Posterior sternoclavicular joint dislocation: the value of intra-operative ultrasound

Missed Medial Clavicular Physeal Fracture-Posterior Dislocation Complicated by Brachiocephalic Pseudoaneurysm: A Case Report

CASE

We present a 17-year-old male patient with an initially missed posterior sternoclavicular fracture dislocation who presented with symptoms related to thrombotic emboli arising from a pseudoaneurysm. He was treated 6 weeks after injury with a figure-of-eight tendon allograft repair with good clinical outcomes.

CONCLUSION

This is a unique presentation that highlights the significant risk of a missed diagnosis, life-threatening complications that may ensue, and biomechanically superior surgical intervention.

Posterior sternoclavicular joint dislocation in a young male: a case report

The traumatic dislocation of the posterior sternoclavicular joint is a serious injury with possibly severe complications and therefore has to be managed with the greatest caution. We report the case of a young male with a posterior dislocation of the medial clavicle with compression of the brachiocephalic artery as well as the esophagus. Open reduction and placement of a wire cerclage were performed with a good postoperative outcome.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department

BACKGROUND

Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician.

DISCUSSION

SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification.

CONCLUSIONS

SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Sports-related sternoclavicular joint injuries

Sports-related injuries to the shoulder are common causes of disability. Injuries to the sternoclavicular joint (SCJ) in sports are more rare, though have been reported in a small number of cases. SCJ injury classification is determined by the degree of joint displacement and direction of clavicular displacement. Direction of displacement is particularly important due to risk of injury to intrathoracic structures, which has the potential to result in fatal outcomes. These injuries are important to identify in athletes and can be difficult to assess on the field. Specific radiographic views and use of ultrasound can improve accuracy of diagnosis. Reduction of acute traumatic SCJ dislocations is recommended and may require open reduction in the case of posteriorly displaced dislocations. Surgical treatment is indicated in cases of persistent pain or significant compression to intrathoracic soft tissue structures. Long-term outcomes are generally favorable, and athletes are able to return to sport without functional limitations.

Chest wall - underappreciated structure in sonography. Part II: Non-cancerous lesions

The chest wall is a vast and complex structure, hence the wide range of pathological conditions that may affect it. The aim of this publication is to discuss the usefulness of ultrasound for the diagnosis of benign lesions involving the thoracic wall. The most commonly encountered conditions include sternal and costal injuries and thoracic lymphadenopathy. Ultrasound is very efficient in identifying the etiology of pain experienced in the anterior chest wall following CPR interventions. Both available literature and the authors' own experience prompt us to propose ultrasound evaluation as the first step in the diagnostic workup of chest trauma, as it permits far superior visualization of the examined structures compared with conventional radiography. Sonographic evaluation allows correct diagnosis in the case of various costal and chondral defects suspicious for cancer. It also facilitates diagnosis of such conditions as degenerative lesions, subluxation of sternoclavicular joints (SCJs) and inflammatory lesions of various etiology and location. US may be used as the diagnostic modality of choice in conditions following thoracoscopy or thoracotomy. It may also visualize the fairly common sternal wound infection, including bone inflammation. Slipping rib syndrome, relatively little known among clinicians, has also been discussed in the study. A whole gamut of benign lesions of thoracic soft tissues, such as enlarged lymph nodes, torn muscles, hematomas, abscesses, fissures, scars or foreign bodies, are all easily identified on ultrasound, just like in other superficially located organs.

Diagnosis of a Posterior Fracture Dislocation of the Medial Clavicle in an Adolescent With Point-of-Care Ultrasound

We report a case of an adolescent patient with medial clavicular tenderness after a fall on the lateral left shoulder. Initial radiographs did not reveal a fracture or dislocation. Point-of-care ultrasound was used to diagnose a posterior clavicular fracture dislocation.

Pediatric Posterior Sternoclavicular Joint Injuries

Posterior sternoclavicular joint injuries are increasingly diagnosed in children and young adults. Most of these injuries are the result of indirect mechanisms, typically lateral compression, with a posterior-to-anterior force applied to the shoulder during sports. Less frequently, these injuries are caused by direct impact on the medial clavicle, which can occur in rollover motor vehicle accidents, or may represent atraumatic instability. In patients younger than 25 years, physeal separation is more common than true dislocation. Theoretically, these patients have increased remodeling potential. Reduction is recommended to prevent and/or manage the compression of mediastinal structures, which can lead to life-threatening injury. Open surgical stabilization is the preferred treatment for acute and chronic retrosternal injuries. A thoracic or trauma surgeon should be available during stabilization in the rare event of potentially life-threatening hemorrhage after reduction. Outcomes have been largely successful, with pain-free, unrestricted range of motion and return to activity.

A Case of Posterior Sternoclavicular Dislocation in a Professional American Football Player

Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete’s return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.

Posterior sternoclavicular dislocation presenting with upper-extremity deep vein thrombosis

Posterior sternoclavicular dislocation is an uncommon injury and often remains initially undiagnosed due to variable clinical presentation and inadequate visualization of the joint on plain radiographs. It is frequently associated with serious and life-threatening injuries involving the trachea, esophagus, or great vessels. A 15-year-old boy was knocked to the ground during wrestling and landed on his left shoulder. He presented 6 days after trauma with increasing arm swelling and pain. A Doppler ultrasound revealed deep vein thrombosis involving the left shoulder and arm. Contrast-enhanced computed tomography of the chest confirmed the diagnosis of left posterior sternoclavicular dislocation with the medial end of left clavicle compressing the underlying brachiocephalic vein. Venous duplex scan confirmed acute venous thrombosis of the left jugular and subclavian veins. Open reduction of the left posterior sternoclavicular dislocation was performed under general anesthesia with cardiothoracic surgery backup. The reduced joint was stable, negating the need for internal fixation. Postoperatively, the pain and arm swelling gradually subsided, and patient recovered well with no complications. Deep vein thrombosis has not been reported as a presenting symptom for posterior sternoclavicular dislocation. Orthopedic, trauma, and thoracic surgeons should be aware of this presentation and obtain a chest computed tomography scan with 3-dimensional reconstruction to confirm the diagnosis. In cases of posterior sternoclavicular dislocation with vascular compromise, patients should immediately undergo open reduction with or without internal fixation.

The value of ultrasound in assessing displacement of a medial clavicular physeal separation in an adolescent

We describe a case of medial clavicular physeal separation with posterior displacement of the metaphysis in a 13-year-old girl, focusing on the role played by ultrasound in the diagnosis, planning of treatment and post-reduction follow-up. On clinical examination and conventional radiography, the injury is essentially indistinguishable from a sternoclavicular dislocation or a fracture of the medial aspect of the clavicle; however, the pathogenesis is different, consisting in medial physeal separation and 'degloving' of the inner cancellous bone of the metaphysis from the surrounding periosteal collar with posterior metaphyseal dislocation. In our case, attempted closed reduction failed, and the injury required open reduction with relocation of the clavicle into the periosteal sleeve followed by suturing of the periosteal tear.

Posterior sternoclavicular epiphyseal fracture-dislocation with delayed diagnosis

Posterior sternoclavicular joint dislocations and epiphyseal fractures are relatively rare injuries. We present a case report of a 16-year-old male who presented with a 10-day delay in diagnosis. The medial clavicular fragment was widely displaced and rested against the cervical vertebral body. Despite the degree of displacement, the patient had very few symptoms, and the diagnosis was not appreciated in the emergency department and became apparent at 10-day clinic follow-up. Treatment consisted of attempts at closed reduction, which were not successful. Open reduction was performed and the repair done with strong sutures. At 1-year follow-up the patient is doing well without any symptoms. A literature review consisting of anatomy, ossification patterns, classification systems, diagnosis and associated symptoms, imaging recommendations, treatment recommendations, outcomes, and complications is included.