle as the scapula is retracted by utili- zation of a bump placed between the shoulders. Subsequently, the patient is placed in a figure-of-eight strap or Velpeau-type sling for 6 weeks. 55 Successful reduction can often be obtained; however, recurrent instability is common. Closed reduction of a posterior dislocation is performed by placing the patient supine on an operating room table with a thick bump placed between the scapulae to extend the shoul- ders and the involved arm off the edge of the table. The ipsilat- eral arm is then abducted in line with the clavicle, with traction applied, while an assistant applies countertraction and stabilizes the patient. Traction is continued and increased and the arm is brought into extension as the joint reduces. 55 Alternatively, the arm can be placed in adduction while posterior pressure is applied to the shoulder which levers the clavicle over the first rib to permit reduction of the joint. 20 If these maneuvers fail, a sterile towel clip can be used to percutaneously grasp the medial clavicle and draw it anteriorly while traction is applied to the ipsilateral limb. An audible snap is typically noted as the joint reduces. 55 Closed reductions of posterior sternoclavicular injuries are at risk for mediastinal hemorrhage and hemodynamic com- promise. Therefore, closed reductions are performed in the controlled setting of the operating suite with vascular surgery standby. In addition, the orthopedic concern with closed reduc- tion is recurrent instability. 50,56,155 Outcomes Most patients treated with immobilization alone for anterior dislocations yield good outcomes, despite the high rates of recurrent instability. 36 Those patients who develop symptoms following closed treatment of anterior dislocations may achieve relief of symptoms with physical therapy to promote scapular retraction and avoid provocative positions. If therapy is unsuc- cessful, ligament reconstruction can be performed with reason- able outcomes anticipated. 7,23,139 Posterior fracture–dislocations that are reduced by closed means have been reported by some to be stable following reduc- tion, 56 whereas others have shown recurrent instability does occur. 50,56,84,155 If the reduction is maintained over time, return to full activities can be expected in the majority of patients. 144 OPERATIVE TREATMENT OF STERNOCLAVICULAR

❑❑ Standard table capable of going into beach chair position

OR table

❑❑ Beach chair position with Mayfield head positioner and a bump behind the scapula

Position/positioning aids

❑❑ Contralateral side, if used

Fluoroscopy location

❑❑ Heavy nonabsorbable suture, drill ❑❑ General surgery or thoracic surgery backup

Equipment

It is imperative to be familiar with the anatomy surrounding the sternoclavicular joint as well as the bony articulation of the medial clavicle and clavicular notch of the sternum. Having a general surgeon or thoracic surgeon available to assist the ortho- pedic surgeon in case of hemodynamic compromise is essential during the reduction maneuver or open reduction. Positioning Patients undergoing any procedure involving the sternoclavic- ular joint are placed in the modified beach chair position with a large bump or rolled towel placed between the scapulae to provide scapular retraction. The entire limb and hemithorax including the contralateral sternoclavicular joint, medial clav- icle, and chest is prepped and draped into the operative field. The sternum to upper abdomen is prepped and draped in case an emergency median sternotomy is required (Fig. 19-20). Surgical Approach A transverse incision is made through the skin from the medial aspect of the clavicle over the ipsilateral sternoclavicular joint in Langer lines. The subcutaneous tissue and platysma are divided, utilizing electrocautery. The supraclavicular nerves are protected if in the operative field. The periosteum of the mid portion of the clavicle is elevated and a bone clamp is applied to the clavicle for control. The anterior periosteum is delicately divided over the posteriorly displaced clavicle until either the epiphysis or sternum is reached depending on whether it is a dislocation or a physeal fracture (Fig. 19-21). Typically, the

FRACTURE–DISLOCATIONS Indications/Contraindications

Although many surgeons have attempted closed treatment of pos- terior fracture–dislocations with either immobilization alone or closed reduction followed by immobilization, recurrent instability can occur leading to symptomatic patients who require operative