[Traumatic injuries of the sternoclavicular joint]

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.

Dislocations of the acromioclavicular and sternoclavicular joint in children and adolescents: A retrospective clinical study and big data analysis of routine data

Background

Dislocations of the sternoclavicular joint (anterior/posterior) and acromioclavicular joint (SCJ and ACJ, respectively) are rare injuries in childhood/adolescence, each having its own special characteristics. In posterior SCJ dislocation, the concomitant injuries in the upper mediastinum are most important complication, while in anterior SCJ dislocation there is a risk of permanent or recurrent instability.

Methods

In a retrospective analysis from seven pediatric trauma centers under the leadership of the Section of Pediatric Traumatology of the German Trauma Society, children (<18 years) were analyzed with focus on age, gender, trauma mechanism, diagnostics, treatment strategy and follow-up results. Additional epidemiological big data analysis from routine data was done.

Results

In total 24 cases with an average age of 14.4 years (23 boys, 1 girl) could be evaluated (7x ACJ dislocation type ≥ Rockwood III; 17x SCJ dislocation type Allman III, including 12 posterior). All ACJ dislocations were treated surgically. Postoperative immobilization lasted 3–6 weeks, after which a movement limit of 90 degrees was recommended until implant removal. Patients with SCJ dislocation were posterior dislocations in 75%, and 15 of 17 were treated surgically. One patient had a tendency toward sub-dislocation and another had a relapse. Conservatively treated injuries healed without complications. Compared to adults, SCJ injuries were equally rarely found in children (< 1% of clavicle-associated injuries), while pediatric ACJ dislocations were significantly less frequent (p<0.001).

Conclusions

In cases of SCJ dislocations, our cohort analysis confirmed both the heterogeneous spectrum of the treatment strategies in addition to the problems/complications based on previous literature. The indication for the operative or conservative approach and for the specific method is not standardized. In order to be able to create evidence-based standards, a prospective, multicenter-study with a sufficiently long follow-up time would be necessary due to the rarity of these injuries in children. The rarity was emphasized by our routine data analysis.

[Injuries of the sternoclavicular joint]

Injuries of the sternoclavicular joint (SCJ) are rare accounting for 3% of all injuries to the shoulder girdle and are often overlooked. The SCJ is surrounded by tight ligamentous structures, thus substantial energy with corresponding force vectors is needed to cause dislocation. Causative are mostly high-energy traumas. Anterior dislocation is most common but in rare cases potentially life-threatening posterior dislocation occurs, which requires immediate reduction. The established gold standard is 3D reconstruction in contrast-enhanced computed tomography (CT) for depiction of neurovascular structures. Low-grade instability can initially be treated conservatively. For unsuccessful attempts at reduction, high-grade instability and chronic instability various surgical techniques are established. Next to retentive augmentation with suture materials, in acute cases with chronic instability biological tendon augmentation is preferred. In cases of posttraumatic instability arthritis SCJ resection with or without additive biological augmentation can be carried out. Various study groups have shown good to very good midterm outcome.

[Acute posterior dislocation of the sternoclavicular joint: Reduction, fixation by endobutton system and alternative procedures]

Acute posterior dislocation of the sternoclavicular (SC) joint is rare but can lead to life-threatening vascular injuries of the mediastinum; however, diagnosis is difficult and the injury can be initially overlooked so that surgical treatment is delayed. Although a variety of different treatment modalities have been published, the ideal fixation technique has not yet been identified. We report the case of a patient suffering from a locked posterior SC joint dislocation caused by a skiing accident. The injury was treated by transarticular endobutton fixation. This article describes the technique and highlights its advantages and disadvantages in comparison to previously published treatment options.

[Surgical treatment of sternoclavicular joint instability with tenodesis]

BACKGROUND

Instability of the sternoclavicular joint is a very uncommon disorder of the shoulder girdle. Acute traumatic dislocations are commonly treated nonoperatively. But severe displacement or chronic instability with recurrent symptomatic subluxation may require surgical intervention. We present our results with open reduction and internal fixation through an autologous gracilis tendon transplant or fiber tape in 8 patients treated surgically. The operative stabilisation of the sternoclavicular joint reduces pain level and improves function of the shoulder. This technique provides an effective surgical procedure for treatment of symptomatic sternoclavicular joint instability.

OBJECTIVE

Restoration of the function and aspect of the sternoclavicular joint.

INDICATIONS

Chronic and painful instabilities.

CONTRAINDICATIONS

Local infection, tumor.

SURGICAL TECHNIQUE

The gracilis tendon graft is harvested as previously described by Petersen. Direct incision over the sternoclavicular joint. Sharp dissection of the periostal sleeve and partial release of sternocleidomastoideus and pextoralis muscle. Resection of osteophytes. Careful placement of a raspatorium under the proximal clavicle and sternum to protect the mediastinal structures. Application of 2.5 or 3.2 mm drill holes to the sternum and the proximal clavicle. The gracilis tendon or the fiber tape is pulled through the drill holes in a figure of eight and then sutured. Recontruction of the joint capsule, closure of the wound.

POSTOPERATIVE MANAGEMENT

Gilchrist brace for 3-5 days, functional physiotherapy with a maximum abduction of 90° for 6 weeks. No carrying or lifting of weights greater than 5 kg for 3 months.

RESULTS

During the period from January 2006 to December 2010, 8 patients with sternoclavicular instability were treated. Four patients were treated with fiber tape and four were treated with a gracilis tendon autograft. Postoperative all patients described a reduction of pain and improved shoulder function. The Constant score was 72 points, the DASH 58 points.

Novel utilization of 3D technology and the hybrid operating theatre: Peri‐operative assessment of posterior sterno‐clavicular dislocation using cone beam CT

A patient with a medial and posterior dislocation of the right sterno-clavicular (SC) joint and displacement of the trachea and brachiocephalic artery by the medial head of the clavicle underwent general anaesthetic in the operating theatre for an open reduction procedure. The surgeon initially attempted a closed reduction, but this required imaging to check SC alignment. The patient was transferred to an adjacent hybrid operating theatre for imaging. Cone beam computed tomography (CBCT) was performed, which successfully demonstrated a significant reduction in the dislocation of the SC joint. The trachea and brachiocephalic artery were no longer compressed or displaced. This case study demonstrates an alternative to the patient being transferred to the medical imaging department for multi-slice CT. It also describes a novel use of the hybrid operating theatre and its CBCT capabilities.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.