Right sternoclavicular dislocation after traumatic delivery: A case report

Right

Sternoclavicular By Stefan

Aretz,

Gabriele

Dislocation After A Case Report Benz-Bohm, Hanns J. Helling, and Bernhard Roth KrYn-Lindenthal,

Sternoclavicular

(SC) dislocation is an injury that is very rare in the newborn. Thus far there have been no reports describing this in neonates after a traumatic birth injury. This condition can be difficult to differentiate from epiphyseal separation, which occurs more often in older children. For successful treatment, early diagnosis is essential. Emely surgical reposition and fixation with following immobilization is recommended in instances of complete (SC) dislocation. We report a trauma-induced case of SC dislocation in a

D

ISLOCATIONS of the sternoclavicular joint are uncommon. Almost exclusively caused by indirect trauma, rarely on a habitual or congenital basis, until now they have been described only in older infants.‘J Sternoclavicular dislocation in the newborn period, particularly as birth injury, has not been mentioned in the literature to our knowledge. Ogden3 mentioned a sternoclavicular injury in a newborn after difficult delivery, but it was supposed to be an epiphyseal separation. We report on a sternoclavicular joint dislocation noticed postpartum after forceps delivery and its surgical management. CASE

Traumatic

REPORT

Anamnesis and Examination After uncomplicated pregnancy the child was born at 40 weeks’ gestation by forceps extraction. Postnatal absence of movement of the right arm was noticed. We saw a healthy mature newborn in only slightly reduced general condition. The right arm was flaccid and turned inward, the fingers were seldom actively moved. There was reaction to painful stimuli, and peripheral blood circulation was normal. Grasp reflexes were equal on both sides, Moro reflex was less pronounced on the right side. Right arm and shoulder showed no superficial injuries.

Course and Therapy

Delivery:

Peter Herkenrath,

Germany

neonate successfully managed tion. J Pediatr Surg 341872-1873. Saunders Company.

INDEX WORDS: lar joint injuries, ceps delivery.

Sternoclavicular birth injuries,

by polydioxanon Copyright

dislocation, birth trauma,

o

1999

cord

fixa-

by

W.B.

sternoclavicunewborn,

for-

the right clavicle was projected to the level of the first costovertebral joint (Fig 1). Radiographically, there was no evidence of fractures or epiphyseal separation of the proximal humeral epiphysis. With knowledge of the radiological findings subsequently a slight swelling above the right stemoclavicular joint was visible. Palpation in this area showed a small step between sternum and medial clavicular joint. During careful closed manipulation the dislocation was easily, but not stably. reducible. Despite arm fixation with a Dessault’s bandage, recurrent spontaneous dislocations occurred. After unchanged clinical course, the dislocation was treated surgically on the fifth day of life with open reposition and fixation of the cranially displaced clavicle to the sternum with polydioxanon cord. The postoperative and further radiographic control on the seventh postoperative day showed the medial parts of both clavicles in the same level and thus a satisfying result with a good fixation of the clavicle to the sternum (Fig 2).

The right arm was immobilized for 1 week with a Dessault’s bandage. The patient was discharged on the 10th day, at this time with good motion of the fingers of the right hand and equal reflexes on both sides. Elbow joint was fleeted spontaneously, and abduction of the right arm of more than 90” was possible. Sensibility was intact at all times. Follow-up examination showed an uncomplicated postoperative course.

DISCUSSION

A diagnosis of a sternoclavicular dislocation might be difficult especially in newborns and infants because of the

The absence of motion of the right arm initially made a fracture of the clavicle or an injury to the brachial plexus most likely. A posteroanterior chest film showed dislocation of the right clavicle. The medial part of

From the Children’s Hospital, Institute of Diagnostic Radiology, and the Department of Surgery, University of Cologne, Germany. Address reprint requests to Bernhard Roth, MD, Children’s Hospital, University of Cologne, Joseph-Stelzmann-Str 9, 50924 K&-Lindenthal, Germany. Copyright o 1999 by WB. Saunders Company 0022.3468/99/3412-0031$03.00/O

1872

radiograph shows displacement of the medial Fig 1. Preoperative part of the right clavicle in comparison with the left side.

Journaloffediatric

.Sorgery,Vol34,

No 12 (December),

1999: pp 1872-1873

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Fig 2. Postoperative sternoclavicular joints.

control.

Note

the

normal

position

of the

obvious low incidence of this entity and the sometimes problematic interpretation of the standard radiographic views1 Because the epiphysis does not yet contain an ossified center, the differentiation between a real dislocation, and, in pediatric patients, much more common traumatic epiphyseal separation, can be problematic, clinically and radiologically, and sometimes even impossible. For exclusion of an epiphyseal separation, ultrasonography has proved to be particularly valuable.4J If there is any uncertainty, computed tomography or MRI examination is the ideal method of displaying the joint and the intraarticular disc.(j

In the current case, the standard chest film in connection with the clinical symptoms was sufficient for quick and doubtless diagnostic clarification. This finding is in contrast to those of some investigators, who state that an isolated traumatic dislocation of a joint probably never occurs at birth and that every dislocation in infants should be regarded as an epiphyseal fracture.1,3 Because of the possible dangerous complications, a general agreement with regard to a surgical approach only exists for retrostemal dislocation. Relative indications for a surgical treatment of the anterior dislocation especially are recurrent spontaneous dislocations, a relevant functional and painful impairment, and when closed reduction fails. To achieve an optimal functional outcome, a generous surgical procedure for ventral dislocations is recommended because of the high risk of redislocations with conservative therapy and the unfavorable outcome of secondary stabilization after failed conservative reduction.3 Among the recently described methods, the fixation with polydioxanon cord was successful in addition to the widespread internal stabilization with Kirschner wires, which sometimes leads to severe complications because of mediastinal wire migration.7 This method, which is gentle, low-risk, and even in newborns, technically practical, was applied to our patient with good results.

REFERENCES 1. Cope R, Riddervold HO, Shore JL, et al: Dislocations stemoclavicular joint: Anatomic basis, etiologies, and radiologic sis. J Orthop Trauma 5:379-384, 1991

of the diagno-

2. Sons HU, Danneberg A, Jerosch .I: Diagnosis and treatment luxation of the stemoclavicular joint. Z Orthop 130:22-30, 1992 3. Ogden JA: Skeletal Injury Saunders, 1990, pp 329-332 4. Broker

FHL,

Burbach

in the Child

T: Ultrasonic

(ed 2). Philadelphia,

diagnosis

of separation

of

PA?

of the

proximal humeral epiphysis in the newborn. J Bone Joint Surg 72:187-191: 1990 5. Riebel T, Nasir R: Sonography of injuries to extremities due to birth trauma. Ultraschall in Med 16:196-199, 1995 6. Klein MA, Spreitzer AM, Miro PA, et al: MR Imaging of the abnormal Sterno-clavicular joint-A pictorial essay. Clin Imaging 21:138-143, 1997 7. Fried1 W. Fritz T: Polydioxanon cord fixation in stemoclavicular joint dislocation and paraarticular fractures of the clavicle. Unfallchiirg 971263-265, 1994