Carl J Basamania Elizabeth G Matzkin and George K

In This Chapter

Clavicle fractures

Nonoperative management Surgery

Plate fixation Intramedullary fixation Sternoclavicular joint disorders Degenerative conditions Atraumatic subluxation/dislocation Traumatic injury/dislocation Surgery—sternoclavicular (S-C) reconstruction

CLAVICLE

Clinical Features and Evaluation

Displaced fractures of the clavicle are easily diagnosed if the patient is seen soon after injury. Patients usually present with an obvious clinical deformity and a consistent history of some form of direct or indirect injury to the shoulder. The proximal frag ment is commonly displaced upward and backward and may be tenting the skin. Mobilization of the extremity elicits pain, and therefore the patient prefers to splint the involved extremity at the side in a forward and downward position due to the weight of the arm and pull of the pectoralis minor muscle. This position may accentuate the posterosuperior angulation seen in most clavicle fractures. The acute swelling and hemorrhage may hide the initial injury and deformity. In a fracture in close proximity to the acromioclavicular or sternoclavicular joints, the deformity may mimic a purely ligamentous injury.

Examination reveals tenderness to palpation over the fracture site and pain with any attempts at movement. There may be a significant amount of bruising over the fracture site, especially with severely displaced fractures. This indicates a tearing of the underlying soft tissues. Some patients may present with their heads tilted toward the injury, relaxing the pull of the trapezius. Alternatively, some may tilt their chin to the opposite side to decrease the pull of the sternocleidomastoid. A complete and thorough examination should rule out any associated injuries to the entire extremity, lungs, scapula, chest wall, and neurovas-cular structures.

Nondisplaced fractures or isolated fractures of the articular surfaces may not cause deformity and may be overlooked unless they are specifically sought for radiographically. If the diagnosis is in doubt, special radiographs or a repeat radiograph of the clavicle in 7 to 10 days may be indicated.

Radiographic Evaluation

In most cases, the diagnosis of a clavicular fracture is fairly obvious with the clinical deformity and confirmatory radiographs. Unfortunately, many physicians obtain only an antero-posterior radiograph of the shoulder when a clavicle fracture is suspected. Due to the unusual shape and orientation of the clavicle, it is difficult to adequately determine displacement and angulation on a single anteroposterior radiograph. This is due to the fact that the plane of the fracture is not perpendicular to the plane of the x-ray beam. The clavicle not only shortens, but it also becomes angulated inferiorly and rotated medially; therefore, the deformity is truly in three planes. It is extremely difficult, if not impossible, to characterize the true deformity with radiographs. For the most accurate radiographic evaluation of the fractured clavicle possible, at least two projections of the clavicle should be obtained: an anteroposterior view and a 45-degree cephalic tilt view. In the anteroposterior view, the proximal fragment is characteristically displaced upward and the distal fragment downward (Fig. 27-1A). In the cephalic tilt, the tube is directed from inferior, projecting upward. This view more accurately reveals the anteroposterior relationship of the two fragments and hence is the best view for assessment of

INTRODUCTION

• Clavicle fractures account for 1 of every 20 fractures1 and most occur in men and women younger than the age of 25. Most commonly they are secondary to participation in contact or collision sports.

• Eighty percent of these fractures occur in the middle one third, 12% to 15% in the lateral one third, and 5% to 6% in the medial one third of the clavicle.2

• Most fractures of the clavicle unite by various treatment methods including benign neglect, sling, sling and swathe, figure-eight, Velpeau dressing, collar and cuff, external fixation, and open reduction and internal fixation with plates, screws, or intramedullary pins.

• Each treatment option has been shown to allow for fracture healing, nearly normal function, cosmesis, activity level, and satisfaction, but more recent studies have suggested that the satisfaction that patients achieve after fractures of the clavicle may not be as high as previously thought.3-5

• Many patients are left with some residual deformity and shortening. The ultimate goal of treatment is to restore the anatomy and allow rapid and safe return of the athlete to sports participation.

Figure 27-1 A, Preoperative anteroposterior radiograph of a patient with a middle third clavicle fracture. B, Preoperative 45-degree cephalic tilt radiograph of same patient.

displacement (see Fig. 27-1B).6 An axillary view with the beam angled slightly cephalad can also help determine fracture displacement and can be useful in assessing possible nonunions.

Rowe7 has recommended that with an anteroposterior radiograph, the film should include the upper third of the humerus, the shoulder girdle, and the upper lung fields to rule out any associated injuries. The fracture personality is also important to assess because it may give a clue to the presence of associated injuries. Normally the clavicular shaft fracture in the adult is slightly oblique; however, if there is significant comminution, this is indicative of significant force and neurovascular and pulmonary injuries must be ruled out.

Relevant Anatomy

The clavicle is the first bone in the body to ossify, around the fifth fetal week, but the medial physis does not fuse until young adulthood at ages 22 to 25. This is important in order to distinguish medial clavicle physeal injuries from fractures in this age group. The clavicle is an S-shaped bone that is anchored by strong ligamentous attachments on both its medial and lateral ends.

Muscular attachments to the clavicle include the sternoclei-domastoid, pectoralis major, and subclavius muscles proximally and the deltoid and trapezius muscles distally. There are no muscular or ligamentous attachments on the middle section of the clavicle, and this supports the fact that most fractures occur in this area. There is thin coverage of the superior aspect of the clavicle by the platysma muscle. The supraclavicular nerves lie just below the platysma muscle, which give sensory innervation to the overlying skin and after injury may result in painful neuroma. Below the clavicle lie the important neurovascular structures: the subclavian vessels and brachial plexus. These are protected by the clavipectoral fascia within the costoclavicular space. The medial cord of the brachial plexus (ulnar nerve) is located in the smallest portion of the costoclavicular space and can be compromised by fracture or healing callus.8

Behind the medial clavicle and the sternoclavicular joint, the internal jugular and subclavian veins join to form the innominate vein. Medially, the omohyoid fascia covers the internal jugular and subclavian veins. The myofascial layer also protects the sub-clavian and axillary veins at the middle and medial thirds behind the clavicle.9

Treatment Options

The concept of nonoperative treatment historically has consisted of bracing the shoulder girdle to raise the outer fragment upward, outward, and backward; depressing the inner fragment; maintaining the reduction; and enabling the ipsilateral elbow and hand to be used so that associated problems with immobilization can be avoided. Review of the literature indicates that immobilization of a clavicle fracture is virtually impossible to accomplish and shortening and deformity are often the results. Historically, clavicle shortening appeared to be inconsequential; however, more recent data indicate that this is one of the most significant predictors of an unsatisfactory outcome.10,11 There are numerous methods to attempt to immobilize the clavicle, ranging from long-term recumbency,12,13 various types of ambulatory treatment,14 and numerous internal fixation methods.15-25

Partial immobilization can be performed by numerous bandaging methods such as a sling, sling and swathe, Velpeau dressing, figure-eight, or cuff and collar. These options are used to treat many middle third or shaft fractures. It is important to understand that the injury radiographs are predictive of the fracture healing results, and a completely displaced or shortened fracture is more likely to stay in this position regardless of the immobilization method used. A reduction maneuver may be performed and if crepitus between the two fractured ends of the clavicle are felt, then it may be more likely that the fracture will go on to union. If there is no crepitus felt, then soft tissue may be interposed and this may contribute to fracture nonunion.25

Operative treatment of clavicle fractures (external fixation or open reduction internal fixation) should be considered in the following cases:

1. Open fractures requiring debridement.

2. Neurovascular compromise that is progressive or nonre-sponsive to reduction maneuvers.

3. Displacement (angulation and comminution) that tents the skin.

4. Polytrauma patients that may need to use upper extremities for mobilization purposes.

5. The "floating shoulder" injury (clavicle and unstable scapular fracture with compromised acromioclavicular and coracoacromial ligaments).

6. Type II distal clavicular fractures.

7. Factors that render the patient unable to tolerate closed immobilization, such as with neurologic problems.25

8. Patients for whom the cosmetic lump over the healed clavicle is intolerable.

9. Relative indications are shortening of more than 15 to 20 mm and displacement greater than the width of the clavicle.

Medial clavicle fractures and physeal injuries are easily and best treated by nonoperative measures. One must also rule out sternoclavicular injuries in these cases, which may require additional treatment. Middle third clavicle fractures, which are the most common, can also be managed nonoperatively. The most concerning fractures of the midshaft of the clavicle are generally those that have absorbed the greatest energy. In the senior author's experience, these higher energy fractures tend to have a remarkably consistent pattern: shortened and comminuted with an anterior/inferior butterfly fragment. Soft-tissue injury and stripping are significant, leading to greater instability, all of which increase the risk of nonunion. It is our belief that these fractures are best treated with open reduction and internal fixation. Distal clavicle fractures, if nondisplaced, can be treated nonoperatively. If displaced, one must determine the integrity of the coracoclavicular ligaments. If the coracoclavicular ligaments or some portion of them remain attached to the medial clavicular fragment, then the coracoclavicular interval will be maintained and prevent further displacement of the fracture ends. If the coracoclavicular ligaments are not attached, then the medial fragment can displace, with an increased risk of nonunion. In unstable cases, operative stabilization of the cora-coclavicular interval may be indicated.

Techniques

Open reduction and internal fixation can be performed by intramedullary devices or plate fixation. Plate fixation can be performed with a six- to eight-hole low-contact dynamic compression or reconstruction plate. Semitubular plates are less rigid and have a high risk of failure. The patient may be placed in a beach chair position. The fracture is exposed through a curvilinear incision. The platysma muscle is incised in line with its fibers, and care is taken to protect the branches of the supra-clavicular nerve. The periosteum is sparingly stripped off the superior surface of the clavicle for plate application. Care must be taken when drilling and placing screws to avoid injury to the underlying subclavian vessels and thoracic cavity. A malleable retractor may be placed beneath the clavicle to protect the drill from unintentionally entering the thorax. The screw-plate fixation is performed using standard AO techniques. The plate does have the disadvantage of requiring a second operation to remove the hardware if its prominent position irritates the skin after healing. Also, the screw holes weaken the bone and protection is needed after hardware removal.

At our institution, intramedullary fixation is used for most of these fractures with a modified Hagie pin (Depuy Orthopaedics). We prefer this method for several reasons. First, the exposure for an intramedullary pin is much smaller than what is necessary for a formal open reduction and internal fixation with plates and screws. This preserves what remains of the soft-tissue envelope. The intramedullary pin allows for compression at the fracture site and load sharing, which has been shown to be advantageous in the healing of other long bone fractures. The intramedullary pins come in different sizes to allow for proper canal fill and can easily be removed under local anesthesia. Last, unlike plate and screw fixation, placement of the intramedullary pin allows us to avoid drilling in the direction of the lungs and neurovascular structures.

The patient is placed in a beach chair position on the operating table. A radiolucent shoulder-positioning device optimizes clavicle and shoulder visibility and an image intensifier or a C arm facilitates pin placement. A 2- to 3-cm incision in Langer's lines over the distal end of the medial fragment is made. Care

Figure 27-2 Incision over distal end of medial fragment. Splitting platysma muscle in line with its fibers.

is taken to prevent injury to the thin platysma muscle, which can be divided in line with its fibers using scissors (Fig. 27-2). The middle branch of the supraclavicular nerve, which is usually found directly beneath the platysma muscle near the mid-clavicle, should be identified and protected.

The proximal end of the medial clavicle is elevated through the incision using a towel clip, elevator, or bone-holding forceps. Once the appropriate sized drill is attached to the ratchet T handle or a power drill, the intramedullary canal is reamed and then tapped without penetrating the anterior cortex. Proper sizing is important. If the fit is too loose, the fixation will not be adequate, and if the fit is too tight, this may compromise the integrity of the bone. The C arm is used to assess the orientation of the drill (Fig. 27-3).

DUKEASC 03.r¿2/ZCKM 12:10:29 PW

Figure 27-3 Drill positioned in medial fragment.

The lateral fragment is then elevated through the incision. The arm may be placed in external rotation to facilitate positioning of the lateral fragment canal. The same size drill used in the medial fragment is used to drill the intramedullary canal of the lateral fragment followed by the appropriate tap. Under C-arm guidance, the drill is advanced out through the posterolateral cortex of the clavicle, usually at the level of the coracoid.

While holding the distal fragment with a bone clamp, the nuts from the pin assembly are removed and the smaller trocar end of the DePuy clavicle pin are passed into the medullary canal of the lateral fragment. The pin should exit through the previously drilled hole in the posterolateral cortex. The pin tip can be felt subcutaneously, and a small incision is created over this area. The Jacobs chuck and T handle is attached to the end of the pin protruding laterally, and the pin is pulled in a retrograde fashion into the lateral fragment.

The shoulder and lateral fragment may be elevated by pushing up on the bent elbow to facilitate fracture reduction. The pin is then advanced into the medial fragment and the fracture reduced, ensuring that all threads of the pin are across the fracture site. Pin position and fracture reduction are then verified by the C arm or by obtaining a radiograph. The medial nut is then placed on the pin, followed by the smaller lateral nut. The two nuts are cold-welded together. The T-handle wrench is then placed on the medial nut and the pin backed out until the lateral nut is seen at the skin surface. A double-action pin cutter is used to cut the pin flush with the lateral nut. The pin is then advanced back in the medial fragment using the lateral wrench. The pin can generate considerable compression force, and care must be taken not to overreduce the fracture.

The common butterfly fragment may be cerclaged into a reduced position using no. 1 polydiaxone monofilament suture passed beneath the fragment and protected with a Crego elevator. The periosteum, platysma muscle, and skin are then reap-proximated. Postoperative radiographs confirm reduction (Fig. 27-4).

Postoperative Rehabilitation

The patient is placed in a sling for comfort postoperatively but may remove it when comfort allows. The patient is allowed to resume daily living activities as soon as tolerated but is instructed to avoid strenuous activities such as pulling, lifting, or pushing and arm elevation higher than face level for 4 to 6 weeks. Sutures are removed at 7 to 10 days. Radiographs are

Figure 27-4 Postoperative reduction anteroposterior radiograph.

obtained at the 4- to 6-week postoperative clinic visit. If the fracture appears clinically healed (nontender, palpable callus), the patient can advance to daily activities as tolerated. The patient should be seen at 8 to 12 weeks postoperatively. Once radiographs (anteroposterior and 45-degree cephalic tilt antero-posterior radiographs) show healing of the fracture, the pin is removed.

The pin can be removed in the office or in an ambulatory surgery setting. We typically use local anesthesia, which may be supplemented with IV sedation. Following pin removal, patients may resume activities of daily living as tolerated but are asked to refrain from strenuous or competitive sports for 6 weeks. If open reduction and internal fixation with plate and screws are performed, hardware removal is not routine, unless the plate and screws are prominent or are causing patient discomfort after evidence of fracture healing. This must be done through the initial incision in the operating room. Protection after plate removal is warranted for an extended period of time to avoid refracture.

Complications and Results

Complications of both plate and pin fixation include infection, hardware breakage, neurovascular compromise, refracture, malunion, and nonunion.11,26-32

Shen et al27 treated 251 middle third clavicle fractures with a 3.5-mm reconstruction plate. Average time to union was 10 weeks with 7 nonunions, 14 malunions, and 5 infections; 28 had residual skin numbness and 171 eventually required plate removal. Overall, 94% were satisfied with the end result. Bostman et al26 treated 103 middle third clavicle fractures with plate fixation and 24 (23%) had 1 or more complications, including infection, plate breakage, nonunion, and refracture after plate removal. Results of plate fixation have been favorable for both malunions and nonunions with or without bone grafting.11,28

Prior to the introduction of a specifically designed clavicle pin, the use of intramedullary devices has historically been fraught with complications, mostly secondary to pin migra-tion.29,30 More recently, intramedullary pin fixation using a specifically designed clavicle pin has had excellent results.31,33 Boehme et al33 treated 21 patients with a clavicle nonunion with a modified Hagie pin and bone grafting and showed healing in 20 of 21 of them. Wu et al32 compared plate and intramedullary nail fixation with bone grafting in 33 patients with a middle third clavicular nonunion and noted a higher union rate and lower complication rate in the intramedullary group. Complications of the clavicle pin, in our experience, have been potential posterior skin breakdown from a prominent pin, possible skin numbness in the supraclavicular nerve distribution, and rarely nonunion.

Conclusions

Clavicle fractures are common and treatment historically has been conservative.

The ultimate goal of treatment is to achieve bone healing with minimal morbidity while avoiding loss of function and residual deformity. Nonoperative immobilization of the clavicle is nearly impossible and shortening is customary, resulting in altered bio-mechanics of the shoulder girdle. Recent studies indicate that displaced midshaft clavicle fractures have a higher nonunion rate (15% to 25%)10,34 than previously thought, and as many as half of patients are symptomatic as long as 10 years after injury.10 In view of this, we recommend operative intervention for displaced and shortened midshaft clavicle fractures, particularly in high-demand individuals and athletes. The clavicle pin offers an easy and safe method of treatment for most clavicle fractures with excellent results both cosmetically and functionally.

Sternoclavicular Joint

Relevant Anatomy

The S-C joint is the isolated articulating point for the upper extremity to the axial skeleton. The blood supply to the joint arises from the clavicular branch of the thoracoacromial arch, with contributions from the internal mammary and suprascapu-lar arteries. The innervation of the S-C joint is from both the nerve to the subclavius and the medial suprascapular nerve. The joint ends are flattened, with poor congruity, and relatively little innate stability. The joint surface of the medial end of the clavicle is much larger than the corresponding joint surface of the sternum.35 The superior portion of the clavicle is easily palpable in the sternal notch. A thick intra-articular disk is present, which improves the articular congruity. The disk is attached to the first rib and sternum inferiorly and superiorly to the superior border of the clavicle. The major ligaments supporting the joint are the anterior and posterior S-C ligaments. The costoclavicular ligaments run from the superior surface of the first rib to the inferior surface of the medial clavicle. The interclavicular ligament runs between the medial ends of both clavicles, attaching to the anterior surface of the sternum (Fig. 27-5). The epiphysis on the medial end of the clavicle is the last to ossify, at 18 to 20 years, and the last to close, at age 23 to 25.

Range of Motion

Motion of the S-C joint is directly linked to upper extremity motion. Fusion of the S-C joint has been shown to severely limit shoulder abduction. The sternum remains fixed as the clavicle moves in rotation, elevation, and levers anterior to posterior with upper extremity motion. The main resistance to rotation comes from the anterior and posterior S-C ligaments. The intra-articular disk resists superior translation of the medial end of the clavicle. The anterior capsule resists anterior translation. The posterior capsule is the most important restraint to posterior translation of the S-C joint.36 The subclavius muscle functions as a dynamic stabilizer during activity.

Pathology

Degenerative Conditions

Osteoarthritis is the most common degenerative condition occurring in the S-C joint. It may occur as a primary process or secondary to injury/chronic instability. Other degenerative conditions include rheumatoid arthritis, gout, Reiter's syndrome, condensing osteitis, sternoclavicular hyperostosis, and psoriasis.37

Atraumatic Subluxation/Dislocation

Spontaneous instability of the S-C joint has been well described.38 It most commonly occurs in young patients and is associated with ligamentous laxity in other joints. The patient is typically able to displace the medial end of the clavicle anteriorly with abduction or overhead motion. The condition is rarely symptomatic, and conservative treatment is usually acceptable. Attempting to operatively stabilize the joint in these patients is generally unsuccessful and should be avoided.

Trauma

Mechanisms of injury to the S-C joint can be viewed in two ways: direct blows and indirect force applied to the shoulder or upper back. As previously described, the medial epiphysis of the clavicle can persist into the mid-20s. Injuries to the epiphysis can mimic S-C joint injuries. Sprains and subluxations to the SC joint can also be seen. These typically present as isolated pain and swelling. A spectrum of injuries can be grouped into three categories: type I (sprain), type II (subluxation), and type III (dislocation).39 Recurrent subluxations can occur and should be treated similarly to the methods described in the following for traumatic dislocations. The two primary directions of dislocation are anterior and posterior.

Anterior dislocations occur more frequently than posterior. The most common mechanism is sports-related injuries. A com-pressive force is applied to the anterolateral shoulder, whether by a direct blow or traction, and the medial clavicle dislocates anteriorly. The injury presents with pain and swelling over the medial end of the clavicle. The patient will usually support the affected arm in internal rotation and resist any shoulder motion. The medial end of the clavicle can be palpated anterior to the sternum.

Posterior dislocations typically result from a direct blow to the medial end of the clavicle or compressive force applied to the posterolateral shoulder. This is seen most commonly in motor vehicle accidents and sports and crush injuries. There may be swelling over the S-C joint and a palpable defect where the medial clavicle would normally be felt. The patient will again resist any motion of the involved shoulder. More concerning symptoms can manifest with posterior dislocations because of pressure on the vital structures posterior to the joint. Shortness

Figure 27-5 Anatomy of the sternoclavicular joint.

Anterior sternoclavicular ligament

Interclavicular ligament

Intra-articular disk

Subclavius muscle and tendon

Costoclavicular ligament

Intra-articular disk of breath, hoarseness, or difficulty swallowing can be seen. Venous congestion of the involved arm or neck may also be present.

Radiographic Evaluation

The S-C joint is difficult to visualize on plain chest or shoulder radiographs. The shadows from surrounding structures overlap the outlines of the joint. Several radiographic views have been described in a specific attempt to better visualize the S-C joint. The most familiar is the serendipity view, initially described by Rockwood and Wirth.39 The view is obtained by placing the patient supine, with the x-ray cassette placed under the upper shoulders and neck. The x-ray beam is centered on the upper chest and tilted 40 degrees off of vertical. Plain tomography was originally described as the preferred way to visualize S-C joint injuries. When available, tomograms can be a simple, inexpensive way to evaluate the joint.

Computed tomography is now recognized as the most reliable way to identify abnormalities of the S-C joint. Fine-cut sections (1 to 2 mm) through the joint can easily define medial clavicle fractures, dislocations, or degenerative changes. Computed tomography should be performed to visualize any acute injury to the S-C joint. For posterior dislocations, compression of structures behind the medial end of the clavicle can be well seen on computed tomography. Efforts have been made to visualize structures of the S-C joint with magnetic resonance imaging. While not as well accepted as computed tomography for trauma, magnetic resonance imaging has been found to reliably identify damage to the intra-articular disk and supporting ligamentous structures.40

Treatment Options

Sprains (type I injuries) and subluxations (type II injuries) should be treated with ice and rest initially. A sling to prevent painful motion is useful. Persistent subluxations may require reduction by retracting the shoulders. Mild sprains should be protected for 1 to 2 weeks and then may gradually return to regular activity. More significant sprains or subluxations should be protected for 4 to 6 weeks. Occasionally, the subluxation may progress to chronic instability. Treatment for this eventuality is addressed in that section.

Medial clavicle epiphysis displacement must be considered when evaluating injuries to the S-C area in young patients. Most injuries can be treated conservatively, with the expectation that some remodeling of the deformity will occur. Symptomatic posterior deformities should be reduced. If the closed reduction is unsuccessful, an open reduction and possible internal fixation should be performed.41

The treatment of traumatic anterior dislocations is not clearly defined. There are reports of good outcomes with conservative management.42 However, an initial attempt at closed reduction may reduce the deformity. Closed reduction usually requires IV sedation or general anesthesia. The patient is placed supine, with a towel or pad between the shoulders. The affected shoulder is pushed posterior, while manual pressure is used to reduce the medial end of the clavicle. The medial end of the clavicle is frequently unstable after the reduction. If a closed reduction cannot be maintained, conservative management is the best course. Operative stabilization is not recommended for the initial treatment of unstable anterior dislocations. If the reduction remains stable, the arm should be placed in a sling. Retraction and elevation of the shoulder should be avoided. A

figure-eight wrap can be used to assist. These limitations should be followed for 6 to 8 weeks before activities progress.

Acute posterior dislocations need extremely careful evaluation. Associated intrathoracic injuries are commonly seen. Hoarseness or difficulty swallowing can indicate pressure on the trachea or esophagus. Venous congestion in the affected arm or jugular distention can indicate pressure on the great vessels. If these symptoms are present, a general or thoracic surgeon should be consulted. Computed tomography is indicated, possibly combined with arterial contrast, to evaluate the position of the medial clavicle and vascular structures. Attempted closed reduction should only be performed after careful preparation. Most authors agree that the reduction should be done in an operating room under general anesthesia. The positioning is the same as described for the reduction of anterior dislocations. Traction is then placed on the affected extremity, and the arm gradually extended. If the clavicle does not reduce easily, the skin over the area is cleaned, and the medial end of the clavicle grasped with a sharp towel clamp. Once the reduction is obtained, it is usually stable. Postreduction care is similar to that used for anterior dislocations, except that adduction of the affected extremity is the motion that should be avoided. This can be facilitated with a figure-eight harness.

If a closed reduction cannot be obtained, an operative reduction should be performed. An unreduced posterior dislocation can cause late intrathoracic complications from the posteriorly displaced medial clavicle.43 The operative technique involves a curved incision over the S-C joint. Every effort should be made to preserve the intact anterior ligaments. The assistance of a thoracic surgeon should be considered if significant posterior displacement is present. Stabilization of the joint with pins or wires should be avoided, secondary to concerns of late migration.

Recurrent Instability

Recurrent instability or chronic dislocation of the S-C joint may result in persistent symptoms that require surgical treatment. The goals of the surgical reconstruction are the same as those for instability or persistent dislocation: to remove the degenerative, or damaged, end of the clavicular joint surface and stabilize the medial end of the clavicle. There were several procedures initially described for stabilization of the medial clavicle. These included subclavius tendon transfer, free fascia lata, and osteotomy of the medial clavicle. Arthrodesis of the S-C joint should not be performed because of the associated loss of motion. A recent biomechanical comparison suggests that a figure-eight free tendon graft reconstruction is stronger than using the intra-articular ligament or subclavius tendon.44 The senior author advocates one of two reconstructive methods for S-C joint instability: free tendon transfer or transfer of the intra-articular ligament, as originally described by Rockwood et al.45

Surgical Technique

A curvilinear incision is made, based over the medial end of the clavicle and onto the sternum (Fig. 27-6). The attachment of the sternocleidomastoid muscle should be preserved and retracted medially. The anterior capsule is incised carefully to preserve the anterior capsular ligaments and intra-articular disk. The periosteal sleeve is elevated off of the medial clavicle, taking care to preserve it for later repair (Fig. 27-7). On exposure of the joint, care should also be used to preserve the inferior attachments of the intra-articular disk. Using a side-cutting bur, the medial end of the clavicle is resected, using caution to protect underlying structures (Fig. 27-8). Care should also be

Figure 27-8 Resection of medial clavicle with side-cutting bur.

taken to avoid resecting too much bone and thus injuring the inferior costoclavicular ligaments and further destabilizing the medial clavicle. When using the intra-articular disk for reconstruction, the end of the clavicle must be hollowed with a bur (Fig. 27-9). Nonabsorbable sutures are woven into the ligament/disk and pulled into the medial clavicle, out through dorsal drill holes, and tied over a bone bridge (Fig. 27-10). If a free tendon graft (palmaris longus, semitendinosis, or allograft) is to be used, drill holes are placed in the sternum and medial clavicle. The tendon is passed through these tunnels, tensioned, and sewn into place (Fig. 27-11). At the completion of either reconstruction, the periosteal sleeve is closed carefully over the repair.

Postoperative Care

Initial postoperative swelling and pain can be severe. The extremity should remain protected in a sling for 6 to 8 weeks.

Figure 27-9 Preparation of medial clavicle for ligament transfer.
Figure 27-10 A-C, Intra-articular disk reconstruction. (From Spencer EE, Kuhn JE: Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg [Am] 2004;86:98-105.)

Figure 27-11 A-C, Sternoclavicular joint reconstruction with free soft-tissue graft. (From Spencer EE, Kuhn JE: Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg [Am] 2004;86:98-105.)

Range-of-motion and strengthening exercises are slowly progressed. Activity restrictions should be enforced for 4 to 6 months. Recurrent instability can occur if activity is resumed too early.

Treatment for Arthritis

Symptomatic degenerative changes of the S-C joint are not usually associated with instability. Operative management should only be considered for persistently painful arthritis that is otherwise unresponsive. The goal of surgical treatment is to achieve pain relief by removing the degenerative end of the medial clavicle. The surgical technique is essentially the same as described previously, with the exception that no ligamentous reconstruction is necessary.46 Postoperatively, for arthritic resections, a gradual return to full activity may begin after 8 weeks.

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CHAPTER 28

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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