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Ingoe HMA, Mohammed K, Malone AA, Beadle G, Sharpe T, Cockfield A, Lloyd R, Singh H, Colgan F. Traumatic posterior sternoclavicular joint dislocation - Current aspects of management. Injury 2023; 54:110983. [PMID: 37634999 DOI: 10.1016/j.injury.2023.110983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/19/2023] [Accepted: 08/05/2023] [Indexed: 08/29/2023]
Abstract
The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.
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Affiliation(s)
- Helen M A Ingoe
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand.
| | - Khalid Mohammed
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Alex A Malone
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Gordon Beadle
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Thomas Sharpe
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Allen Cockfield
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Richard Lloyd
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Harsh Singh
- Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand; Dept of Cardiothoracic Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Frances Colgan
- Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand; Department of Interventional Radiology, Christchurch Hospital, Christchurch, 8011 New Zealand
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Carius BM, Long B, Gottlieb M. Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department. J Emerg Med 2021; 61:499-506. [PMID: 34511297 DOI: 10.1016/j.jemermed.2021.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - Brit Long
- Brooke Army Medical Center, Joint Base San Antonia, Fort Sam Houston, Texas, and.
| | - Michael Gottlieb
- Department of Emergent Medicine, Rush University Medical Center, Chicago, Illinois
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