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Afifi MFA, Waldmann S, Pisano A. A rare rotated, medially displaced fracture-dislocation of the medial clavicle - Case report and review of the literature. Trauma Case Rep 2023; 48:100967. [PMID: 38098810 PMCID: PMC10719449 DOI: 10.1016/j.tcr.2023.100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/17/2023] Open
Abstract
Clavicle fractures combined with sternoclavicular joint dislocations are very rare injuries that need to be addressed quickly and treated effectively due to the altered biomechanics of the shoulder girdle as well as to the potential damages to the surrounding "noble" anatomical structures. A diagnostic and therapeutic algorithm for such injuries has not yet been established. Computer Tomography with 3D reconstruction should be the diagnostic gold standard. In case of a highly displaced fracture and/or dislocation in an active patient, surgical treatment is advised in order to obtain proper bone and joint healing with satisfactory functional outcomes as well as to protect the surrounding anatomical structures from potential damages. We present the case of an 18-year-old male, skeletally mature patient, who had a fall while snowboarding. Subsequently he was diagnosed with a very uncommon combination of a displaced medial clavicle fracture and complete posterior Sterno-Clavicular dislocation with 111° rotation of the sternoclavicular fragment. We opted for surgery, decided to use "off-label" a 2.5 V-plate Ulna plate long (Medartis®) and to associate this procedure with a Sterno-Clavicular arthrodesis with tape-augmentation to stabilize the SC joint; this treatment strategy resulted in a good clinical outcome without any remaining instability and satisfactory ROM. We collected this case to describe this seldom combination, to show our treatment strategy and to advocate the creation of a standardized diagnostic and therapeutic algorithm. X-rays, Computer Tomography images and intraoperative photos are presented.
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Albors LM, Lee RJ. Chronic Posterior Sternoclavicular Dislocation in a Contact Athlete: A Case Report. JBJS Case Connect 2020; 10:e0032. [PMID: 32044788 DOI: 10.2106/jbjs.cc.19.00032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE Traumatic posterior sternoclavicular dislocation (PSCD) is an uncommon injury that often presents in a delayed fashion and can be difficult to diagnose. Standard treatments include reduction of acute injuries and possible reconstruction for chronic injuries. We describe a 16-year-old male football player with a traumatic PSCD and initial dyspnea and dysphagia. He returned to playing contact sports without undergoing reduction. CONCLUSIONS Contrary to the literature that suggests reduction as a primary treatment of PSCD, this case shows that a contact-sport athlete may be able to return to competitive sports with a chronic PSCD.
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Affiliation(s)
- Laura Mena Albors
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - R Jay Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Kendal JK, Thomas K, Lo IKY, Bois AJ. Clinical Outcomes and Complications Following Surgical Management of Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review. JBJS Rev 2019; 6:e2. [PMID: 30399119 DOI: 10.2106/jbjs.rvw.17.00157] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Traumatic posterior sternoclavicular joint dislocations are rare orthopaedic emergencies. Treatment typically consists of closed reduction, with surgical management reserved for unstable cases. Because of the low prevalence of this condition, limited clinical evidence exists for a superior surgical stabilization technique. METHODS A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. MEDLINE and Embase databases were searched using a comprehensive search strategy. A descriptive and critical analysis of the results was performed. RESULTS Forty relevant studies (108 cases) were identified. Favorable subjective and objective outcomes were reported for all 5 categories of stabilization described. The overall complication rate was 16%, including 4 cases of recurrent instability. Ligament reconstruction using tendon graft had the lowest recurrent instability and complication rates, and open reduction and internal fixation techniques required a second operation for implant removal in 80% of cases. CONCLUSIONS A comprehensive review of the surgical management of traumatic posterior sternoclavicular joint dislocations is presented. Results suggest favorable outcomes for all of the methods of stabilization, with a modest complication rate. The trends observed have helped to guide the development of clinical care recommendations that aid in treatment decision-making for these injuries. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph K Kendal
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Martetschläger F, Reifenschneider F, Fischer N, Wijdicks CA, Millett PJ, Imhoff AB, Braun S. Sternoclavicular Joint Reconstruction Fracture Risk Is Reduced With Straight Drill Tunnels and Optimized With Tendon Graft Suture Augmentation. Orthop J Sports Med 2019; 7:2325967119838265. [PMID: 31041330 PMCID: PMC6481000 DOI: 10.1177/2325967119838265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background: Despite the rare entity of sternoclavicular joint (SCJ) instability, a variety of different reconstruction techniques for SCJ dislocations have been described. A technique with oblique drilling has been proposed to reduce intraoperative risks. Purpose: To biomechanically investigate different cerclage reconstruction techniques and the benefit of additional reinforcement using suture tape. Study Design: Controlled laboratory study. Methods: Reconstructed artificial bone specimens were mounted on a mechanical testing machine. They were subjected to anterior and posterior translation, analyzing ultimate strength, displacement, stiffness, and elongation. For stage 1, different angulations of the drill tunnels through the sternum and clavicle were compared. Straight drill tunnels from anterior to posterior were compared with 45° oblique drill tunnels. For stage 2, three different materials for cerclage reconstruction were compared: (1) suture tape alone (FT group), (2) tendon graft alone (tendon group), and (3) tendon graft with suture tape augmentation (tendon+FT group). Results: For the FT group, in the anterior and posterior directions, straight drill holes resulted in a significantly higher load to failure (936.9 ± 122.5 N) compared with oblique ones (434.5 ± 20.2 N) (P < .0001). During cyclic testing, all specimens with straight drill holes survived the 5- to 550-N step, while all specimens with oblique ones failed during the 5- to 450-N step. Analyzing the graft material choice, the mean load to failure was 556.6 ± 174.3 N for the tendon group, 936.9 ± 122.5 N for the FT group, and 767.0 ± 110.7 N for the tendon+FT group (P = .089). The stiffness of the tendon+FT group was significantly lower than that of the FT group and significantly higher than that of the tendon group. Conclusion: Oblique tunnel placement during SCJ reconstruction, while reducing the intraoperative risk, results in decreased primary stability of the construct. Tendon graft reconstruction with suture tape augmentation leads to enhanced stability and optimizes biomechanical properties of the construct. Clinical Relevance: The surgical technique with straight drill holes has superior initial biomechanical properties and may likewise produce superior clinical outcomes in the treatment of SCJ instability. Suture tape augmentation can provide additional stability to reconstruction procedures.
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Affiliation(s)
- Frank Martetschläger
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany
| | | | - Nicole Fischer
- Department of Research & Development, Arthrex GmbH, Munich, Germany
| | - Coen A Wijdicks
- Department of Research & Development, Arthrex GmbH, Munich, Germany
| | | | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sepp Braun
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Gelenkpunkt, Sport- und Gelenkchirurgie Innsbruck, Innsbruck, Austria
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Beckmann NM, Sanhaji L, Chinapuvvula NR, West OC. Imaging of Traumatic Shoulder Girdle Injuries. Radiol Clin North Am 2019; 57:809-822. [PMID: 31076034 DOI: 10.1016/j.rcl.2019.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Shoulder girdle trauma is one of the most common injuries encountered in emergency centers. These injuries can be easily overlooked due to the complex osteology of the shoulder. Although radiographs are usually sufficient for assessing traumatic shoulder injuries, cross-sectional imaging is sometimes indicated to assess portions of the shoulder not well visualized by radiographs. In this article, the authors review the spectrum of shoulder girdle injuries: sternoclavicular dislocations, clavicle fractures, acromioclavicular separations, shoulder dislocations, scapula fractures, and scapulothoracic dissociation. They also discuss the presentation, imaging evaluation, and classification of these injuries with emphasis on pitfalls in imaging diagnosis and indications for computed tomography/magnetic resonance.
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Affiliation(s)
- Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX 77030, USA.
| | - Latifa Sanhaji
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX 77030, USA
| | - Naga R Chinapuvvula
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX 77030, USA
| | - O Clark West
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX 77030, USA
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Gerich T, Hoffmann A, Backes F, Duinslaeger AD, Seil R, Pape D. Anterior buttress plate is successful for treating posterior sterno-clavicular dislocation. Knee Surg Sports Traumatol Arthrosc 2019; 27:251-258. [PMID: 30478469 DOI: 10.1007/s00167-018-5298-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/13/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Traumatic posterior instability of the sternoclavicular joint is a potentially life-threatening injury. In contrast to the low incidence there is a plethora of different strategies to treat this lesion. It was the objective of this retrospective analysis to evaluate and further develop current strategies. METHODS In this retrospective analysis all posterior dislocations that were diagnosed and treated between 2011 and 2018 were included. In this 7 year period, eight male patients (median age 32 years) were operated. RESULTS Three patients were not diagnosed at the primary institution and were referred later. Five patients were treated with an anterior buttress plate with clavicular stabilisation only. One patient was stabilized with a temporary sternoclavicular arthrodesis. Two patients were operated using an autologous tendon graft. All of the patients underwent an immediate postoperative CT-scan that documented the anatomical articulation. All patients treated with a plate underwent implant removal. A final CT examination after removal documented the maintenance of the anatomic alignment. CONCLUSIONS The buttress plate technique with clavicular screw fixation is a sufficient treatment to restore and preserve a normal sternoclavicular alignment. The technique finds its indication in unidirectional posterior instability. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Torsten Gerich
- Centre Hospitalier de Luxembourg, 4, Rue Barble, 1210, Luxembourg, Luxembourg.
| | - Alexander Hoffmann
- Centre Hospitalier de Luxembourg, 76 Rue d'Eich, 1460, Luxembourg, Luxembourg
| | - Francois Backes
- Centre Hospitalier de Luxembourg, 4, Rue Barble, 1210, Luxembourg, Luxembourg
| | | | - Romain Seil
- Centre Hospitalier de Luxembourg, 76 Rue d'Eich, 1460, Luxembourg, Luxembourg
| | - Dietrich Pape
- Centre Hospitalier de Luxembourg, 76 Rue d'Eich, 1460, Luxembourg, Luxembourg
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Edwin J, Ahmed S, Verma S, Tytherleigh-Strong G, Karuppaiah K, Sinha J. Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies. EFORT Open Rev 2018; 3:471-484. [PMID: 30237905 PMCID: PMC6134883 DOI: 10.1302/2058-5241.3.170078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton. Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints. This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome. The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.
Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078
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Affiliation(s)
| | - Shahbaz Ahmed
- Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
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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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Beckmann N, Crawford L. Posterior sternoclavicular Salter-Harris fracture-dislocation in a patient with unossified medial clavicle epiphysis. Skeletal Radiol 2016; 45:1123-7. [PMID: 27107998 DOI: 10.1007/s00256-016-2399-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/08/2016] [Accepted: 04/18/2016] [Indexed: 02/02/2023]
Abstract
Sternoclavicular injuries are relatively rare, composing less than 1 % of all musculoskeletal fractures or dislocations. When sternoclavicular injuries do occur, they typically present as an isolated dislocation of the sternoclavicular joint without associated fracture of the clavicle or manubrium. However, in patients with unfused medial clavicle physis, sternoclavicular joint injuries can present as a fracture-dislocation through the unfused physis. These physeal injuries are important to recognize as the displaced epiphysis can block reduction of the sternoclavicular joint. We present a case of a 15-year-old female basketball player presenting with suspected sternoclavicular joint injury after sustaining a direct blow to the left shoulder. An initial shoulder CT confirmed the presence of the clinically suspected posterior sternoclavicular dislocation without fracture identified. An MRI of the left sternoclavicular joint was then performed for suspected physeal fracture, which confirmed the presence of a fracture through the medial clavicle physis with anterior displacement of the unossified epiphysis, blocking reduction of the metaphysis. Given the findings on MRI, the pediatric orthropedic surgeon was able to counsel the family of the high likelihood of failed closed reduction of the sternoclavicular joint requiring conversion to open reduction and internal fixation. The patient underwent successful open reduction and internal fixation of the medial clavical physeal fracture after an initial gentle attempt at closed reduction was unsuccessful.
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Affiliation(s)
- Nicholas Beckmann
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Lindsay Crawford
- Department of Orthopedic Surgery, University of Texas Health Science Center, 6400 Fannin Street; Suite 1700, Houston, TX, 77030, USA
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