Sternoclavicular Joint Approach

What it exposes. The anterior approach gives direct access to the sternoclavicular joint, the medial end of the clavicle and the upper manubrium. It is the workhorse exposure for open reduction of sternoclavicular dislocation, resection arthroplasty of the medial clavicle, figure-of-eight reconstruction for chronic instability, and arthrotomy and washout for septic arthritis. Why this approach matters. The sternoclavicular joint is the only true bony articulation between the upper limb and the axial skeleton - a diarthrodial, plane-type synovial joint with an intra-articular fibrocartilaginous disc. Despite its small size it moves through a substantial arc as the clavicle rotates, which is why instability here is so disabling and why this approach must be understood precisely. Critically, the great vessels and mediastinum lie directly behind the joint, so the whole technique is built around one idea: stay strictly anterior and on bone. Selecting the approach. The clinical problem dictates the exposure and, above all, whether a cardiothoracic surgeon must be standing by:

Direction is everything. Dislocations are classified by direction and by timing, and it is direction that determines the danger. Anterior dislocation is common and comparatively benign; posterior dislocation is uncommon but potentially life-threatening because the medial clavicle is driven back toward the mediastinum.

Surface Landmarks Palpate and mark the following before draping: - Suprasternal (jugular) notch - the midline depression between the medial ends of the two clavicles

• Medial third of the clavicle - subcutaneous along its entire length
• Manubrium sterni - the upper part of the sternum immediately below the notch
• The joint line itself - palpable as a shallow step approximately one to two centimetres lateral to the suprasternal notch
• Sternocleidomastoid inserting onto the medial third of the clavicle superiorly
• Pectoralis major clavicular head along the anterior surface of the medial clavicle ### Incision Use a curved or gently transverse incision centered on the joint, following the natural skin lines (Langer lines) for the best cosmetic result. Two common patterns are taught: - Transverse incision along the skin crease over the joint - most cosmetic, used for simple arthrotomy or washout
• Curved (lazy-S) incision beginning over the medial third of the clavicle, curving medially over the joint and onto the upper manubrium - gives more extensile exposure for resection or reconstruction A typical incision measures six to ten centimetres and crosses the joint at the level of the joint line. Infiltration with local anaesthetic and adrenaline may be used to aid haemostasis in the subcutaneous layer. Mark the joint line and the planned incision before the prep. ### Internervous Plane The sternoclavicular approach does not exploit a single classical internervous plane in the way that limb approaches do, because the dissection is made directly onto the joint capsule. However, a true internervous interval exists between two muscles of different nerve supply, and it is developed to reach the capsule:

Work down through the layers in the line of the incision, splitting the platysma, opening the sternocleidomastoid-pectoralis interval, and exposing the anterior capsule directly - all while staying strictly anterior, because everything that matters lies behind the joint. The joint capsule is reinforced by dedicated ligaments that must be respected during dissection, and the dissection is aimed at these structures: - Anterior sternoclavicular ligament - a thickening of the anterior capsule, incised to enter the joint

• Posterior sternoclavicular ligament - the strongest capsular restraint, the last barrier to the mediastinum and never to be violated
• Interclavicular ligament - spans the suprasternal notch, connecting both medial clavicles across the upper manubrium
• Costoclavicular ligament - the key extra-articular stabilizer, running between the first rib and the rhomboid fossa of the clavicle; preserve it during resection
• Articular disc - an intra-articular fibrocartilage that divides the joint into two compartments and acts as a shock absorber
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  Image Needed: Clinical PhotoHigh Priority

  Intra-operative photograph of the anterior approach to the sternoclavicular joint: a curved incision centred over the joint, the platysma split, vessel loops protecting the supraclavicular nerves, and the anterior capsule exposed over the medial clavicle and manubrium with the interval developed between sternocleidomastoid above and pectoralis major below.

  Context: A verified image is being sourced for this exposure.

  Pending image generation or sourcing

Structures at risk, by layer

The posterior danger zone. Immediately behind the joint lie the great vessels and the mediastinal viscera. The left brachiocephalic vein crosses horizontally behind the manubrium just below the joint, and the brachiocephalic trunk arises behind the right sternoclavicular joint. Any instrument passed posteriorly through the capsule can enter the mediastinum and cause catastrophic haemorrhage.

When things go wrong. If brisk dark venous or bright arterial bleeding is encountered from the posterior aspect, immediately pack the wound, alert anaesthesia, and call for vascular or cardiothoracic assistance. Do not attempt blind clipping. A controlled median sternotomy by a thoracic surgeon gives definitive access to the great vessels and is the reason that backup must be arranged in advance for posterior dislocations. Extensile options. - Lateral extension along the clavicle toward the acromioclavicular joint - exposes more of the clavicle and connects with the clavicle approach

• Medial and inferior extension down the manubrium - toward a partial or complete sternotomy when more access is needed
• Median sternotomy - performed by a cardiothoracic surgeon for a posterior dislocation with mediastinal or great-vessel compromise, sometimes combined with a medial claviculectomy to deliver the displaced end safely Closure restores stability, so it must be meticulous: - Repair the anterior capsule and the anterior sternoclavicular ligament with strong, non-absorbable or slowly absorbable sutures - this is the principal soft-tissue stabilizer you can reconstruct
• Reattach the elevated sternocleidomastoid and pectoralis major fibres to the clavicle over the repaired capsule
• Close the platysma as a distinct layer to restore the soft-tissue cover over the joint and any plate
• Close the subcutaneous tissue and skin with a subcuticular suture for the best cosmetic result, given the visible location
• Immobilize in a figure-of-eight bandage or shoulder immobilizer for several weeks to protect the repair

Anterior versus posterior dislocation. The direction of the dislocation changes the entire plan. An anterior dislocation is cosmetically obvious but functionally benign and is usually managed closed; a posterior dislocation is clinically subtler but potentially fatal, because the medial clavicle lies against the great vessels and the airway.

• Open reduction of sternoclavicular dislocation - for anterior dislocations that are irreducible or recurrent, and for posterior dislocations after failed closed reduction or with vascular compromise
• Resection arthroplasty - excision of the medial one to one and a half centimetres of the clavicle for painful osteoarthritis, post-traumatic arthritis or infection
• Figure-of-eight reconstruction - for chronic instability, using a tendon graft (semitendinosus, palmaris longus or fascia lata) passed through tunnels in the clavicle and sternum or first rib
• Arthrotomy and washout - for septic arthritis, with tissue sent for culture before antibiotics
• Biopsy or resection of tumour of the medial clavicle or manubrium (rare) ### Resection Arthroplasty in Detail Excise the medial one to one and a half centimetres of the clavicle with an oscillating saw or osteotome, smoothing the cut edge. The critical principle, established by Rockwood, is to preserve or reconstruct the costoclavicular ligament; if it is deficient the medial clavicle will be unstable in an anteroposterior direction and the patient will have a poor result. An interposition material may be placed in the defect to prevent recurrence of bony contact. ### Figure-of-Eight Reconstruction in Detail For chronic symptomatic instability, drill tunnels through the medial clavicle and the sternum (or the first rib) and pass a tendon graft in a figure-of-eight to reconstruct the restraint that the capsule and costoclavicular ligament have lost. Biomechanical work has shown that a figure-of-eight graft through the clavicle and sternum is the strongest of the commonly tested reconstructions. ### Post-operative Care and Rehabilitation - Immobilization in a figure-of-eight bandage or a shoulder immobilizer for three to six weeks to protect the capsular repair and any reconstructed ligaments
• Analgesia and ice to settle the operative site, with the limb supported in a sling
• Early gentle pendulum and elbow and hand exercises to prevent stiffness, avoiding active elevation against resistance for the first six weeks
• Neurovascular monitoring after a posterior dislocation to detect any delayed vascular or airway compromise
• Wound review at two weeks, then a progressive return of shoulder range of movement
• Return to contact sport only after full, pain-free movement and stable imaging, typically around three months

Guidelines, Registries and Global Practice Management of sternoclavicular joint injuries is uncommon and occurs at trauma and shoulder centres worldwide, with principles that are convergent across examination systems (advanced orthopaedic practice or advanced orthopaedic practice, DNB or MS, MRCS, SICOT). Two principles are near-universal: posterior dislocations are dangerous and demand cardiothoracic or vascular backup, and after any resection the costoclavicular ligament must be preserved or reconstructed. Side-by-side principles (where guidance converges): | Body | Position on sternoclavicular joint injuries |

|------|---------------------------------------------| | AO Foundation | Posterior dislocation is a high-risk injury with potential for mediastinal injury; obtain a CT and arrange vascular or thoracic review before reduction | | BOA and BOAST (trauma) | Recognise the posterior dislocation as a polytrauma-level threat; image with CT and reduce with appropriate surgical backup immediately available | | AAOS and shoulder societies | Resection arthroplasty is appropriate for refractory symptomatic arthritis; stability depends on the costoclavicular ligament, which must be preserved or reconstructed | Epidemiology and global variation: - Sternoclavicular dislocation is uncommon, accounting for a small minority of all shoulder-girdle dislocations; anterior dislocation is more frequent than posterior.

• In high-resource settings, contrast CT and immediate cardiothoracic or vascular availability are standard for posterior dislocation; in resource-limited settings, the same principle of recognising the posterior dislocation as dangerous and arranging the highest available level of surgical backup applies, with transfer to a thoracic centre when mediastinal injury is suspected. Consent (globally applicable): discuss the rare but catastrophic risk of great-vessel injury (especially with posterior dislocation), instability or recurrence after resection if the costoclavicular ligament is sacrificed, numbness from supraclavicular nerve injury, infection, and the cosmetic scar in this visible location.