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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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Abstract
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.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedics, School of Medicine, University of Colorado , Aurora , CO , USA
| | - Eric C McCarty
- Department of Orthopedics, School of Medicine, University of Colorado , Aurora , CO , USA
| | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, School of Medicine, University of Colorado , Aurora , CO , USA
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Imaging Patterns of Injuries After the 2015 Amtrak Philadelphia Train Derailment. AJR Am J Roentgenol 2018; 210:948-961. [PMID: 29489405 DOI: 10.2214/ajr.17.18832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment. CONCLUSION Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.
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Gun B, Dean R, Go B, Richardson C, Waterman BR. Non-modifiable Risk Factors Associated with Sternoclavicular Joint Dislocations in the U.S. Military. Mil Med 2018; 183:e188-e193. [DOI: 10.1093/milmed/usx095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
INTRODUCTION
Sternoclavicular joint (SCJ) dislocations, although uncommon, are observed in patients with ligamentous laxity as well as those who experience traumatic injuries. The incidence and epidemiology of this costly and debilitating injury to our relatively young and active military population have not previously been reported. The purpose of this study is to consider and quantify the non-modifiable risk factors associated with this injury.
METHODS
Using Defense Medical Epidemiological Database, first-time occurrences, from 2006 to 2015 for the ICD-9-CM code 839.61 (closed dislocation of the SCJ), were obtained and further categorized by gender, race, age, rank, and branch of service. Race was classified based on self-reporting of patients into White, Black, or other categories. Age was divided into the categories of less than 20 yr, 20–24 yr, 25–29 yr, 30–34 yr, 35–39 yr, and greater than 40 yr. Rank was categorized as junior enlisted (E-1 to E-4), senior enlisted (E-5 to E-9), junior officer (O-1 to O-3), and senior officer (O-4 to O-10). Branch of service includes Army, Navy, Air Force, and Marines. Multivariate data analysis was performed to obtain rate per 1,000 person-years as well as adjusted rate (adjusted for age group, gender, race, rank, and service) to isolate risk factors.
RESULTS
Between 2006 and 2015, 427 cases of closed SCJ dislocations occurred among an at-risk population of 13,772,342 person-years for an unadjusted incidence rate (IR) of 0.031 per 1,000 person-years. The annual unadjusted IR ranged from 0.017 in 2006 to 0.059 in 2014 with the greatest increase occurring between 2006 and 2007 representing 61% increase in the rate of injuries. Males were almost twice as likely to sustain these injuries compared with females (adjusted rate ratio 1.73; 95% confidence interval [CI] 1.23, 2.43). Age was not found to be a risk factor for the development of these injuries with IRs for each age group overlapping with 95% CI for all other age groups. Similarly, the other category for race was also not found to be a statistically significant risk factor. Junior Officers (adjusted rate 0.017; 95% CI 0.011, 0.025) were found least likely to suffer from these injuries with Junior Enlisted (0.034; 95% CI 0.030, 0.040) and Senior Enlisted (0.032; 95% CI 0.028, 0.037) most at risk. Being in the Navy (0.019; 95% CI 0.015, 0.025) was found to be most protective compared with Air Force (0.032; 95% CI 0.026, 0.039), Army (0.036; 95% CI 0.031, 0.041), and Marines (0.036; 95% CI 0.028, 0.045).
DISCUSSION and CONCLUSION
Annual unadjusted IR of SCJ dislocations readily increased from 2006 to 2014. Statistically significant risk factors, for suffering a closed SCJ dislocation, identified by our study, were male sex, enlisted rank, and branch of service other than Navy. Age and race were not found to have a statistically significant risk. These results can shed light on non-modifiable risk factors for dislocations of the SCJ and can be used in other studies to aid in reducing injury burden on the U.S. Military.
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Affiliation(s)
- Baris Gun
- Department of Graduate Medical Education, William Beaumont Army Medical Center, 5005 N Piedras Street, El Paso, TX 79930
| | - Robert Dean
- Midwest Orthopaedics at RUSH, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612
| | - Beatrice Go
- Midwest Orthopaedics at RUSH, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612
| | - Catherine Richardson
- Midwest Orthopaedics at RUSH, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, 4th Floor Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157
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