Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury

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.

Non-Cardiac Conditions that Mimic Cardiac Symptoms in Athletes

When considering the variety of complaints an athlete can present with, chest pain is arguably the most concerning given the potential for catastrophic outcomes. Luckily, these do not comprise the majority of cases, and indeed, are quite rare. The bulk of presentations of athletes with chest pain are due to musculoskeletal, gastrointestinal, and pulmonary causes. Each and every healthcare provider who works closely with athletes must have a thorough understanding of contributing conditions that present as chest pain. Here, we explore some of the more prevalent causes of non-cardiac chest pain, classic presentations, and management considerations.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department

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.

A rare case of complicated pure posterior sternoclavicular dislocation in a young athlete

Sternoclavicular joint dislocation (SCJD) is a rare injury, generally classified in anterior and posterior. The posterior SCJD is very infrequent yet potentially associated with life-threatening complications. In patients with unfused medial clavicle physis, SCJD can be associated with fracture-dislocation (Salter type I or II). We hereby present the case of a 12-year-old basketball player with severe pain in sternoclavicular region and arising dysphagia after a fall and tackle by another player. A SCJ injury was hypothesised and the CT scan detected the presence of a true posterior SCJD with no associated fracture, which was also confirmed during open reduction. As the patient complained dysphagia, it was also necessary to study other possible mediastinal compressions by a contrast medium CT scan of the great vessels. The CT scanned brachiocephalic vein compression without additional clinical evidence or signs. Twenty hours after the trauma the patient underwent an unsuccessful closed reduction; for this reason, surgical treatment with open reduction and fixation was mandatory. After 12 weeks of therapy she returned to her previous sport activity. (www.actabiomedica)

Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management

Sternoclavicular joint (SCJ) instability is a rare condition and results from either a traumatic high energy impact, such as a motor vehicle crash or contact sports injury, or non-traumatically as a result of structural pathology. The infrequency of this injury has contributed to its diagnosis being missed as well as the paucity of literature on treatment and outcomes. Patients with SCJ instability often report diminished range of motion as well as shoulder girdle pain. The presentation of instability in the sternoclavicular joint can vary in severity and anterior or posterior directionality. Variation in severity of the instability changes the course of treatment regarding either operative or non-operative interventions to stabilize the SCJ. In general, anterior instability of the SCJ (the medial clavicle is displaced anterior to the sternum) is less urgent and generally manageable by symptom alleviation and rehabilitation, although some anterior instability cases require surgical intervention. In the case of posterior SCJ instability (the medial clavicle is displaced posterior to the sternum), patients require prompt joint reduction as they are at the greater risk of life-threatening injury due to the location of critical structures of the mediastinum posterior to the SCJ. Computed tomography visualization is useful to confirm dislocation or subluxation direction to better formulate a proper treatment plan. The purpose of this review is to report the clinical presentation and management of SCJ instability including pertinent symptoms, the diagnostic approaches to evaluating SCJ instability, as well as operative and non-operative management of the joint instability.

Sternoclavicular joint replacement case report

INTRODUCTION

This report describes the first known sternoclavicular joint (SCJ) replacement with a custom-made prosthesis.

HISTORY

A 42-year-old male who presented post left medial clavicular excision with significant pain and limited range of motion impeding his daily activities and ability to work. The patient subsequently underwent a left SCJ arthroplasty with a custom-made prosthesis. Postoperatively, the patient suffered an anterior dislocation of the prosthetic joint which was successfully rectified and stabilized with soft tissue reconstruction, creating a pseudo-capsule from adjacent tissues of the joint. Thereafter, the patient required a final procedure to remove prominent sutures.

RESULTS

Currently, the patient has regained full range of motion and is pain free during most activities and has now returned to work, with a plan to review his progress in 1 year. These initial promising results post SCJ replacement with the custom-made prosthesis could potentially lead SCJ reconstruction in an exciting new direction.

DISCUSSION

More research should be encouraged regarding this nascent operative option, in order to identify the indications, parameters, and effectiveness of SCJ arthroplasty.

Sports-related sternoclavicular joint injuries

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.

Sternoclavicular Joint Dislocation: A Systematic Review and Meta-analysis

OBJECTIVES

This meta-analysis was performed to answer the following questions: (1) What is the expected outcome of sternoclavicular (SC) dislocations left untreated? (2) What are the indications for closed reduction of SC dislocations? (3) What are the indications for open reduction of SC dislocations? and (4) Does the evidence support the need for a cardiothoracic surgeon to be available for the open reduction of a SC dislocation?

DATA SOURCES

Articles were obtained from the database EBSCOhost and supplemented by hand searching of bibliographies of included references. A search using the following terms: SC joint AND (dislocation OR injuries OR vascular injury OR cardiovascular surgeon) of the English-language literature from 1970 to 2018 on the topic of SC joint dislocations was performed.

STUDY SELECTION

Studies were included if they contained clinical data on one or more of our study objectives. Articles were included if they contained participants presenting with an acute (<3 week old) SC joint dislocation who were 16 years of age or above. A total of 92 cases fit this participant criteria.

DATA EXTRACTION

Studies chosen based on the inclusion and exclusion criteria were assessed for level of evidence and were then carefully reviewed for data pertaining to the current study questions. Data from individual articles were recorded in a spreadsheet program and grouped appropriately.

DATA SYNTHESIS

Individual cases of acute SC joint dislocations reported in the literature were noted by the authors. The cases were organized into a spreadsheet, which allowed for the calculation of total patients treated and with what treatment option. Complications that followed treatment were also noted, allowing for a quantitative analysis of patient outcome.

CONCLUSIONS

Based on the current body of literature, closed reduction should be attempted in the acute setting and open treatment performed in cases of failed closed reduction in posterior SC dislocations.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transarticular plating for acute posterior sternoclavicular joint dislocations: a valid treatment option?

BACKGROUND

Restoration of the sternoclavicular joint after posterior dislocation is important for upper limb function. The proximity of neuro-vascular mediastinal structures makes open reduction and internal fixation (ORIF) a high-risk procedure. The ideal treatment strategy is still debated. Our aim is to review the treatment of acute posterior sternoclavicular joint dislocation with a locking compression plate.

MATERIALS AND METHODS

We present our experience of transarticular plating using a locking compression plate for the treatment of three consecutive patients with posterior sternoclavicular dislocation (SCD). Our primary outcome measure was objective functional outcome using DASH (disability of the arm, shoulder and hand) and PROMIS (patient-reported outcomes measurement information system) questionnaires. All patients had a minimum follow-up of six months, and serial radiographs were reviewed to evaluate maintenance of reduction.

RESULTS

All three patients presented a posterior SCD with instability refractory to closed reduction. In all three patients, we opted for surgical management using open reduction and fixation with a locking compression plate and allowed early mobilization at two weeks postoperatively. No complications were encountered during follow-up. Good functional outcomes were evidenced by DASH scores of 7.5, 20 and 30, and PROMIS scores were 53.8, 53.8 and 38.1 in each patient, respectively.

CONCLUSION

Our experience of transarticular plating using a locking compression plate for posterior SCD is positive, as it allows early mobilization and resulted in good functional outcomes.