| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | |
| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| A Fourteen-Year-Old Boy with Shoulder Pain and Respiratory Symptoms (continued) | ||
| Answer: Posterior dislocation of the right sternoclavicular joint and mild extrinsic compression of the trachea by the medial third of the right clavicle. | ||
| Retrospectively, the initial chest radiograph demonstrates a subtle asymmetry with narrowing of the tracheal shadow (Fig. 4). The computed tomographic scan and the 3-D reconstruction image demonstrate posterior dislocation of the right clavicle, with mild extrinsic compression of the trachea (Figs. 2 and 3). | ||
 Fig. 4 |
Fig. 4 Anteroposterior radiograph of the upper chest. The black arrow points toward the asymmetry of the sternoclavicular joint, and the white arrow points toward the narrowed tracheal shadow. For larger view, click on image |
|
 Fig. 2 |
Fig. 2 Axial computed tomographic image at the upper chest level. The arrow points toward compression of the trachea. For larger view, click on image |
|
 Fig. 3 |
Fig. 3 The 3-D computed tomographic reconstruction demonstrates posterior dislocation of the medial aspect of the right clavicle. The arrow points toward the dislocated medial end of the clavicle. For larger view, click on image |
|
| The patient was taken to the operating room for fiberoptic guided intubation, which demonstrated extrinsic compression of the trachea (Fig. 5). | ||
 Fig. 5 |
Fig. 5 Fiberoptic image demonstrates extrinsic compression of the trachea (arrow). For larger view, click on image |
|
| Initially, an attempt at closed reduction was performed. A bolster (rolled towels) was placed vertically along the midline of the thoracic spine. The reduction maneuver involved gentle traction, and the extremity was abducted and extended while a posteriorly directed force was applied to the anterior aspect of the right shoulder. Following two failed attempts at closed reduction, an open reduction of the sternoclavicular joint was performed. A transverse incision was made, beginning at the most medial portion of the clavicle that could be palpated and extending across the sternoclavicular joint. The anterior portion of the periosteum was stripped from the medial half of the clavicle, and a hematoma was easily decompressed. The exposed clavicle was grasped with a bone-holding clamp and reduced. Direct observation suggested that this injury was a dislocation rather than a physeal fracture. Following reduction, stability was assessed while moving the extremity through a normal range of motion. The sternoclavicular joint remained unstable, and the clavicle displaced easily posteriorly. Therefore, the sternoclavicular joint was stabilized with a nonabsorbable number-2 Ethibond suture (Ethicon, Somerville, New Jersey) in a "figure-of-eight" fashion, through drill-holes in the anterior aspect of the sternum and the medial aspect of the clavicle (Fig. 6). | ||
 Fig. 6 |
Fig. 6 Intraoperative image shows anatomic reduction and internal fixation of the sternoclavicular joint with use of a nonabsorbable suture that has been placed in a figure-of-eight fashion. For larger view, click on image |
|
| Although the surrounding ligaments (sternoclavicular and costoclavicular) could not be clearly identified, a soft-tissue reconstruction was performed by repairing the periosteal sleeve and the remnants of these ligaments. The patient was maintained in a shoulder immobilizer for six weeks and then was transitioned to a sling. Physical therapy was begun after six weeks. At three months, the reduction was found to be maintained and the patient was allowed to resume his normal level of activity. | ||
| A postoperative plain radiograph showed a normal and symmetric relationship of the sternoclavicular joints (Fig. 7). | ||
 Fig. 7 |
Fig. 7 Anteroposterior radiograph of the upper chest demonstrates reestablishment of the relationship of the right sternoclavicular joint (arrow points toward the reduced sternoclavicular joint). For larger view, click on image |
|
| Discussion | ||
| Traumatic subluxation or dislocation at the sternoclavicular joint is rare in children and adolescents and is often difficult to diagnose1. Such injuries are often sustained during contact sports, particularly football and hockey2. The mechanism of injury is lateral compression, and in most cases there is a physeal fracture (Salter-Harris I or II) rather than a true dislocation. The displacement may be either anterior or posterior. Posterior displacement may cause compression of mediastinal structures, resulting in dyspnea, stridor, dysphagia, and/or vascular injury. Patients usually present with shoulder and/or chest pain, and the involved extremity is placed in a splint. One patient also had transient symptoms related to stretching of the brachial plexus (a “stinger” injury). Exertional dyspnea, vascular compression, and brachial plexus compression have all been observed with chronic posterior sternoclavicular dislocation3. | ||
| Abnormalities at the sternoclavicular joint may be difficult to evaluate on plain radiographs, and the presence of a medial clavicular physis in children can further complicate the diagnosis4. Several views (e.g., the serendipity view or a 40° cephalic-tilt view) have been described for obtaining satisfactory images in adults5,6. A computed tomographic scan (axial image) is probably the most effective imaging tool with which to evaluate these injuries2. | ||
| The treatment of posterior displacement due to either a physeal fracture or dislocation is based on the degree of displacement, the presence of symptoms, and whether the injury is acute or chronic. In the absence of symptoms, mild subluxation may be treated by observation whether the injury is acute or chronic. A physeal injury has the potential to remodel in this setting. Injuries with greater degrees of posterior displacement, especially those associated with signs or symptoms of mediastinal compression, should be treated by reduction with or without stabilization7,8. Given the risk of complications, reduction is generally performed in the operating room with the patient under general anesthesia and with a cardiothoracic surgeon standing by9. | ||
| If a closed reduction is successful, then patients are managed with immobilization alone. A recent study by Waters et al., based on data from computed tomographic scans following closed reduction in three patients (all of whom had recurrent displacement), suggested that loss of reduction may be common in children and adolescents and that operative stabilization should be considered following closed reduction9. Several methods for fixation of the sternoclavicular joint have been reported, including the use of nonabsorbable suture, stainless steel wire, Kirschner wire or Steinmann pins, tendon grafts, and fascial loops10. However, several case reports have documented catastrophic complications, such as vascular perforation from pin migration, from the use of metal implants to stabilize the joint11-13. Our preference is to use nonabsorbable suture (in a figure-of-eight fashion), as reported by Waters et al.9. If the injury is a true dislocation, the suture is placed through drill-holes in the medial aspect of the clavicle and in the sternum. For a physeal fracture, drill holes are placed in the metaphysis and the epiphysis of the medial aspect of the clavicle. The extremity is immobilized for six weeks, after which the patient is transitioned to a sling and begins range of motion and strengthening exercises. Patients are allowed to resume their normal level of activity after three to four months. | ||
| *The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. | ||
| Reference | ||
1. Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma. 1967;7:416-23. |
||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |