Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Reliability of Upright Chest Radiography as a Diagnostic Screening Tool for Acromioclavicular Joint Dislocations

Background

The standard radiographic view for diagnosing acromioclavicular joint (ACJ) dislocations is the Zanca view of both shoulders to assess superior displacement of the distal clavicle by measuring the coracoclavicular distance (CCD) and comparing it with the uninjured shoulder; however, there is no consensus on a gold standard for diagnostic measures to classify acute ACJ injuries.

Purpose

To compare the CCD from an upright chest radiograph with a standard Zanca view of both shoulders in patients with an ACJ dislocation.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

We reviewed the records of 70 patients with an ACJ dislocation between 2010 and 2021 who had both an upright chest radiograph and a Zanca view. An ACJ dislocation was classified as low grade (Rockwood types 1-3) or high grade (Rockwood type 5). The CCD was measured on the upright chest radiograph and the Zanca view by 2 independent reviewers, and the percentage of the CCD difference compared with the unaffected side (ΔCCD) was calculated and compared between the upright chest radiograph and the Zanca view. Interrater and intrarater reliability were determined using the intraclass correlation coefficient.

Results

Included were 70 patients (55 male and 15 female; mean age, 46 years). There were 29 patients (41.43%) with a low-grade injury and 41 patients (58.57%) with a high-grade injury. In the overall analysis, the ΔCCD on the upright chest radiograph and Zanca view was significantly different (130.25% ± 88.42% vs 152.69% ± 106.56%, respectively; mean difference, 22.44% [95% CI, 2.40% to 42.48%]; P = .029). The subgroup analysis revealed that the ΔCCD on the upright chest radiograph and Zanca view was significantly different for patients with a low-grade injury (60.71% ± 25.79% vs 91.46% ± 68.54%, respectively; mean difference, 30.76% [95% CI, 7.18% to 54.33%]; P = .012) but not different for patients with a high-grade injury (179.45% ± 83.87% vs 196.00% ± 107.97%, respectively; mean difference, 16.56% [95% CI, -14.06% to 47.18%]; P = .281). The intraclass correlation coefficients for the ΔCCD measurements indicated good to excellent interrater and intrarater reliability.

Conclusion

The study findings indicated that upright chest radiography can be used as a diagnostic screening tool for high-grade ACJ dislocations, but not for low-grade ACJ injuries, compared with the Zanca view.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

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.