Posterior sternoclavicular joint dislocation

Return to Sports After Closed Reduction of Acute Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review

BACKGROUND

Acute traumatic posterior sternoclavicular (SC) joint dislocation is a serious injury given its potential to cause cardiovascular and airway compromise that typically will require emergent closed reduction. There are limited data on the rate of return to sports (RTS) after this injury pattern when treated in a closed fashion.

PURPOSE

To systematically review the literature and evaluate (1) the rate of RTS after closed reduction of posterior SC dislocation and (2) the timeline for RTS after closed reduction of posterior SC dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed using the PubMed, EBSCOhost, and Elsevier databases with the search term "sternoclavicular dislocation." Inclusion criteria were publications reporting successful closed reduction of posterior SC joint dislocation and containing data relevant to the study objectives. Exclusion criteria were cases with unsuccessful closed reduction, open surgical reduction, concomitant fracture, epiphyseal disruption, superior or anterior dislocation, subluxation injury, treatment without reduction, and atraumatic or congenital origins.

RESULTS

Sixteen studies and an additional forthcoming case at the authors' institution were identified to have documented RTS with a total of 31 patients. Of these patients, 23 (74%) in the cohort had full RTS. Eight of the 16 studies plus the additional case reported a timeline for RTS. The mean time to RTS was 3.1 months (range, 1-6 months). Of the 8 patients who did not return to preinjury sports or activity, 12.9% (4/31) reported restrictions with sports or activity, 6.5% (2/31) changed to a sport with less contact, 3.2% (1/31) experienced symptomatic recurrence requiring surgical stabilization, and 3.2% (1/31) quit the sport.

CONCLUSION

Closed reduction of acute traumatic posterior SC joint dislocations provides high RTS rates with low rates of secondary surgical stabilization. The mean time to RTS at the preinjury activity level was 3.1 months.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

A Case of Posterior Sternoclavicular Dislocation in a Professional American Football Player

Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete’s return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.

Safe surgical technique: reconstruction of the sternoclavicular joint for posttraumatic arthritis after posterior sternoclavicular dislocation

Posttraumatic sternoclavicular arthritis related to chronic ligamentous instability after posterior sternoclavicular dislocation represents a rare but challenging problem. The current article in the Journal’s “Safe Surgical Technique” series describes a successful salvage procedure by partial resection of the medial clavicle and ligamentous reconstruction of the sternoclavicular joint with a figure-of-eight semitendinosus allograft interposition arthroplasty.

Variations in normal sternoclavicular joints; a retrospective study to quantify SCJ asymmetry

OBJECTIVE

A wide degree of normal anatomical variation can occur at the sternoclavicular joint (SCJ). On occasion, this has led to concern for a pathological process, potentially resulting in a costly work-up, unnecessary patient worry and invasive diagnostic procedures such as biopsy. The purpose of this study was to determine the normal range of anatomical variation at sternoclavicular joints.

MATERIALS AND METHODS

One hundred four consecutive patients with chest CT done at our institution were selected. Patients with clear SCJ pathology, chest wall abnormality, CT slice thickness greater than 5 mm and sternotomy wires, were excluded. Chart review was done and showed no SCJ symptoms/signs. We measured the SCJ space, maximum clavicular head diameter within the joint and the distance from manubrium to the anterior margin of the clavicular head.

RESULTS

Left and right SCJ space ranged from 0.2 to 1.37 cm. The difference (delta or asymmetry) between left SCJ space and right SCJ space ranged from 0 (symmetrical) to 0.57 cm in 104 cases. Left and right clavicular head diameter ranged from 1.2 to 3.7 cm with left/right asymmetry (delta) ranging from 0 (symmetrical) to 1 cm. Manubrium to anterior margin of clavicular head ranged from 0.1 to 2.13 cm with delta ranging from 0 to 0.8 cm. Thirty-three patients demonstrated gas in the joint, five had poor articulation and four had calcification in the joint.

CONCLUSION

Greater than 10% of patients show substantial asymmetry in the sternoclavicular joints, which may be misinterpreted as pathological. Gas in the joint is a common phenomenon therefore should not be an indication for further work-up in asymptomatic patients and likely excludes the presence of effusion.

Chest pain in athletes

The symptom of chest pain in the athlete can represent anything from a nonspecific musculoskeletal strain to a life-threatening condition such as tension pneumothorax. For the physician charged with evaluating this patient population, a thorough knowledge of the possible etiologies, their usual diagnostic algorithms, available imaging modalities, and potential therapeutic options is essential. Although the vast majority of patients with traumatic chest pain will not harbor significant pathology, the clinician must be prepared for those few who do have such conditions, and be prepared to intervene in an appropriate, time-sensitive fashion.