Rockwood Children CH19

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SECTION TWO • Upper Extremity

series that included 40 patients treated operatively, of which one patient had a recurrent dislocation on postoperative day 1 that was addressed immediately. None of the other patients had a subsequent dislocation. It is important to note that none of the patients required reconstruction of the sternoclavicular or costoclavicular ligaments to maintain stability. 84 The best evidence regarding these injuries is from a recent meta-analysis that showed that 96% of patients treated with ORIF had full pain-free range of motion without recurrence. 144

Authors’ Preferred Treatment for Sternoclavicular Fracture–Dislocations

Postoperative Care Postoperatively, patients are placed in either a sling and swathe or shoulder immobilizer for 4 to 6 weeks. Subsequently, range- of-motion exercises are begun. Strengthening is permitted at 3 months postoperatively. Return to sports is dependent on full motion and strength, usually 3 to 6 months postoperatively. We treat acute atraumatic anterior dislocations with immobilization alone for 1 to 4 weeks followed by grad- ual return to function. If patients experience recurrent instability, therapy is initiated. Operative intervention is reserved for patients with persistent symptoms and typi- cally involves reconstruction of the ligaments. Acute posterior dislocations are treated operatively with ORIF. Chronic posterior dislocations that are symp- tomatic are treated with ligament reconstruction utilizing allograft. At times, medial clavicle resection is required in painful chronic dislocations that have deformity of the bone and early arthritis of the joint.

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS IN STERNOCLAVICULAR FRACTURE–DISLOCATIONS

Sternoclavicular Fracture–Dislocations: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Failure of closed treatment • Persistent pain • Recurrent instability Attempts at closed reduction may be unsuccessful, leading to the necessity to perform an open reduction and internal fix- ation. Studies have shown that the success of closed reduc- tion greatly reduces beyond 24 to 48 hours from the time of injury. 84,144 Therefore, one may consider proceeding directly to ORIF if the patient presents greater than 48 hours from the ini- tial injury. Recurrent instability following acute repair is relatively rare but can occur, especially if the sternoclavicular joint is overre- duced. Patients will present with persistent pain and a sense of instability. Treatment with ligament reconstruction can be per- formed utilizing semitendinosus autograft or allograft passed in a figure-of-eight fashion similar to the suture utilized during the acute repair. Ideally, the tendon is passed on the “instabil- ity side” to minimize the risk of recurrent instability occurring again. Alternatively, as a salvage procedure, medial clavicle resec- tion arthroplasty can be performed with supplemental ligament reconstruction or soft tissue interposition. Approximately 1 cm of medial clavicle is excised in an oblique fashion to preserve the inferior ligamentous attachments. The intra-articular disk can be passed into the medullary canal of the clavicle by detach- ing its superior end while preserving the inferior attachments. Sutures are passed through drill holes in the superior clavicle and tied over a bony bridge (Fig. 19-23). Additional stability can be provided by sutures passed between the costoclavicu- lar ligament and the clavicle. In a case series by Ting et al. of surgical care for patients, this rare complication revealed pain reduction and improved function. 146 The results of treatment for recurrent anterior instability have been reported by Bae et al. in a retrospective review. 7 Sixty percent of patients had stable, pain-free joints following the procedure. No patients developed instability following their treatment. Many still had some minor limitations of function or persistent pain.

Potential Pitfalls and Preventive Measures

Sternoclavicular Fracture–Dislocations: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Overreduction of clavicle into clavicular notch of sternum

• Be knowledgeable about the bony anatomy of the sternoclavicular joint • Utilize heavy nonabsorbable suture

• Osteolysis from Dacron

• K-wire migration

• Avoid K-wires

It is imperative to be familiar with the sternoclavicular bony alignment as overreduction of the clavicle into the clavicu- lar notch of the sternum can occur. In addition, utilization of Dacron tape may cause osteolysis. Pins may migrate and there- fore should be avoided. 91,125,151 Outcomes The outcomes following ORIF of posterior sternoclavicular dis- locations or medial clavicle physeal fractures in pediatric and adolescent patients have been quite favorable in most reported cases. 13,50,80,147,155 In a retrospective review by Waters et al., 155 all patients treated with open reduction and suture fixation of their posterior sternoclavicular joint fracture dislocation had restoration of joint stability and shoulder motion with full return to activities. Similar findings were reported by Goldfarb et al. 50 with all patients returning to their preinjury function including sports participation. Lee et al. recently published a

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