Suture Repair of Posterior Sternoclavicular Physeal Fractures: A Report of Two Cases

BACKGROUND

Posterior fracture dislocations of the medial sternoclavicular joint represent less than 1%of all fractures of the clavicle in children and young adults.¹ Complications from this injury can be severe, including compression of the great vessels^2,3 or even the airway. Immediate closed reduction is required to prevent potential catastrophe followed by an assessment of fracture stability. For unstable fractures, irreducible fractures or late presentations of displaced posterior fractures, operative intervention has been recommended.⁴ However, no universally agreed upon method for stabilization exists. Fixation options ranging from Kirschner wires⁵ to plates⁶ to suture wires⁷ have been proposed. We report 2 cases of successfully treated, posteriorly displaced, medial physeal fractures of the clavicle with suture fixation and their 2½year follow-up.

CASE 1

A seventeen-year-old wrestler felt a “pop” in his anterior chest wall after being body slammed to the mat. Initially he avoided medical contact in an effort to work through the injury. However, pain in the chest and inability to use right his arm persisted, so he presented to the emergency room the following morning. On radiographs and computed tomography (CT) scan, he was found to have a physeal fracture of the medial clavicle with significant posterior displacement on the right side (Figure 1). Under a general anesthetic, the clavicle was manually reduced to a normal appearance, and his arm was immobilized in a sling. However, during transfer to the CT scanner for post-operative confirmation of his reduction, he felt another “pop” and recurrent dislocation. This was confirmed via CT scan. He underwent definitive surgical fixation the next day using the technique that is described. His post-operative course was uneventful.

Figure 1.

This 3-D reconstruction is viewed from the top as if the patient were prone. The patient’s right medial clavicle is displaced posteriorly into the mediastinum (arrow).

At his 2½year follow-up, he reported no problems with the shoulder. He felt no crepitance or pain. He said the shoulder functioned at least as well as the contralateral shoulder. He participated fully in golf four months following his injury during his junior year of high school. As a senior, he went on to play football, wrestle, and golf. His shoulder function continues to allow him to participate in recreational sports and lift weights in college.

On examination at his follow-up appointment, he had a small, curvilinear scar over the medial sternoclavicular joint with a slightly posteriorly displaced end of the clavicle compared to the left side. There was no crepitance or tenderness over the SC joint or in the shoulder. There was no evidence of instability at the medial sternoclavicular joint.

His right shoulder range of motion was identical to the unaffected left shoulder. Both forward flexion and abduction measured 180 degrees. Internal and external rotation with his elbow to his side and with elbow abducted 90 degrees all measured equally at 90 degrees. He had 70 degrees of extension.

His functional assessment using the patient selfreported section of the American Shoulder and Elbow Score Activities of Daily Living (ASES) was equivalent between right and left shoulders at 27 of a possible 30, an excellent score. This measures both pain and function.⁸ He also scored the maximum possible using the Marx Shoulder Activity scoring system, 20 of 20, meaning the frequency at which he is able to perform stressful shoulder activities is not limited.⁹ Using the Disabilities of Arm, Shoulder and Hand scoring system (DASH), he scored the best possible at zero, meaning he had no pain or disability.⁸

CASE 2

A twenty-year-old hockey player suffered a medial clavicle physeal fracture on the right after getting body checked during a game. He complained immediately of chest and right shoulder pain. He also had some difficulty breathing, which resolved spontaneously. Initially, his exam and plain radiographs were deemed to be normal. However his pain persisted. At his follow up visit 3 weeks later, a CT scan was ordered that revealed a physeal fracture of the medial clavicle with significant posterior displacement and compression of the underlying great vessels. He was referred to our institution for further care. At his initial encounter, his physical exam was notable not only for posterior displacement but also for the amount of mobility he had at the medial sternoclavicular joint, even after three weeks. He then underwent uncomplicated open reduction and suture wire fixation using the described technique. He recovered uneventfully and has experienced a full return of function.

At his 2½ year follow-up, he reported no problems with the shoulder. He felt no pain or crepitance with any range of motion or activities. He had stopped playing hockey for personal reasons but has taken up triathlons and reported swimming 10–15 miles per week without problems.

On examination, he had a small hockey-stick-shaped scar over the medial sternoclavicular joint with slight posterior displacement of the clavicle compared to the left side. No crepitance or tenderness over the SC joint or in the shoulder.

His shoulder range of motion was excellent and identical when compared from right to left. Forward flexion and abduction both measured 180 degrees. Internal and external rotation with arms at the side and in 90 degrees of abduction measured 90 degrees. Extension measured 70 degrees.

His shoulder function was also excellent using three different instruments: ASES, Marx shoulder activity scoring system, and DASH. His raw scores were 30/30 for the ASES (30 being the best function), 16/20 for his Marx activity score (16-20 being excellent shoulder activity), and 0/100 for the DASH (0 being completely asymptomatic).

SURGICAL TECHNIQUE

A hockey-stick-shaped incision is made over the clavicle and curved inferiorly onto the sternum. Dissection is carried down to the level of the platysma muscle, which is then incised. The superior and clavicular fibers of the medial pectoralis major muscle are dissected off the clavicle to expose the medial end of the clavicle. The anterior fibers of the medial sternoclavicular joint are then encountered and opened in line with the clavicle. The physeal fracture, which typically occurs slightly lateral to the sternoclavicular joint, is stripped of surrounding soft tissue. The fracture is then reduced with a towel clip (Figure 3).

Figure 3.

Reduction of the fracture using a towel clip. The physeal fracture line is the vertical line shown on the right side of the wound (arrow). The sternoclavicular joint is medial to it and deep to the skin (not pictured). The fracture is reduced with the towel clip shown on the left.

Figure 2.

Hockey-stick-shaped scar over the right medial sternoclavicular joint (arrow).

A vertical row of three 2 mm holes on each side of the fracture is drilled, being careful to perforate only the anterior cortex of the clavicle. This safely avoids the deep, mediastinal structures. Again, care is taken to preserve the sternoclavicular joint medially. Three #2 Fiberwires®(Arthrex, Inc., Naples, Florida, USA) are threaded through the physeal cartilage medial to the sternoclavicular joint in a simple suture fashion (Figure 4). These sutures are then tied down securely over the fracture (Figure 4). Once fixed, gentle pressure is applied to assure fracture stability. The wound is irrigated and closed in layers.

Figure 4.

Figures 4A (top) and 4B (bottom). Suture wires have been passed in a horizontal fashion from medial to lateral through corresponding holes and tied down securely.

POST-OPERATIVE PROTOCOL

We recommend sling immobilization for three weeks, coming out for pendulum exercises only. From three to six weeks, the sling may be removed for full shoulder passive range of motion in addition to the pendulums. From six to twelve weeks, active range of motion may be attempted, modifying activity according to pain. At twelve weeks, patients can be released to full activities, including weights and contact sports if asymptomatic.

DISCUSSION

Because the physis of the medial clavicle ossifies and fuses from ages 22–25,^4,10 most injuries around the sternoclavicular joint are physeal fractures. Posteriorly displaced physeal fractures of the medial clavicle are rare injuries, representing only 1%of fractures to the clavicle in children.¹ Wirth and Rockwood reported in 1996, the world’s literature revealed fewer than 110 cases.¹¹ Acutely, posteriorly displaced physeal fractures can be life threatening if the displaced fragment puts pressure on the mediastinal structures. Complications include brachial plexus compression, pneumothorax, respiratory distress, vascular compromise and death. There have also been multiple reports of late complications from chronically unreduced, posterior fracture dislocations.¹¹

Because of the potential for catastrophe, these injuries require prompt but carefully controlled reduction followed by an assessment of stability and decision about further stabilization. However, two schools of thought exist regarding the manner of reduction in the acute setting. Some have recommended an attempt at closed reduction without stabilization for all posterior fracture dislocations that present within 7–10 days of injury.^4,12 For fractures that present beyond that time period or unstable fractures, immediate operative stabilization is recommended. On the other hand, other surgeons maintain open reduction and fixation is the index procedure of choice.¹³ Eskola cites his experience with 5 of 8 redislocations after initially successful closed reductions. Three of 8 of those patients went on to have poor outcomes. In contrast, he had good results in all of his patients who underwent primary fixation.¹⁴

Once the decision to operatively stabilize the fracture has been made, the definitive procedure of choice is still up for debate. Fixation options using Kirschner wires,⁵ plates,^6,15 or suture wires⁷ have all been proposed. Kirschner wires have largely been abandoned due to severe complications with pin migration, including death. Plates, although successful, have the potential for a second, hardware removal operation.¹⁵ More recently it has been reported that posteriorly displaced sternoclavicular dislocations can be stabilized safely with sutures confined to the anterior osseous/joint structures.⁷

Our report further contributes to the idea that the deep mediastinal structures can be safely avoided during surgical stabilization of posteriorly displaced physeal fractures of the medial clavicle. The approach is direct, and there is no need to violate any of the deep structures. There is no concern for pin migration using this method of stabilization, nor of hardware irritation. The amount of stability achieved clinically was sufficient to allow these two patients to return to full sporting activities 4 months after surgical repair. They have persisted with excellent function since then. While we agree that an initial attempt at closed reduction is warranted in patients with these injuries, we feel that for patients with unstable (case 1) or late presenting (case 2) injuries this method of open reduction and stabilization provides excellent fixation and long term outcomes.