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Use of an O-arm intraoperative computed tomography scanner for closed reduction of posterior sternoclavicular dislocations
J Shoulder Elbow Surg (2012) 21, e17-e20
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Use of an O-arm intraoperative computed tomography scanner for closed reduction of posterior sternoclavicular dislocations Jaron P. Sullivan, MD*, Brian A. Warme, MD, Brian R. Wolf, MD, MS Department of Orthopedics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Posterior sternoclavicular (SC) dislocations and fracture-dislocations are rare injuries that have been estimated to occur with an incidence of less than 0.1% of all dislocations.5 They can be benign; however, there are reports of injury to the mediastinum and death if not treated appropriately.4,6,8 In the acute setting it is imperative to make the appropriate diagnosis and for reduction to be performed. Patient history, clinical examination, and plain radiographs can help clinicians narrow down the differential, but the definitive diagnosis is sometimes elusive. Because an orthogonal view to the anteroposterior radiograph of the SC joint cannot be easily obtained, it is challenging to make the diagnosis with plain radiographs or fluoroscopy. Ultrasound has been used to confirm reduction,7 but the images can be difficult for people to interpret, with unknown reliabilities at most institutions. Computed tomography (CT) scans are widely accepted as the gold standard for diagnosis.1,2 However, use of CT for assessment of a closed reduction attempt is difficult because it requires patient transport to the CT scanner, either with intubation or after awaking the patient, knowing that if the joint remains dislocated, then the patient has to return to the operating room. We have recently used an O-arm intraoperative CT system (Medtronic Navigation, Louisville, CO, USA) to verify reduction in 2 cases, which to our knowledge has not been used
No institutional review board approval needed. *Reprint requests: Jaron P. Sullivan, MD, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Ste 1700JP, Iowa City, IA, USA. E-mail address: [email protected] (J.P. Sullivan).
previously. This obviated the need for immediate postoperative CT to verify reduction and the possibility of a second trip to the operating room with sedation for open reduction if the initial attempt had failed.
Technique The reduction of a posterior SC dislocation is best accomplished in the controlled environment of an operating room with proper anesthesia, auxiliary teams, and monitoring. Reduction can be painful for the patient, and general anesthesia can provide both pain control and skeletal muscle relaxation to assist with the reduction. It is also recommended that auxiliary teams such as vascular or cardiothoracic surgery personnel be made aware of the procedure in case a life-threatening complication occurs when the clavicle is reduced from its impaled position in the mediastinum. At our institution, we use the abduction traction technique.3 The patient is placed supine on the table with a sandbag or towel under the center of the thoracic spine, elevating the affected shoulder off the table. Lateral traction is applied, and the arm is slowly extended. Manual anterior traction is applied directly to the clavicle at the same time. If the clavicle is unable to be grasped and reduction is not obtained with initial attempts, a sterile towel clamp is placed onto the medial one-third of the clavicle, which is in a sterile field. This allows for firm anterior traction and reduction. If this is unsuccessful, then open reduction is indicated. Often, with closed reduction, there is an audible or palpable pop as the joint is reduced; however, this does not prove reduction. After the reduction,
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.07.015
e18
J.P. Sullivan et al.
Figure 3
Postoperative CT scan verifying reduction.
Figure 1 (A) Plain radiograph and (B) CT scan showing left posterior SC dislocation.
Figure 4 CT scan showing posterior fracture-dislocation of right SC joint.
an intraoperative O-arm CT scan is obtained to verify reduction.
Case reports
Figure 2 Intraoperative O-arm CT image showing reduction of SC joint. S, Sternum; C, clavicle.
The first case is a 20-year-old male collegiate basketball player who sustained a contact injury with another player and then fell onto his left shoulder. He presented with severe pain, holding his arm in an internally rotated and adducted position. He denied any chest pain, dyspnea, weakness, or paresthesias in the arms. There was an apparent asymmetry at the left SC joint. Plain films and then a CT scan were obtained, showing a left posterior SC dislocation (Fig. 1). Given the patient’s age, this likely was an SC physeal fracture-dislocation. He was taken to the operating room and placed supine with a rolled towel between the scapulae. General endotracheal anesthesia was used. Longitudinal traction on the left arm was performed as the clavicle was pulled in the anterior direction manually. There was an audible click, and the patient’s left shoulder was taken through a range of motion with
O-arm CT for posterior sternoclavicular dislocations
Figure 5
e19
Sequential O-arm CT images of intraoperative closed reduction. S, Sternum; C, clavicle.
no evidence of gross instability. His extremity was placed in a shoulder immobilizer. The O-arm CT scanner was used to verify reduction (Fig. 2). The patient was admitted for observation overnight, and then a repeat CT scan was obtained to verify that the reduction was maintained on postoperative day 1 (Fig. 3). After several weeks of immobilization, the patient gradually returned to full activity and participation in collegiate basketball. The second case was a 16-year-old male passenger who was involved in a T-bone motor vehicle collision at highway speeds, impacting the passenger’s side of the car. He was initially evaluated at an outside hospital and found to have multiple pelvic fractures, as well as a posterior right clavicle fracture-dislocation. He had a positive loss of consciousness at the scene. He presented with right shoulder pain and pelvis pain. He denied any noticeable changes in his voice, dyspnea, chest pain, or numbness or paresthesias in the extremities. On clinical examination, the patient had symmetric blood pressures and pulses in the bilateral upper extremities. He had tenderness to palpation over the right clavicle. Right shoulder range of motion was limited because of pain. A contrast CT scan showed a right posterior SC fracture-dislocation, with the displaced clavicle adjacent to the aorta and no evidence of dissection (Fig. 4). There was also concern about mild compression of the trachea. The patient was taken to the operating room and placed under general anesthesia. He was positioned supine with a towel under the thoracic spine. The right arm was abducted with traction and then slightly extended while the clavicle was grasped manually over the skin and pulled upward. There was a palpable clunk. O-arm imaging was used to confirm reduction (Fig. 5). The patient’s extremity was placed into a sling, and he was noneweight bearing for 2 weeks. He was then placed on a 30-lb lifting restriction for 6 weeks, with no return to sports until 3 months after the reduction.
Conclusion The assessment of reduction of an SC joint can be difficult intraoperatively. We recommend the O-arm CT scanner as a useful modality that can verify intraoperative reduction of an SC dislocation. CT is the gold standard, and as such, we believe that this is the most reliable method until further research can establish other modalities.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Cope R. Dislocations of the sternoclavicular joint. Skeletal Radiol 1993;22:233-8. 2. Cope R, Riddervold HO, Shore JL, Sistrom CL. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma 1991;5:379-84. 3. Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg 2011;19:1-7.
e20 4. Howard FM, Shafer SJ. Injuries to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg Am 1965; 47:1335-46. 5. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med 1996;30:71-2. 6. O’Connor PA, Nolke L, O’Donnell A, Lingham KM. Retrosternal dislocation of the clavicle associated with a traumatic pneumothorax.
J.P. Sullivan et al. Interact Cardiovasc Thorac Surg 2003;2:9-11. doi:10.1016/S15699293(02)00066-X 7. Siddiqui AA, Turner SM. Posterior sternoclavicular joint dislocation: the value of intra-operative ultrasound. Injury 2003;34:448-53. doi:10. 1016/S0020-1383(02)00350-9 8. Wasylenko MJ, Busse EF. Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula. Can J Surg 1981;24:626-7.
www.elsevier.com/locate/ymse
Use of an O-arm intraoperative computed tomography scanner for closed reduction of posterior sternoclavicular dislocations Jaron P. Sullivan, MD*, Brian A. Warme, MD, Brian R. Wolf, MD, MS Department of Orthopedics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Posterior sternoclavicular (SC) dislocations and fracture-dislocations are rare injuries that have been estimated to occur with an incidence of less than 0.1% of all dislocations.5 They can be benign; however, there are reports of injury to the mediastinum and death if not treated appropriately.4,6,8 In the acute setting it is imperative to make the appropriate diagnosis and for reduction to be performed. Patient history, clinical examination, and plain radiographs can help clinicians narrow down the differential, but the definitive diagnosis is sometimes elusive. Because an orthogonal view to the anteroposterior radiograph of the SC joint cannot be easily obtained, it is challenging to make the diagnosis with plain radiographs or fluoroscopy. Ultrasound has been used to confirm reduction,7 but the images can be difficult for people to interpret, with unknown reliabilities at most institutions. Computed tomography (CT) scans are widely accepted as the gold standard for diagnosis.1,2 However, use of CT for assessment of a closed reduction attempt is difficult because it requires patient transport to the CT scanner, either with intubation or after awaking the patient, knowing that if the joint remains dislocated, then the patient has to return to the operating room. We have recently used an O-arm intraoperative CT system (Medtronic Navigation, Louisville, CO, USA) to verify reduction in 2 cases, which to our knowledge has not been used
No institutional review board approval needed. *Reprint requests: Jaron P. Sullivan, MD, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Ste 1700JP, Iowa City, IA, USA. E-mail address: [email protected] (J.P. Sullivan).
previously. This obviated the need for immediate postoperative CT to verify reduction and the possibility of a second trip to the operating room with sedation for open reduction if the initial attempt had failed.
Technique The reduction of a posterior SC dislocation is best accomplished in the controlled environment of an operating room with proper anesthesia, auxiliary teams, and monitoring. Reduction can be painful for the patient, and general anesthesia can provide both pain control and skeletal muscle relaxation to assist with the reduction. It is also recommended that auxiliary teams such as vascular or cardiothoracic surgery personnel be made aware of the procedure in case a life-threatening complication occurs when the clavicle is reduced from its impaled position in the mediastinum. At our institution, we use the abduction traction technique.3 The patient is placed supine on the table with a sandbag or towel under the center of the thoracic spine, elevating the affected shoulder off the table. Lateral traction is applied, and the arm is slowly extended. Manual anterior traction is applied directly to the clavicle at the same time. If the clavicle is unable to be grasped and reduction is not obtained with initial attempts, a sterile towel clamp is placed onto the medial one-third of the clavicle, which is in a sterile field. This allows for firm anterior traction and reduction. If this is unsuccessful, then open reduction is indicated. Often, with closed reduction, there is an audible or palpable pop as the joint is reduced; however, this does not prove reduction. After the reduction,
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.07.015
e18
J.P. Sullivan et al.
Figure 3
Postoperative CT scan verifying reduction.
Figure 1 (A) Plain radiograph and (B) CT scan showing left posterior SC dislocation.
Figure 4 CT scan showing posterior fracture-dislocation of right SC joint.
an intraoperative O-arm CT scan is obtained to verify reduction.
Case reports
Figure 2 Intraoperative O-arm CT image showing reduction of SC joint. S, Sternum; C, clavicle.
The first case is a 20-year-old male collegiate basketball player who sustained a contact injury with another player and then fell onto his left shoulder. He presented with severe pain, holding his arm in an internally rotated and adducted position. He denied any chest pain, dyspnea, weakness, or paresthesias in the arms. There was an apparent asymmetry at the left SC joint. Plain films and then a CT scan were obtained, showing a left posterior SC dislocation (Fig. 1). Given the patient’s age, this likely was an SC physeal fracture-dislocation. He was taken to the operating room and placed supine with a rolled towel between the scapulae. General endotracheal anesthesia was used. Longitudinal traction on the left arm was performed as the clavicle was pulled in the anterior direction manually. There was an audible click, and the patient’s left shoulder was taken through a range of motion with
O-arm CT for posterior sternoclavicular dislocations
Figure 5
e19
Sequential O-arm CT images of intraoperative closed reduction. S, Sternum; C, clavicle.
no evidence of gross instability. His extremity was placed in a shoulder immobilizer. The O-arm CT scanner was used to verify reduction (Fig. 2). The patient was admitted for observation overnight, and then a repeat CT scan was obtained to verify that the reduction was maintained on postoperative day 1 (Fig. 3). After several weeks of immobilization, the patient gradually returned to full activity and participation in collegiate basketball. The second case was a 16-year-old male passenger who was involved in a T-bone motor vehicle collision at highway speeds, impacting the passenger’s side of the car. He was initially evaluated at an outside hospital and found to have multiple pelvic fractures, as well as a posterior right clavicle fracture-dislocation. He had a positive loss of consciousness at the scene. He presented with right shoulder pain and pelvis pain. He denied any noticeable changes in his voice, dyspnea, chest pain, or numbness or paresthesias in the extremities. On clinical examination, the patient had symmetric blood pressures and pulses in the bilateral upper extremities. He had tenderness to palpation over the right clavicle. Right shoulder range of motion was limited because of pain. A contrast CT scan showed a right posterior SC fracture-dislocation, with the displaced clavicle adjacent to the aorta and no evidence of dissection (Fig. 4). There was also concern about mild compression of the trachea. The patient was taken to the operating room and placed under general anesthesia. He was positioned supine with a towel under the thoracic spine. The right arm was abducted with traction and then slightly extended while the clavicle was grasped manually over the skin and pulled upward. There was a palpable clunk. O-arm imaging was used to confirm reduction (Fig. 5). The patient’s extremity was placed into a sling, and he was noneweight bearing for 2 weeks. He was then placed on a 30-lb lifting restriction for 6 weeks, with no return to sports until 3 months after the reduction.
Conclusion The assessment of reduction of an SC joint can be difficult intraoperatively. We recommend the O-arm CT scanner as a useful modality that can verify intraoperative reduction of an SC dislocation. CT is the gold standard, and as such, we believe that this is the most reliable method until further research can establish other modalities.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Cope R. Dislocations of the sternoclavicular joint. Skeletal Radiol 1993;22:233-8. 2. Cope R, Riddervold HO, Shore JL, Sistrom CL. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma 1991;5:379-84. 3. Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg 2011;19:1-7.
e20 4. Howard FM, Shafer SJ. Injuries to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg Am 1965; 47:1335-46. 5. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med 1996;30:71-2. 6. O’Connor PA, Nolke L, O’Donnell A, Lingham KM. Retrosternal dislocation of the clavicle associated with a traumatic pneumothorax.
J.P. Sullivan et al. Interact Cardiovasc Thorac Surg 2003;2:9-11. doi:10.1016/S15699293(02)00066-X 7. Siddiqui AA, Turner SM. Posterior sternoclavicular joint dislocation: the value of intra-operative ultrasound. Injury 2003;34:448-53. doi:10. 1016/S0020-1383(02)00350-9 8. Wasylenko MJ, Busse EF. Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula. Can J Surg 1981;24:626-7.