Orthop Clin N Am 39 (2008) 535–545

Acromioclavicular and Sternoclavicular Joint Injuries

Peter B. MacDonald, MD, FRCSCa,*, Pierre Lapointe, MD, FRCSCb
a
Section of Orthopaedic Surgery, PanAm Clinic, University of Manitoba, 75 Poseidon Bay,
Winnipeg, Manitoba, R3M 3E4, Canada
b
PanAm Clinic, University of Manitoba, 75 Poseidon Bay, Winnipeg, Manitoba, R3M 3E4, Canada

Acromioclavicular joint dislocation Classification

Acromioclavicular (AC) joint injuries are Based on the degree of displacement, Allman
a frequent diagnosis following an acute shoulder [4] and Tossy and colleagues [5] initially divided
injury. Approximately 9% of shoulder girdle these injuries into three types. Rockwood and
injuries involve damage to the AC joint [1]. These Green [6] expanded the original classification to
injuries occur commonly in active young adults in six types [7]. Type I represents a minor sprain of
their second through fourth decades of life. Most AC ligaments. Type II is a rupture of AC liga-
often, the patient recalls a fall directly onto the ments with sprain of CC ligaments. If both the
top of the shoulder (acromion) with the arm AC and the CC ligaments are ruptured, this re-
adducted. This fall is the common mechanism sults in a type III AC joint injury. Types IV, V,
for an AC joint injury, with another mechanism and VI have the same ligamentous injuries as
being a direct blow on the shoulder. type III with more displacement of the clavicle
and are also associated with detachment of deltoid
Anatomy
and trapezius. In type IV injuries, the clavicle is
The AC joint is a diarthrodial articulation with displaced posteriorly into the trapezius muscle.
a fibrocartilaginous meniscal disk that separates the The clavicle is elevated between 100% and 300%
articular surfaces of the acromial process and the in type V injuries (Fig. 1). Type VI injuries are
distal clavicle. The capsule surrounding the joint is rare and the clavicle is displaced inferiorly behind
reinforced by the AC ligaments. These include the the coracoid process and conjoint tendon (short
superior, inferior, anterior, and posterior liga- biceps head and coracobrachialis tendon). This
ments. The superior and inferior ligaments are classification scheme is useful in the decision-mak-
stronger than the anterior and posterior ligaments. ing process for the treatment of AC joint injuries.
The AC ligaments are the principle restraint to
anteroposterior translation between the clavicle Assessment
and the acromion [2,3]. Vertical stability of the clav- Patients commonly complain of shoulder pain.
icle is provided by the coracoclavicular (CC) liga- The history and the mechanism of injury are
ments, which are composed of the conoid and important. Usually the pain is acute with a history
trapezoid. The AC and CC ligaments are the static of a recent fall or trauma to the shoulder. The
stabilizers of the AC joint. The dynamic stabilizers pain is localized to the anterosuperior part of the
are the deltoid and trapezius muscles. After an shoulder around the AC joint.
injury, the degree of clavicular displacement Physical examination consists of inspection of
depends on the severity of injury to the ligaments both shoulders, which may highlight deformities
and the muscles that attach to the clavicle. that assist with diagnosis. In types I or II, swelling
and bruising can be visualized and in other types
* Corresponding author. a prominent clavicle is generally obvious. Some-
E-mail address: [email protected] times an abrasion over the superior aspect of the
(P.B. MacDonald). shoulder can be seen secondary to the fall. The
0030-5898/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ocl.2008.05.003 orthopedic.theclinics.com
536 MACDONALD & LAPOINTE

a type III injury. The axial view is important to

differentiate a type III from a type IV. In the axial
view of a type IV AC joint injury, the clavicle is
displaced posteriorly. The radiographs of a type
III and a type V are similar except that clavicular
elevation is more pronounced in type V injuries.
Usually in type V, the acromion to clavicle
displacement on the AP view is between 100%
and 300%. On the rare type VI, (three cases were
reported by Gerber and Rockwood Ref. [10]) the
clavicle is displaced inferiorly subacromial or
subcoracoid.
CT is the best test to evaluate the bony
structure of the AC joint. It assists with imaging
of distal clavicle fractures, displacement of the
Fig. 1. Type V superior dislocation of the acromiocla-
vicular joint.
clavicle, and any arthritic changes. MRI is also an
excellent imaging study to visualize the details of
the injury, including the ligamentous tears. In
AC joint is tender and the distal clavicle is acute AC joint dislocations, however, the routine
generally prominent. With high-grade AC sepa- use of CT and MRI are not necessary.
rations superior and inferior translation can be
detected (positive piano key sign). The active and
passive range of motion should be evaluated. The Treatment
adduction and cross-body adduction test is usu-
The literature on AC joint dislocation is exten-
ally painful around the AC joint. An injection of
sive, reflecting the intense debate surrounding the
a local anesthetic agent normally relieves the pain.
topic. A review of the history of treatment reveals
A neurovascular evaluation is always important
the controversy and the evolution of surgical
although neurovascular injury is rare in AC joint
technique. The general goals of treatment of
injuries.
patients who have AC joint injury are a normal
pain-free range of motion of the shoulder, return of
Radiography strength, and no limitations in activities [1]. The
choice of treatment is influenced by factors includ-
The imaging begins with standard radiographs
ing the type of injury, the patient’s occupation, the
(anteroposterior [AP], lateral, and axillary views).
patient’s past medical history, the acuity of the
Contralateral AP views allow determination of
injury, and patient expectations [11]. The type of
the degree of clavicular displacement. The AP
injury is an important determinant of nonoperative
view identifies the amount of vertical migration of
versus operative treatment. The final decision mak-
the clavicle, whereas the axillary view identifies
ing should take into account the whole patient.
anterior or posterior displacement of the distal
clavicle. The Zanca view provides improved
Type I and II injuries
imaging of the AC joint because it removes the
scapula from the field. In a trauma view the Type I and II AC joint injuries are treated
radiographic beam is cephalic tilted about 10 to nonoperatively [1,11–13]. In these types of
15 degrees. Bilateral anteroposterior stress radio- injuries, the joint retains some of its stability
graphs of the shoulders with 10 to 15 lb weights in [2,3]. Analgesic medication and nonsteroidal
each hand are of limited usefulness, painful, and anti-inflammatory drugs are used to relieve pain.
not recommended in acute injury [8,9]. Our cur- Cryotherapy can be applied on the shoulder to
rent recommendation for routine assessment of reduce swelling and pain. A sling is worn for com-
the AC joint radiographically is an AP or Zanca fort. As the pain and swelling subside, early active
view, a lateral view, and an axillary view. and passive motion and physiotherapy are recom-
In type I injuries, the radiographic examina- mended. Gladstone and colleagues [14] described
tion is normal. In type II, the clavicle is partially a four-phase rehabilitation program: phase 1,
elevated on radiographs but if the clavicle is pain control and immediate protected range of
completely elevated (as much as 100%) this is motion and isometric exercises; phase 2,
AC AND SC JOINT INJURIES 537

strengthening exercises using isotonic contractions published in the orthopaedic literature [22,23].
and proprioceptive neuromuscular facilitation ex- Bannister and colleagues [23] concluded that non-
ercises; phase 3, unrestricted functional participa- operative management of AC dislocation is supe-
tion with the goal of increasing strength, power, rior to early open reduction and coracoclavicular
endurance, and neuromuscular control; and phase screw fixation. They suggest, however, that youn-
4, return to activity with sport-specific functional ger patients who have severe displacement are
drills. Most patients are able to return to normal more likely to achieve an excellent result if the in-
activity in 2 to 4 weeks. An athlete is ready to jury is stabilized early. Larsen and colleagues [22]
return to competitive sports once the following recommended conservative treatment of most
criteria are met: full range of motion, no pain or patients who had AC dislocation except for thin
tenderness, satisfactory clinical examination, and patients who had a prominent lateral end of the
demonstration of adequate strength on isokinetic clavicle and those who did heavy labor.
testing [14]. Most athletes are able to return to Active young patients and overhead throwing
play in 2 to 4 weeks but other authors reported athletes are sometimes considered as special cases.
that some require up to 12 weeks [11]. Some authors suggest that these patients who
have AC joint complete dislocations should be
considered for operative treatment [12,22–25].
Type III injuries
Iannotti and Williams [12] have conducted an
The treatment of type III AC joint injury is still informal survey of physicians involved in the
somewhat controversial. This injury involves care of professional athletes and found that
a complete tear of the AC ligaments and CC most favor a nonoperative approach. These physi-
ligaments. In the Rookwood classification, based cians, however, would consider operative reduc-
on progressive severity of ligament involvement, tion for the throwing athlete. McFarland and
type III injuries are the turning point between the colleagues [26,27] conducted a survey on the treat-
stable type I and II injuries and the unstable type ment of grade III AC separations in professional
IV, V, and VI injuries. throwing athletes with the 42 team orthopaedists
Schlegel and colleagues [15] prospectively stud- representing all 28 major league baseball teams.
ied the natural history of untreated acute grade They found that 29 (69%) of the physicians would
III AC joint dislocation. At 1-year follow-up, the treat the injury nonoperatively, whereas 13 (31%)
objective examination and strength testing of the would operate early for a hypothetical starting
20 patients revealed no limitation of shoulder rotation pitcher who had sustained this injury.
motion in the injured extremity and no difference The nonoperative treatment of type III AC joint
between sides in rotational shoulder muscle injury is similar to that for types I and II. Analgesic
strength. Tibone and colleagues [16] evaluated medication, nonsteroidal anti-inflammatory drugs,
20 patients with an average follow-up of 4.5 years cryotherapy, and a sling for pain and patient
after injury. This study shows that the strength of comfort are used. As the pain and swelling
the shoulder is not significantly affected by conser- diminish, early motion and exercises are initiated.
vative treatment. Phillips and colleagues [17] pub-
lished a literature review and a meta-analysis of Type IV, V, and VI injuries
AC joint injury. They concluded that the literature
These injuries involve rupture of the AC
does not support recommending an operative pro-
ligaments, the CC ligaments, and deltotrapezius
cedure to a patient who has an acute type III AC
disruption with resultant severe displacement of
joint injury. Taft and colleagues [13] also
the distal clavicle. In type IV, the posterior trans-
concluded that most patients should be treated
lation of the distal clavicle into the trapezius
nonoperatively. A comparative analysis of opera-
muscle creates pain and discomfort. Type V,
tive versus nonoperative treatment by Galpin and
with severe superior migration of the clavicle,
colleagues [18] showed that nonoperative treat-
can potentially lead to skin compromise. These
ment provided an equal if not superior result with
rare type VI AC joint injuries generally require
an earlier return to activities, sports, and work.
operative intervention [1,11,12,25,28,29].
Several other studies and review articles advocate
conservative treatment over operative repair
Surgical management
[1,11,12,19–21]. Two prospective randomized con-
trolled studies between conservative and surgical Types IV, V, VI, some specific type III, and
treatment of acromioclavicular dislocation are open AC joint injuries are indications for surgical
538 MACDONALD & LAPOINTE

treatment. The orthopedic literature is replete Fixation between the clavicle and the coracoid
with a wide variety of surgical approaches to treat
Extra-articular stabilization, with a fixation
these injuries [1,12,22,23,30–38]. Many different
between the clavicle and the coracoid, is another
surgical techniques have been described with one
surgical method to address AC joint injuries.
goal in mind: to stabilize the distal clavicle.
Several different techniques have been described
Most surgical options can be grouped into a few
for coracoclavicular fixation. In 1941, Bosworth
general techniques [1,12,25,28]. Those involve pri-
[45] published a method of screw fixation. Several
mary fixation across the acromioclavicular joint,
modifications of this original technique exist
dynamic muscle transfer, fixation between the
(Fig. 3). The surgery consists of an open reduction
clavicle and the coracoid, and ligament
of the AC joint dislocation with the insertion of
reconstruction.
a screw from the distal clavicle to the coracoid
Primary fixation across the acromioclavicular joint process. A concurrent repair of the coracoclavicu-
lar ligaments and deltotrapezius fascia may be
The AC joint dislocation can be stabilized by done. Because of the high rate of hardware migra-
a transfixing device, including Kirschner wires, tion and screw breakage over time, a second
Steinmann pins, or screws (threaded preferred). surgery is usually recommended between 8 and
These techniques can be done percutaneously or 12 weeks postoperatively [12,28]. At times, hetero-
open. In association with the open methods, topic ossification can be seen on follow-up radio-
primary repair of the AC ligaments, coracocla- graphs between the clavicle and the coracoid
vicular ligaments, or deltotrapezius fascia may be process, but this complication does not have a sig-
done. Some concerns and complications are nificant clinical impact [46,47]. The placement of
associated with this technique. These include the screw may be done percutaneously; however,
a second procedure for hardware removal, risk this increases the technical difficulty of the proce-
for hardware migration and breakage [39,40], and dure and has been associated with a higher com-
an increased incidence of AC joint arthritis. plication rate [48]. Using the coracoclavicular
The hook plate, a newer fixation device, is fixation principle, several other techniques have
designed for primary fixation across the AC joint been described to replace the screw. These include
(Fig. 2) [12,25,28,41,42]. The construct involves metallic cerclage fixation, Dacron graft, sutures,
plate fixation of the distal clavicle with a hook suture anchors, or bioabsorbable implants
component that slides under the acromion for [49–53]. Complications associated with these tech-
trans-AC joint fixation. Some authors find this niques are implant specific: failure, erosion of the
technique demanding and associated with a higher bone, infection, and neurovascular injury that can
rate of wound infections and healing problems occur during the passage of the loop around the
[12,41,42]. Most all patients require hardware coracoid process. Specific to the cerclage tech-
removal as the hook component may erode into nique, the distal clavicle may translate anteriorly
the acromion over time. This plate may also be relative to the acromion because of anterior place-
used for distal clavicle fractures [43,44]. ment of the cerclage device on the coracoid. To
avoid this problem, it is recommended that the
cerclage loops be placed around the base of the
coracoid process, as posterior as possible [25,50].

Dynamic muscle transfer

Most surgical stabilizations for complete AC
joint dislocation are static procedures. Dynamic
forms of stabilization have also been described by
different authors [12,28,54,55]. The tendon of the
coracobrachialis and the short head of the biceps
are normally attached to the coracoid process.
The surgical technique involves an osteotomy of
the tip of the coracoid process, which is trans-
ferred to the undersurface of the clavicle. The
Fig. 2. Hook plate fixation of a type V acromioclavicu- inferior pull of the conjoint tendon on the clavicle
lar joint dislocation. should dynamically hold the AC joint reduced.
AC AND SC JOINT INJURIES 539

Fig. 3. Coracoclavicular screw fixation and distal clavicle excision to stabilize the distal clavicle (A). Because the screw
had limited purchase in the coracoid, failure occurred (B).

Complications associated with this technique Anatomic reconstruction

include traction injury to the musculocutaneous
Most recently, authors have advocated ana-
nerve, delayed union, nonunion, and excessive
tomic reconstruction of the different ligament
motion at the AC joint because of the dynamic
complexes (coracoclavicular and acromioclavicu-
nature of the reconstruction.
lar ligaments) using free grafts [1,12,34]. Recent
biomechanical studies have demonstrated that
anatomic reconstruction with free graft provided
Ligament transfers and soft tissue reconstruction better stability than other ligament transfers
[56–58]. Mazzocca and colleagues [56] did a con-
Another static form of surgical stabilization of
trolled laboratory study to compare a newly
the AC joint consists of a ligament transfer or soft
developed anatomic coracoclavicular ligament
tissue reconstruction. The most common is the
reconstruction with a modified Weaver-Dunn pro-
Weaver-Dunn technique, described in 1972 for
cedure. They concluded that the anatomic coraco-
acute and chronic AC joint dislocation [38]. This
clavicular reconstruction has less anterior and
procedure consists of excision of the distal clavi-
posterior translation and more closely approxi-
cle, release of the coracoacromial ligament from
mates the intact state, restoring function of the
its acromial attachment, and transfer to the distal
acromioclavicular and coracoclavicular ligaments.
clavicle. Since its first description, many variations
Costic and colleagues [57] published a controlled
of the procedure have been published. Those var-
laboratory study to evaluate the cyclic behavior
iations include release of the coracoacromial liga-
and structural properties of an anatomic tendon
ment with or without a small flake of acromial
reconstruction of the coracoclavicular ligament
bone and augmentation with coracoclavicular fix-
complex. They concluded that the anatomic
ation. In 2007, Jiang and colleagues [31] described
reconstruction approximates more closely the
another type of dynamic transfer of the conjoint
stiffness of the coracoclavicular ligament complex
tendon. The surgical procedure consists of trans-
than current nonanatomic reconstructions.
fer of the lateral half of the conjoined tendon to
the distal aspect of the clavicle with additional
coracoclavicular fixation (double-loaded number
Author’s preferred method
2 Ethibond suture anchor). They found this tech-
nique useful because it spares the coracoacromial The senior author has previously described his
ligament, which serves as a static stabilizer against recommended technique for acromioclavicular
anterosuperior migration of the humeral head. dislocation [34]. This technique consists of an
This technique can also be helpful in cases of open distal clavicle resection and anatomic stabili-
a weak or thin coracoacromial ligament and in zation with a free semitendinosus allograft com-
revision cases in which the coracoacromial bined with heavy nonabsorbable suture as an
ligament has already been harvested. augmentation and coracoacromial ligament
540 MACDONALD & LAPOINTE

transfer (acromion based) to augment the recon- then sutured with number 2 nonabsorbable
struction of the AC ligaments. sutures to secure it through drill holes in the
distal clavicle. These sutures are not tied until the
suture braid is tied and the clavicle is reduced.
Preferred technique
The clavicle is then reduced into position with
The patient is placed in a modified beach chair respect to the coracoid and the distal clavicle. The
position with the head of the bed elevated braided suture limbs are then tied to secure the
20 degrees and a 1-L intravenous bag under the construct so that the knot is located inferiorly
affected scapula. A free limb drape is used with between the clavicle and the coracoid. This suture
adequate exposure of the AC joint area. An augment acts as an internal splint until tendon-
incision is made in Langer lines from the posterior graft incorporation occurs biologically. The trans-
extent of the distal clavicle anteriorly to the level ferred coracoacromial ligament can now be tied
of the coracoid. Dissection is carried down first to securely to the distal clavicle. The semitendinosus
the distal clavicle. In type IV and V AC joint tendon graft is passed and tied so that the knot in
injures, the clavicle is herniated through the the tendon lies superior to the clavicle.
trapezius fascia and is irreducible without bony As a final step, any free excess ends of the
resection or soft tissue release. The distal 1 cm of tendon graft are folded over and sutured to
the clavicle is resected with an oscillating saw in the reconstructed AC ligaments (acromial-based
a line perpendicular to the shaft of the clavicle. coraco-acromial ligament). The deltoid and the
Further dissection is then carried down to the deltotrapezius fascia are then closed to cover the
coracoid, which involves splitting the overlying augment suture knot and the top of the clavicle.
deltoid muscle fibers. Subperiosteal dissection A subcuticular suture completes wound closure.
proceeds around the coracoid approximately Postoperatively, the patient is placed in a sling,
3 cm posterior from its tip, followed by passing and gentle pendulum exercises are started imme-
a curved suture passing device around the cora- diately. Active assisted exercises are delayed until
coid at its base. At this point, a double number after postoperative week 4. Active motion then
1 monofilament suture is passed around the follows at week 6, with resisted exercises started at
coracoid. week 8. Full return to contact sports or heavy
As the dissection is performed, the free semite- labor typically occurs around weeks 14 to 16.
ndinosus graft is prepared by passing leading
sutures (number 2 nonabsorbable) to secure either
end. Two number 2 heavy nonabsorbable Fibre-
Sternoclavicular joint dislocation
wire sutures (Arthrex, Naples, Flordia) are used
as an augment to the semitendinosus graft. The Sternoclavicular (SC) joint dislocation is an
graft is first passed around the coracoid using the uncommon injury. It is of two general types:
single suture as a shuttle to pass the leading anterior and posterior. The posterior dislocation
sutures. Subsequently, the augment is passed is much less common than anterior dislocation.
along the same path. The SC dislocation may follow direct force to the
The distal clavicle is prepared next. In an clavicle or more commonly from an indirect force
attempt to replicate the natural anatomy, two to the shoulder. The direction of the force on the
holes are drilled through the clavicle at the origins shoulder usually determines the type of disloca-
of the conoid and the trapezoid ligaments (Fig. 4). tion. When an anterolateral force compresses the
This procedure is done by first passing a guidewire clavicle toward the sternum and propels the
and then reaming to the appropriate diameter shoulder backward, this produces an anterior
derived from the measured limbs of the semitendi- dislocation of the SC joint. Also, a posterolateral
nosus graft along with one limb of the suture aug- compression on the shoulder moves it forward
ment. The composite graft limbs are then passed and the force directed toward the clavicle pro-
through their respective holes in the clavicle to duces a posterior dislocation. In addition, many
anatomically reconstruct the coracoclavicular presupposed SC dislocations in patients younger
ligaments. than 25 years old are actually fractures through
To strengthen the reconstruction, the coracoa- the physeal plate. The medial clavicular epiphysis
cromial ligament is mobilized off its insertion on may not close until this age. Those physeal
the coracoid so that it can rotate on its attachment injuries represent Salter-Harris type I or II
on the acromion. The free end of the ligament is fractures.
AC AND SC JOINT INJURIES 541

Fig. 4. Acromioclavicular joint reconstruction. Drill tunnels are created in the distal clavicle at the origin sites of the
conoid and trapezoid ligaments (A). A semitendinosus tendon graft and an absorbable suture augment are passed
around the base of the coronoid (B). The distal clavicle is reduced and the tendon graft and suture augment are tied (C).

The SC joint is the only bony articulation At physical examination, the affected shoulder
between the limb and the upper extremity. It is usually appears shortened. In general, the patient
a saddle-type synovial joint. The capsule sur- has edema, tenderness, and ecchymoses over the
rounding the joint is reinforced by different SC joint. Pain is exacerbated with range of
ligaments, including, superiorly, the interclavicu- motion. Palpation can reveal an anterior and
lar ligament, and inferiorly the costoclavicular medial protrusion in anterior dislocations.
ligaments and the anterior and posterior SC In posterior dislocations, findings may be more
ligaments. The articular cartilage is mainly fibro- subtle. It is important to check vital signs and the
cartilaginous. The articular surfaces are separated circulation to the upper extremity with posterior
by a fibrocartilaginous articular disc. It is located dislocations because mediastinal structures may
inside the joint and divides it into two synovial be compressed. The patient should also be asked
cavities. This disc is an important shock absorber about shortness of breath from possible tracheal
of forces transmitted along the clavicle. impingement.
Patients who have an SC joint injury com- Imaging studies are an important step in the
monly complain of anterior chest and shoulder evaluation of a patient who has an SC joint injury.
pain after usually a violent injury. The most Routine radiographs rule out other injuries, such
common cause of SC dislocation is motor vehicle as clavicle fractures, rib fractures, or a sternal
collisions followed by athletic injuries and falls. fracture. Radiographs are difficult to interpret for
The pain is exacerbated by arm movement or by SC joint dislocations because of overlying
assuming a supine position. Other symptoms, shadows. The serendipity view, a specialized
such as dyspnea, stridor, dysphagia, and pares- view described by Rockwood, may help to
thesias, may be the result of a posterior SC determine the clavicle position. The beam is tilted
dislocation with compression of adjacent to 40 degrees from vertical and directed cephalad
structures. through the manubrium of the patient while in
542 MACDONALD & LAPOINTE

a supine position. A CT scan, however, is a better a progressive program of range of motion and
imaging modality to evaluate SC joint injury. strengthening. Surgical stabilization of the clavicle
A CT scan allows evaluation of both SC joints, is not recommended by most authors [12,59,60].
provides important information on the vital In most cases, the risks of surgery outweigh the
structures of the superior mediastinum, and helps potential benefits. The literature reports signifi-
to distinguish a physeal injury in younger patients. cant complications, such as hardware migration,
infections, recurrence of the dislocation, and non-
cosmetic results. Operative treatment should be
Treatment of anterior sternoclavicular
considered only in symptomatic patients who
joint dislocation
have failed conservative treatment. (See posterior
The treatment of acute anterior SC joint dislocations section for more surgical details.)
dislocations is controversial. It is difficult to study
with a well-designed prospective study because of
Treatment of posterior sternoclavicular
the low frequency of this injury. A few studies in
joint dislocation
the literature can help us with the choice of
treatment, however. Most anterior dislocations Posterior dislocations are much less common
have little long-term functional impact [59,60]. than anterior dislocations. Posterior dislocations,
One study reported long-term follow-up results however, are more serious and associated with
in 10 patients treated nonoperatively [61]. The significant complications and require prompt
results of treatment were good in 7 patients, fair attention. Initially, a complete examination of
in 2 patients, and poor in 1 patient. They the patient is important for the diagnosis of
concluded that nonoperative management is the a posterior SC joint injury and for other associ-
treatment of choice. Also, the contribution of ated lesions secondary to mediastinal compression
the clavicle for most daily activities is minimal by the clavicle. Behind the SC joint and the inner
[59]. In most cases, the joint remains unstable third of the clavicle are vital anatomic structures.
regardless of the treatment [12,59,60]. A study Some of these vital structures include the
by Savastano and Stutz [62] reported the results innominate artery, innominate vein, vagus nerve,
of 12 patients treated closed and open. They con- phrenic nerve, internal jugular vein, trachea, and
cluded that stability of the SC joint is not neces- esophagus. If other lesions are associated, appro-
sary to ensure normal function of the involved priate consultants should be called in before any
limb. They also found that residual prominence specific treatment. Most authors recommend that
of the medial portion of the clavicle does not closed reduction is the initial treatment
cause pain and does not interfere with shoulder [12,59,60,64]. A cardiothoracic surgeon should
function. be present during the reduction.
Despite the common residual instability of The closed reduction is performed under gen-
anterior dislocations, most authors recommend eral anesthesia. Many different techniques have
at least one closed reduction attempt [12,59,60]. been described for closed reduction. The standard
A study by Nettles and Linscheid [63] treated abduction traction technique is similar to the
14 patients with closed reduction. Eleven had no technique used for anterior dislocations. The
recurrence or pain. The reduction may be per- patient is supine with the shoulder of the injury
formed with local anesthetic, under sedation, or side near the edge of the table with a thick pad
under general anesthesia. The patient is placed between the scapulas. Lateral traction is applied
supine with a thick pad between the shoulders. with the arm in abduction and extension.
The reduction entails abduction of the shoulder If reduction is not obtained, the clavicle can be
to 90 degrees, 10 to 15 degrees of extension, and grasped with the fingers to dislodge it from behind
traction on the arm with posterior pressure over the sternum. If the clavicle is still dislocated,
the medial end of the clavicle [60]. Immobilization a towel clip is used to grasp it and it is lifted
after the closed reduction depends on the stability back into position. This procedure is always done
of the joint. If the anterior dislocation reduced with sterile technique. When the clavicle is
and is stable, the patient is immobilized in a sling reduced after a posterior dislocation, it is usually
for 6 weeks. At week 3, the patient should start stable.
elbow exercises and glenohumeral rotation. In After reduction, the patient should be immo-
an unstable SC joint, a sling is used for a few bilized in a figure-of-8 strap for 6 weeks. Active
weeks until symptoms resolve, followed by assisted range-of-motion exercises are started at
AC AND SC JOINT INJURIES 543

3 to 4 weeks. Usually, full activities and sport can progressive strengthening exercises can be allowed
be allowed around 12 to 16 weeks. around 12 weeks.

Surgical treatment posterior sternoclavicular References

joint dislocation [1] Mazzocca AD, Arciero RA, Bicos J. Evaluation and
The complication rate of posterior dislocations treatment of acromioclavicular joint injuries. Am
of the SC joint is high [65]. Also, most patients J Sports Med 2007;35(2):316–29.
[2] Fukuda K, Craig EV, An KN, et al. Biomechanical
cannot tolerate posterior dislocation of the SC
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