Sternoclavicular ligament sprain

1. High-Yield Summary

Sternoclavicular (SC) ligament sprains and joint dislocations represent uncommon injuries accounting for under 3% of shoulder girdle trauma and 1% of all joint dislocations; however, posterior dislocations represent true surgical emergencies due to the intimate proximity of the retrosternal great vessels and mediastinal viscera.

• Late Physeal Fusion Rule: In patients younger than 23 to 25 years of age, traumatic sternoclavicular disruption represents a Salter-Harris type I or II physeal fracture-separation of the medial clavicular epiphysis rather than a pure ligamentous dislocation, as the medial physis is the last in the human skeleton to appear (ages 18 to 20) and fuse (ages 23 to 25).
• Definitive Diagnostic Gold Standard: Thin-slice computed tomography (CT) with multiplanar 2D and 3D reconstructions is mandatory to differentiate anterior from posterior displacement, assess physeal involvement, and rule out mediastinal compression; CT angiography (CTA) is indicated whenever posterior displacement or vascular compromise is suspected.
• Contrasting Natural Histories: Anterior subluxations and dislocations carry a benign prognosis when managed nonoperatively, achieving over 90% good-to-excellent functional and pain-free outcomes despite residual cosmetic prominence; in contrast, acute posterior dislocations carry up to a 30% risk of life-threatening mediastinal complications (airway obstruction, vascular laceration, pneumothorax).
• Acute Reduction & Stabilization: Acute posterior dislocations require emergent closed reduction under general anesthesia with cardiothoracic or vascular surgery standby; chronic instability or failed closed reduction warrants open anatomical figure-of-eight tendon autograft reconstruction using semitendinosus or gracilis tendon.
• Strict Transarticular Pin Contraindication: Transarticular Kirschner wires, Steinmann pins, or smooth metallic hardware are absolutely contraindicated across the SC joint due to documented lethal fatal migration into the aortic arch, pulmonary artery, right atrium, and cardiac structures.

2. Anatomy

The sternoclavicular joint represents the sole true skeletal articulation anchoring the upper appendicular extremity to the axial skeleton. Functioning as a diarthrodial saddle-type (sellar) joint, it possesses minimal intrinsic osseous stability, as less than 50% of the medial clavicular articular surface articulates with the shallow clavicular notch of the sternal manubrium. An intra-articular fibrocartilaginous disc divides the joint into two separate synovial cavities, attaching superiorly and posteriorly to the posterosuperior clavicular articular margin and inferiorly to the junction of the first costal cartilage and manubrium. This disc acts as a mechanical shock absorber and static restraint against medial displacement under axial shoulder loads.

Static ligamentous stability is governed by four primary structures:

• Posterior Sternoclavicular (Capsular) Ligament: The thickest and mechanically strongest stabilizer of the SC joint. Biomechanical studies confirm it is three times stiffer than the anterior capsule and serves as the primary restraint against posterior displacement, horizontal anterior-posterior translation, and superior translation.
• Anterior Sternoclavicular (Capsular) Ligament: Reinforces the anterosuperior capsule, acting as the primary static checkrein against anterior translation of the medial clavicle during shoulder retraction.
• Costoclavicular (Rhomboid) Ligament: A robust, two-fascicle ligament spanning from the upper surface of the first rib synchondrosis to the costal tuberosity on the inferior medial clavicle. Its anterior and posterior fascicles resist clavicular elevation, lateral translation, and superior displacement, serving as the central fulcrum for clavicular rotation during shoulder elevation.
• Interclavicular Ligament: Courses across the suprasternal (jugular) notch between the superomedial aspects of bilateral clavicular heads, resisting excessive downward depression of the lateral shoulder girdle and preventing upward subluxation of the medial clavicular head.

Retrosternal Neurovascular Danger Zones: The medial clavicle is separated from the superior mediastinum by mere millimeters (3 to 5 mm in physiological positions). Structures lying directly posterior to the thin posterior capsule and manubrium include the right and left brachiocephalic (innominate) veins and their confluence into the superior vena cava, the brachiocephalic trunk (innominate artery) on the right, the left common carotid artery and left subclavian artery on the left, the internal jugular veins, the vagus nerve (CN X), the recurrent laryngeal nerve, the phrenic nerve traversing the anterior scalene, the apex of the lung and pleural cupola, the trachea, the esophagus, and the thoracic duct on the left side.

Internervous Plane: Surgical exposure of the sternoclavicular joint utilizes the internervous interval between the sternocleidomastoid (SCM) muscle superiorly (innervated by the spinal accessory nerve, cranial nerve XI, and cervical plexus branches C2-C3) and the clavicular head of the pectoralis major muscle inferiorly (innervated by the medial and lateral pectoral nerves, C5-T1).

Medial Clavicular Physis Fusion: The medial clavicular epiphysis is developmentally unique: it is the last ossification center in the human skeleton to appear radiographically (between ages 18 and 20) and the last physis to achieve complete osseous fusion with the clavicular diaphysis (between ages 23 and 25). Consequently, what clinically presents as an SC joint dislocation in patients under 25 years is almost universally a Salter-Harris type I or II physeal fracture-separation through the cartilaginous physis, with the thick posterior periosteal envelope remaining attached to the sternum.

3. Pathogenesis

The sternoclavicular joint possesses substantial multi-planar mobility, accommodating up to 35 degrees of upward elevation, 35 degrees of combined anterior-posterior excursion (protraction-retraction), and 45 to 50 degrees of axial rotation along its longitudinal axis during full arm elevation. Ligamentous sprain, subluxation, and frank dislocation occur when applied force vectors exceed the structural yield strength of the capsuloligamentous envelope.

High-energy mechanisms account for more than 80% of traumatic sternoclavicular injuries, with motor vehicle collisions and motorcycle crashes responsible for approximately 45%, contact athletic collisions (rugby, American football, hockey, martial arts) accounting for 35%, and direct crushing industrial trauma causing the remainder.

• Indirect Anterolateral Shoulder Impact (Anterior Dislocation Mechanism): A compressive impact applied to the anterolateral shoulder drives the acromion and lateral clavicle backward. The clavicular shaft hinges upon the robust costoclavicular ligament as a fulcrum, levering the medial clavicle forward through the anterior capsular ligament, resulting in an anterior SC sprain or complete anterior dislocation.
• Indirect Posterolateral Shoulder Impact (Posterior Dislocation Mechanism): A compressive impact delivered to the posterolateral shoulder forces the shoulder girdle forward and inward. The clavicle pivots across the first rib and costoclavicular ligament, levering the medial clavicle backward through the posterior capsule into the retrosternal space, producing a posterior dislocation.
• Direct Anterior Impact (Posterior Dislocation Mechanism): A direct blow applied over the anterior medial clavicle (such as a helmet-to-chest tackle, steering wheel compression, or a heavy object falling on a supine individual) directly drives the medial clavicular head backward behind the manubrium.
• Compression-Deceleration (Pile-On Mechanism): In contact sports, a fallen athlete lying on their side who is crushed by multiple collapsing players sustains forceful bilateral shoulder compression, driving the clavicle into anterior or posterior displacement depending on scapular protraction or retraction at the instant of impact.

4. Natural History

Sternoclavicular injuries represent rare clinical entities, accounting for approximately 1% of all joint dislocations and under 3% of all shoulder girdle traumatic injuries. Anterior subluxations and dislocations outnumber posterior injuries by a ratio of approximately 9 to 1. The demographic distribution is predominantly young, active males between 15 and 30 years of age participating in contact sports or involved in vehicular trauma, with a secondary smaller peak in elderly osteoporotic females following ground-level falls.

The natural history diverges sharply between anterior and posterior patterns:

• Anterior Dislocation & Sprain Prognosis: Grade I and II sprains resolve uneventfully within 3 to 6 weeks with conservative management. Complete anterior dislocations (Grade III) frequently remain chronically subluxated or unreduced because closed reduction routinely fails or re-dislocates. Despite permanent cosmetic asymmetry with a visible prominence, long-term prognostic cohorts confirm that over 90% of patients achieve painless, full functional upper extremity recovery without surgical stabilization. Late post-traumatic degenerative arthritis develops in under 10% of cases and rarely requires surgical excision.
• Posterior Dislocation Prognosis & Mediastinal Hazard: Posterior dislocations carry substantial morbidity. Up to 30% of acute presentations present with immediate or evolving compression of superior mediastinal structures. If left unreduced, chronic posterior displacement can cause persistent thoracic outlet syndrome, chronic brachial plexopathy, dysphagia, tracheal stenosis, vascular pseudoaneurysm formation, or fatal late erosion into the brachiocephalic trunk or aortic arch.

5. Clinical Presentation

History

Patients report an acute traumatic event involving direct chest trauma or lateral shoulder compression, presenting with severe localized pain at the base of the neck and sternoclavicular junction. Pain radiates into the ipsilateral shoulder, neck, or hemithorax and is sharply exacerbated by arm elevation, cross-body adduction, and deep inspiration. The patient typically cradles the injured extremity against the abdomen with the opposite hand and tilts the head toward the affected side to relax tension on the sternocleidomastoid muscle.

A rigorous systematic review of mediastinal red flag symptoms is mandatory for all suspected SC injuries:

• Respiratory Symptoms: Dyspnea, tachypnea, orthopnea, or audible stridor indicating extrinsic compression of the trachea.
• Gastrointestinal Symptoms: Dysphagia or odynophagia (painful swallowing) signaling posterior esophageal impingement.
• Neurological Symptoms: Paresthesias, numbness, or motor weakness in the C8-T1 distribution of the ipsilateral arm indicating brachial plexus trunk compression.
• Vascular Symptoms: Upper extremity swelling, venous engorgement of the neck or arm, facial fullness, or coldness/pallor in the hand indicating subclavian or brachiocephalic venous or arterial compromise.
• Phonatory Symptoms: Hoarseness or vocal changes resulting from traction or compression of the recurrent laryngeal nerve.

Physical Exam

Physical examination begins with visual inspection and bilateral vascular examination. Bilateral radial, ulnar, and brachial pulses must be palpated and blood pressure measured in both arms. In anterior injuries, an obvious localized subcutaneous prominence is visible immediately lateral to the sternal notch, often with overlying ecchymosis and localized soft-tissue swelling. In posterior injuries, a visible and palpable depression or hollow fossa is present at the sternoclavicular junction, and the ipsilateral shoulder appears forward-rotated and shortened. Palpation elicits exquisite point tenderness directly over the SC joint, and pathological horizontal translation may be felt.

6. Imaging and Diagnostic Studies

Evaluation of suspected sternoclavicular ligament sprains and dislocations follows a definitive diagnostic hierarchy. Standard anterior-posterior (AP) radiographs of the chest and clavicle demonstrate poor diagnostic sensitivity (under 50%) due to overlapping mediastinal anatomy, thoracic ribs, and the sternal manubrium.

Specialized plain radiographic projections can assist when advanced imaging is delayed:

• Serendipity View (Rockwood): The beam is centered directly on the manubrium and angled 40 degrees cephalad with the patient positioned supine on the cassette. In an anterior dislocation, the displaced medial clavicle projects superior to the interclavicular reference line of the normal side. In a posterior dislocation, the displaced medial clavicle projects inferior to the contralateral clavicle.
• Heinig View: An AP projection with the patient supine and the central ray angled 45 degrees toward the affected SC joint through the opposite shoulder, tangential to the sternal joint line.
• Hobbs View: A 90-degree superior-inferior trans-axial projection taken with the patient seated and leaning forward over the cassette with the cervical spine flexed; limited by patient discomfort during acute trauma.

Thin-Slice Computed Tomography (Gold Standard): Thin-slice (<1 mm) CT with axial, coronal, sagittal, and 3D multiplanar volume reconstructions is the undisputed gold standard investigation. CT accurately identifies the direction and magnitude of displacement, detects subtle avulsion fractures of the costal cartilage or manubrium, and definitively distinguishes Salter-Harris type I or II physeal fracture-separations from true capsuloligamentous dislocations in skeletally immature or young adult patients under 25 years.

Computed Tomography Angiography (CTA): Contrast-enhanced CTA is mandatory for all posterior dislocations, cases with unexplained hemodynamic changes, or when mediastinal symptoms (stridor, dysphagia, pulse discrepancy) are present. CTA defines the precise spatial proximity of the retrosternal clavicle to the brachiocephalic vein, innominate artery, and aortic arch, identifying vessel compression, intimal flap dissection, thrombosis, or pseudoaneurysm formation.

Magnetic Resonance Imaging (MRI): MRI is the modality of choice for non-ionizing evaluation of soft tissue pathology. T2-weighted and proton density fat-suppressed sequences accurately evaluate disruptions of the anterior and posterior SC ligaments, tears of the costoclavicular ligament, intra-articular disc tears, and bone marrow edema within the medial clavicular physis in adolescent athletes.

7. Classification

Sternoclavicular joint injuries are classified according to injury severity, anatomical direction, and underlying etiology to guide clinical and surgical management.

8. Treatment

Medical / Nonoperative

First-line conservative management is dictated by injury grade and directional stability:

• Grade I Sprains: Managed with brief ice application, oral NSAIDs, and sling support for comfort for 7 to 10 days. Active-assisted range of motion is initiated as pain subsides, with full return to athletics and physical labor permitted at 2 to 4 weeks once painless strength is demonstrated.
• Grade II Subluxations: Immobilized in a figure-of-eight harness or sling for 3 to 4 weeks to relax tension across the anterior capsule and encourage fibrous scarring. Heavy lifting, overhead sports, and contact activities are restricted for 6 to 8 weeks. Physical therapy focuses on progressive periscapular and rotator cuff strengthening.
• Acute Anterior Grade III Dislocations: Closed reduction can be attempted in the acute setting (90% satisfaction) without operative intervention. Routine acute surgical stabilization for anterior dislocations is not recommended.
• Stanmore Group III Instability: Operative intervention is strictly contraindicated. Management consists of specialized physiotherapy focusing on biofeedback, postural correction, dynamic rotator cuff rebalancing, and cognitive cessation of voluntary provocative maneuvers.

Operative

The primary goals of operative management are to eliminate life-threatening retrosternal neurovascular compression, restore anatomical stability and joint congruity, re-establish physiological multi-axial kinematics, and avoid iatrogenic injury to mediastinal structures.

Acute Posterior Dislocation Closed Reduction Protocol: Closed reduction of an acute posterior SC dislocation should be performed within 48 hours of injury under general endotracheal anesthesia. The surgical field, including the entire anterior chest and neck, must be prepped and draped, and a cardiothoracic or vascular surgery team must be on immediate standby with median sternotomy instruments open in the operating room. The patient is positioned supine with a firm bolster between the scapulae. Longitudinal traction is applied to the arm in 90 degrees of abduction and slight extension. If the medial clavicle remains locked behind the sternum, a sterile percutaneous towel clip is applied around the mid-portion of the medial clavicle to exert direct anterior traction, pulling the clavicular head forward into the manubrial notch. Successful reduction is usually accompanied by a palpable release, and posterior stability is confirmed under fluoroscopy. The extremity is immobilized in a figure-of-eight bandage or sling for 4 to 6 weeks.

Open Surgical Techniques:

• Figure-of-Eight Biological Tendon Autograft Reconstruction (Gold Standard): Indicated for failed closed reduction of posterior dislocations, chronic symptomatic posterior instability, or chronic painful anterior instability failing prolonged rehabilitation. A semitendinosus, gracilis, or palmaris longus tendon graft is harvested. Paired transosseous bone tunnels (3.5 to 4.5 mm diameter) are drilled through the manubrium and medial clavicle from anterior to posterior under direct protection of a malleable retractor placed behind the posterior cortex. The tendon graft is routed in a figure-of-eight configuration through the tunnels, tensioned with the arm in neutral retraction, and sutured back onto itself with high-strength non-absorbable braided suture. This reconstructs both the posterior capsular and costoclavicular constraints, restoring 750 N of ultimate failure load comparable to native ligaments.
• Cortical Suture-Button Suspension: Utilizes high-strength suture tape anchored with cortical buttons across transosseous clavicular and manubrial drill holes. It provides rigid immediate mechanical fixation and avoids autograft harvest morbidity, though long-term biological incorporation relies on fibrous scarring.
• Sternocleidomastoid (SCM) Tendon Tenodesis: A vascularized strip of the SCM clavicular tendon insertion is dissected, reflected inferiorly, and passed through drill holes in the clavicle and first costal cartilage (Burrows technique) to reinforce anterior stability.
• Medial Clavicle Resection Arthroplasty: Reserved for end-stage post-traumatic SC osteoarthritis or painful non-reconstructible joint destruction. Critical Principle: Resection must not exceed 10 to 12 mm of the medial clavicle. The costoclavicular ligament insertion begins approximately 12 to 15 mm lateral to the articular margin; violating this insertion causes catastrophic vertical and posterior instability of the remaining clavicular stump.

Absolute Hardware Contraindication: The historical use of smooth or threaded transarticular Kirschner wires or Steinmann pins across the sternoclavicular joint is strictly and universally contraindicated. Cyclic respiratory excursion and upper extremity motion invariably cause transarticular pins to migrate medially and posteriorly into the superior mediastinum, resulting in fatal laceration of the aortic arch, brachiocephalic trunk, pulmonary artery, superior vena cava, or cardiac chambers.

Indications & Contraindications

• Absolute Indications for Urgent / Operative Intervention: Acute posterior dislocation (Rockwood IIIB) failing closed reduction or presenting with acute mediastinal neurovascular, tracheal, or esophageal compression; displaced medial clavicular physeal fracture-separation in patients under 25 years with greater than 50% shaft displacement failing stable closed reduction; open sternoclavicular dislocation or associated expanding retrosternal hematoma.
• Relative Indications for Elective Reconstruction: Chronic, recurrent, or fixed posterior dislocation with persistent pain, thoracic outlet symptoms, or late vascular compromise; chronic symptomatic anterior instability (Rockwood IIIA / Stanmore Group I) causing persistent pain, mechanical catching, or functional weakness that has failed at least 6 months of structured nonoperative therapy.
• Absolute Contraindications: Stanmore Group III atraumatic muscle patterning instability (surgery fails in over 50% of cases, causing worsening pain and intractable instability); transarticular metallic pin, K-wire, or Steinmann pin fixation (strictly contraindicated due to lethal cardiovascular migration risk); asymptomatic anterior sternoclavicular dislocation (cosmetic concern alone does not justify surgical mediastinal exposure risks); active systemic or localized infection.

9. Outcome

Modern clinical outcomes for sternoclavicular joint injuries reflect significant advancements in diagnostic precision, nonoperative understanding, and anatomical reconstruction techniques.

• Patient-Reported Outcome Measures (PROMs): Patients undergoing anatomical figure-of-eight tendon autograft reconstruction for chronic or unstable SC instability achieve marked improvements in validated shoulder outcome scores. American Shoulder and Elbow Surgeons (ASES) scores improve from a preoperative baseline mean of 48.5 points (range, 32 to 58) to a postoperative mean of 91.2 points (range, 84 to 98) at final follow-up. QuickDASH scores demonstrate parallel improvements, decreasing from 46.2 preoperatively to 9.8 postoperatively. Visual Analog Scale (VAS) pain scores decrease from 7.4 to 1.1 at minimum 2-year follow-up.
• Return to Athletic Activity & Manual Labor: Systematic reviews encompassing surgical cohorts confirm an overall return-to-sport rate of 89% to 93% following biological tendon reconstruction. In competitive contact athletes (rugby, American football, hockey), return to full collision sports is achieved in 82% to 86% of patients at a mean of 5.2 months postoperatively (range, 4 to 8 months), following confirmation of complete radiographic stability and full symmetric periscapular strength.
• Closed vs. Open Reduction Long-Term Efficacy: For acute anterior dislocations, closed reduction fails to maintain joint stability in 62% of patients; however, nonoperative functional cohorts demonstrate that 90% of patients achieve satisfactory, pain-free upper extremity function despite permanent anterior prominence. For acute posterior dislocations, closed reduction under general anesthesia succeeds in approximately 50% of cases without recurrence; when closed reduction is unstable or in chronic cases, open anatomical tendon reconstruction provides a 93.4% joint stability rate with low complication and revision rates.

10. Complications

Complications associated with sternoclavicular ligament injuries range from benign cosmetic asymmetry to catastrophic intraoperative exsanguination.

11. Pearls and Pitfalls

• The 25-Year Physeal Rule: In any patient younger than 25 years presenting with an apparent sternoclavicular dislocation, obtain a thin-slice CT to verify whether the injury is a true capsular dislocation or a Salter-Harris type I or II physeal fracture-separation. Physeal injuries possess tremendous remodeling capacity, and anatomical reduction with periosteal repair yields superior stability compared to ligament reconstruction.
• Mandatory Thoracic Surgery Standby: Never attempt closed reduction of a posterior dislocation or open retrosternal exposure without notifying a cardiothoracic or vascular surgeon and confirming that median sternotomy instruments and cardiopulmonary bypass capabilities are immediately accessible in the operating suite.
• Subperiosteal Dissection & Malleable Retractor Shielding: When exposing the posterior aspect of the manubrium or drilling transosseous tunnels, maintain a strict subperiosteal plane directly against bone. Always position a broad malleable retractor or blunt elevator behind the posterior cortex to serve as an impenetrable physical shield protecting the retrosternal great vessels from drill plunge.
• Drill Trajectory & Mechanical Stops: Drill manubrial tunnels from anterior to superior-posterior with a 15 mm drill stop attached, or utilize manual hand reaming or oscillating drill drivers. Avoid high-speed rotary drilling through the posterior cortex to eliminate plunging risk.
• Costoclavicular Ligament Preservation Rule: If performing medial clavicle resection arthroplasty for post-traumatic degenerative disease, never resect more than 10 to 12 mm of the medial clavicle. Always identify and preserve the insertion of the costoclavicular ligament on the inferior cortex to avoid creating intractable clavicular stump instability.
• The Pitfall of Operating on Stanmore Group III: Operating on patients with atraumatic muscle patterning instability (Stanmore Group III) represents a severe surgical pitfall. Tendon reconstructions and hardware fixations invariably stretch out, pull through, or fail, often resulting in worsening chronic pain and catastrophic surgical morbidity.
• The Pitfall of Relying on AP Plain Radiographs: Standard chest or clavicle radiographs miss up to 50% of posterior dislocations due to mediastinal overlap. A patient with persistent SC tenderness following high-energy trauma must undergo thin-slice CT before being discharged from the emergency setting.
• The Absolute Prohibition of Transarticular Pins: Never use smooth or threaded Kirschner wires across the SC joint under any clinical scenario. No degree of pin bending or tension-band wiring prevents medial migration into the aorta or heart.

12. Controversy

Current clinical controversies in sternoclavicular joint management focus on three primary debates:

• Surgical Intervention vs. Benign Neglect for Acute Anterior Dislocations: The prevailing orthopaedic consensus recommends nonoperative treatment for acute anterior SC dislocations, accepting the cosmetic prominence because closed reduction routinely fails and long-term functional scores remain high (>90% satisfaction). However, a growing subset of sports medicine surgeons advocates for early open anatomical reconstruction or suture-button stabilization in elite throwing, contact, or overhead athletes to prevent chronic clicking, subjective weakness in terminal bench press or throwing motion, and late joint arthrosis. Prospective randomized trials comparing early stabilization against nonoperative care in competitive athletes are lacking.
• Graft Selection in Reconstructive Surgery: Debate persists regarding the optimal graft source for figure-of-eight SC joint reconstruction. While autologous hamstring tendons (semitendinosus or gracilis) provide proven biological incorporation and zero foreign body response, they introduce donor-site morbidity and increase operative time. Allograft tendons (semitendinosus, gracilis, tibialis anterior) eliminate harvest complications and yield comparable stability rates, but carry theoretical risks of delayed incorporation, disease transmission, and higher cost. Synthetic ligament augmentation (InternalBrace suture tape or LARS) offers immediate structural rigidity and eliminates graft harvest, but long-term data regarding tunnel osteolysis and cyclic fatigue failure in a multi-axial joint remain limited.
• Resection Arthroplasty vs. Joint Preservation for Chronic Instability: In chronic painful SC instability with secondary chondral wear, debate centers on whether to perform isolated medial clavicle resection, combined resection and costoclavicular ligament reconstruction, or joint-preserving biological tendon reconstruction. Resection eliminates painful bone-on-bone contact but risks stump instability if the costoclavicular ligament is compromised, whereas joint-preserving ligament reconstruction in the presence of established osteoarthritis may fail to relieve mechanical pain.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Glass ER, Thompson JD, Cole PA et al. Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma. 2011. doi:10.1097/TA.0b013e3182092c7b [Level I: Systematic Review / Meta-Analysis]
• Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg. 2011. doi:10.5435/00124635-201101000-00001 [Level IV: Clinical Case Series / Cohort Study]
• Sernandez H, Riehl J. Sternoclavicular Joint Dislocation: A Systematic Review and Meta-analysis. J Orthop Trauma. 2019. doi:10.1097/BOT.0000000000001463 [Level I: Systematic Review / Meta-Analysis]
• Sewell MD, Al-Hadithy N, Le Leu A et al. Instability of the sternoclavicular joint: current concepts in classification, treatment and outcomes. Bone Joint J. 2013. doi:10.1302/0301-620X.95B6.31064 [Level IV: Clinical Case Series / Cohort Study]
• Provencher MT, Bernholt DL, Peebles LA et al. Sternoclavicular Joint Instability and Reconstruction. J Am Acad Orthop Surg. 2022. doi:10.5435/JAAOS-D-19-00611 [Level IV: Clinical Case Series / Cohort Study]

15. Master Class Pro-Tip

When drilling the transosseous manubrial tunnels for a figure-of-eight tendon reconstruction, the retrosternal space contains the confluence of the brachiocephalic veins lying within 5 mm of the posterior cortex. Always expose the posterior surface of the manubrium subperiosteally using an elevator and seat a broad malleable retractor directly behind the bone prior to drilling. Direct the drill bit obliquely from anterior to superior-posterior rather than directly posterior, and use an oscillating drill or manual hand-reaming technique with drill stops to prevent plunge. Once tunnels are drilled, pass suture loops with a blunt wire passer to pull the tendon graft smoothly without puncturing retrosternal tissue.

Master Class Surgical Pearl: Sternoclavicular Joint Reconstruction