Swarup Ishaan, Hughes Michael S, Cazzulino Alejandro, Spiegel David A, Shah Apurva S
UCSF Benioff Children's Hospital, San Francisco, California.
Wake Forest Baptist Health, Winston-Salem, North Carolina.
JBJS Essent Surg Tech. 2020 Sep 18;10(3). doi: 10.2106/JBJS.ST.19.00074. eCollection 2020 Jul-Sep.
Acute sternoclavicular fracture-dislocation is associated with high-energy trauma and is being increasingly recognized in children. These injuries are associated with compression of mediastinal structures and can be life-threatening. The management of acute sternoclavicular fracture-dislocation includes closed reduction or open surgical stabilization; however, limited success is reported with closed reduction. To our knowledge, there are no detailed descriptions of open reduction and suture fixation of acute sternoclavicular fracture-dislocation in children.
Following diagnosis of acute sternoclavicular fracture-dislocation, the timing of surgical treatment is determined according to several patient and surgical factors. Among patients with hemodynamic instability, respiratory compromise, or evidence of asymmetric perfusion, surgical treatment is needed on an emergency basis. In the absence of these factors, surgical treatment can be performed on an urgent basis. It is important to communicate with vascular or thoracic surgeons prior to proceeding to the operating room because of the rare case in which advanced surgical access or vascular repair is required. In the operating room, general anesthesia and large-bore intravenous access are required. Patients are positioned supine on a radiolucent table, and a small bump is placed between the scapulae to elevate the medial aspect of the clavicle. The contralateral sternoclavicular joint and medial aspect of the clavicle should be prepared into the sterile field, as well as both sides of the groin in case vascular access is needed. A 6 to 8-cm incision is centered on the medial aspect of the clavicle, extending to the manubrium. Standard dissection to the clavicle is performed, and care is taken to maintain the integrity of the sternoclavicular ligament complex. Circumferential dissection of the medial clavicular metaphysis is usually required in order to mobilize the dislocated fragment. Reduction of the physeal fracture usually requires axial traction and extension of the ipsilateral shoulder with the aid of a reduction clamp on the medial clavicular metaphysis. In some cases, a Freer elevator can be placed between the metaphysis and epiphysis to shoehorn the clavicle from posterior to anterior. Once reduced, the fracture-dislocation is usually stable; however, the reduction is augmented with suture fixation. The sternoclavicular joint capsule should be repaired if disrupted, and the incision should be closed in layers. Postoperatively, the arm is placed in a sling, and range of motion is commenced at 4 weeks.
Alternative management of acute sternoclavicular fracture-dislocation includes closed reduction, plate fixation, and ligament reconstruction.
In our experience, closed reduction is often unsuccessful, which is consistent with the experiences reported by other authors. In addition, suture fixation is sufficient and plate fixation is not required because this injury is relatively stable following reduction. Lastly, ligament reconstruction with use of autograft or allograft may be indicated but is more relevant in chronic cases with injury or attenuation of the sternoclavicular ligament complex. Open reduction allows for direct visualization of the fracture reduction, and suture fixation allows for increased stability without the need for hardware or secondary surgical procedures.
We expect patients to achieve full range of motion and strength without any joint instability as reported by Waters et al..
There is an inherent risk of vascular injury with open reduction and suture fixation. This risk is mitigated with perioperative planning and consultation with vascular or thoracic surgeons. General surgeons should always be available when these procedures are performed in case of vascular issues or emergencies.It is sometimes difficult to reduce the dislocation, but additional maneuvers allow for controlled reduction of the displaced clavicle, such as using a Freer elevator and serrated clamp.Assessing fracture reduction can be difficult intraoperatively. Including the contralateral sternoclavicular joint in the sterile surgical field can be helpful in assessing fracture reduction and osseous contour.
急性胸锁关节骨折脱位与高能量创伤相关，在儿童中越来越受到重视。这些损伤与纵隔结构受压有关，可能危及生命。急性胸锁关节骨折脱位的治疗包括闭合复位或开放手术固定；然而，据报道闭合复位的成功率有限。据我们所知，目前尚无关于儿童急性胸锁关节骨折脱位切开复位及缝线固定的详细描述。
诊断急性胸锁关节骨折脱位后，根据患者及手术的多种因素确定手术治疗时机。对于存在血流动力学不稳定、呼吸功能不全或不对称灌注证据的患者，需要急诊手术治疗。若无这些因素，可在紧急情况下进行手术治疗。由于需要先进手术入路或血管修复的情况罕见，因此在进入手术室之前与血管外科或胸外科医生沟通很重要。在手术室中，需要全身麻醉及大口径静脉通路。患者仰卧于可透射线的手术台上，在双侧肩胛骨之间放置一个小垫块以抬高锁骨内侧。应将对侧胸锁关节及锁骨内侧准备进无菌术野，同时准备双侧腹股沟以备需要血管通路时使用。在锁骨内侧做一个6至8厘米的切口，延伸至胸骨柄。进行至锁骨的标准解剖，注意保持胸锁韧带复合体的完整性。通常需要对锁骨内侧干骺端进行环形解剖以移动脱位的骨折块。骨骺骨折的复位通常需要在锁骨内侧干骺端使用复位钳进行轴向牵引并伸展同侧肩部。在某些情况下，可在干骺端和骨骺之间放置一个Freer剥离子，将锁骨从后向前撬起。一旦复位，骨折脱位通常是稳定的；然而，通过缝线固定可增强复位效果。若胸锁关节囊破裂应予以修复，切口分层缝合。术后，将手臂置于吊带中，4周后开始活动范围练习。
急性胸锁关节骨折脱位的替代治疗方法包括闭合复位、钢板固定和韧带重建。
根据我们的经验，闭合复位常常不成功，这与其他作者报道的经验一致。此外，缝线固定就足够了，不需要钢板固定，因为这种损伤复位后相对稳定。最后，使用自体移植物或同种异体移植物进行韧带重建可能适用，但在胸锁韧带复合体损伤或变薄的慢性病例中更常用。切开复位可直接观察骨折复位情况，缝线固定可增加稳定性，无需植入物或二次手术。
我们期望患者能像Waters等人报道的那样，实现全范围活动和力量恢复，且无任何关节不稳定。
切开复位及缝线固定存在血管损伤的固有风险。通过围手术期规划以及与血管外科或胸外科医生会诊可降低此风险。进行这些手术时，普通外科医生应随时待命，以防出现血管问题或紧急情况。有时脱位难以复位，但可采用其他操作，如使用Freer剥离子和锯齿钳，实现对移位锁骨的可控复位。术中评估骨折复位情况可能困难。将对侧胸锁关节纳入无菌手术野有助于评估骨折复位情况及骨轮廓。
