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Posterior Sternoclavicular Dislocation
The Journal of Emergency Medicine, Vol. 40, No. 3, pp. e53– e54, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2008.07.002
Visual Diagnosis in Emergency Medicine POSTERIOR STERNOCLAVICULAR DISLOCATION Joseph R. Shiber,
MD, FAAEM, FACEP
Department of Emergency Medicine, University of Central Florida, Orlando, Florida Reprint Address: Joseph R. Shiber, MD, Department of Emergency Medicine, University of Central Florida, Orlando, FL 32803
CASE REPORT A 17-year-old boy playing quarterback for his high school football team was tackled by a lineman who fell onto him, driving his right shoulder into the ground. On
Figure 2. Chest computed tomography (CT) scan showing clavicular head (a) abutting the right brachiocephalic artery (b). Also shown are the left bracHiocephalic vein (c), trachea (d), and esophagus (e).
presentation to the Emergency Department, he complained of right shoulder pain and difficulty swallowing. His right arm was semi-adducted and he was unable to move it without significant anterior chest discomfort. A chest radiograph was performed (Figure 1), followed by a computed tomography (CT) scan of the chest with intravenous contrast (Figures 2, 3).
Figure 1. Chest radiograph showing inferior displacement of the clavicular head (arrow).
RECEIVED: 23 March 2007; FINAL ACCEPTED: 9 July 2008
SUBMISSION RECEIVED:
3 July 2008; e53
e54
J. R. Shiber
The chest radiograph demonstrated an inferior-posterior sternoclavicular dislocation. The chest CT scan revealed that the clavicular head abutted but did not penetrate the bracHiocephalic (inominate) artery. He was taken to the operating room, placed under general anesthesia, and a closed reduction was successfully performed using a bolster under the scapula to extend the shoulder with traction, and then applied to extend the arm. An audible “clunk” occurred as the clavicular head then became palpable; a post-reduction CT scan confirmed anatomic positioning (Figure 4). The patient was placed in a sling and swath and was doing well at follow-up 1 month later.
DISCUSSION Sternoclavicular dislocations are a rare injury, comprising approximately 2% of all injuries to the shoulder, with the posterior form being much less common (accounting for ⬍ 0.1% of all joint dislocations) than the anterior form (1,2). The posterior variety is less obvious on physical examination, but is associated with significant
Figure 4. Chest CT scan after reduction of the clavicular head (a).
complications due to secondary injuries of the mediastinal structures (2). Potential serious injuries include: puncture of the pleura/lung causing pneumothorax, puncture, or compression of the great vessels, and perforation of the trachea or esophagus. It is noteworthy that the chest radiograph was interpreted as normal by an attending radiologist and that the CT scan was initially interpreted by a different radiologist as, “increased density within the anterior mediastinum likely represents residual thymus.” Closed reduction utilizing procedural sedation or general anesthesia in the operating room is the standard treatment, with open reduction and internal fixation typically reserved for when closed reduction is unsuccessful (1).
REFERENCES
Figure 3. Chest CT scan showing proximal clavicle (a) posterior to manubrium (f).
1. Franck WM, Siassi RM, Hennig FF. Treatment of posterior epiphyseal disruption of the medial clavicle with a modified balser plate. J Trauma 2003;55:966 – 8. 2. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med 1996;30:71–2.
doi:10.1016/j.jemermed.2008.07.002
Visual Diagnosis in Emergency Medicine POSTERIOR STERNOCLAVICULAR DISLOCATION Joseph R. Shiber,
MD, FAAEM, FACEP
Department of Emergency Medicine, University of Central Florida, Orlando, Florida Reprint Address: Joseph R. Shiber, MD, Department of Emergency Medicine, University of Central Florida, Orlando, FL 32803
CASE REPORT A 17-year-old boy playing quarterback for his high school football team was tackled by a lineman who fell onto him, driving his right shoulder into the ground. On
Figure 2. Chest computed tomography (CT) scan showing clavicular head (a) abutting the right brachiocephalic artery (b). Also shown are the left bracHiocephalic vein (c), trachea (d), and esophagus (e).
presentation to the Emergency Department, he complained of right shoulder pain and difficulty swallowing. His right arm was semi-adducted and he was unable to move it without significant anterior chest discomfort. A chest radiograph was performed (Figure 1), followed by a computed tomography (CT) scan of the chest with intravenous contrast (Figures 2, 3).
Figure 1. Chest radiograph showing inferior displacement of the clavicular head (arrow).
RECEIVED: 23 March 2007; FINAL ACCEPTED: 9 July 2008
SUBMISSION RECEIVED:
3 July 2008; e53
e54
J. R. Shiber
The chest radiograph demonstrated an inferior-posterior sternoclavicular dislocation. The chest CT scan revealed that the clavicular head abutted but did not penetrate the bracHiocephalic (inominate) artery. He was taken to the operating room, placed under general anesthesia, and a closed reduction was successfully performed using a bolster under the scapula to extend the shoulder with traction, and then applied to extend the arm. An audible “clunk” occurred as the clavicular head then became palpable; a post-reduction CT scan confirmed anatomic positioning (Figure 4). The patient was placed in a sling and swath and was doing well at follow-up 1 month later.
DISCUSSION Sternoclavicular dislocations are a rare injury, comprising approximately 2% of all injuries to the shoulder, with the posterior form being much less common (accounting for ⬍ 0.1% of all joint dislocations) than the anterior form (1,2). The posterior variety is less obvious on physical examination, but is associated with significant
Figure 4. Chest CT scan after reduction of the clavicular head (a).
complications due to secondary injuries of the mediastinal structures (2). Potential serious injuries include: puncture of the pleura/lung causing pneumothorax, puncture, or compression of the great vessels, and perforation of the trachea or esophagus. It is noteworthy that the chest radiograph was interpreted as normal by an attending radiologist and that the CT scan was initially interpreted by a different radiologist as, “increased density within the anterior mediastinum likely represents residual thymus.” Closed reduction utilizing procedural sedation or general anesthesia in the operating room is the standard treatment, with open reduction and internal fixation typically reserved for when closed reduction is unsuccessful (1).
REFERENCES
Figure 3. Chest CT scan showing proximal clavicle (a) posterior to manubrium (f).
1. Franck WM, Siassi RM, Hennig FF. Treatment of posterior epiphyseal disruption of the medial clavicle with a modified balser plate. J Trauma 2003;55:966 – 8. 2. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med 1996;30:71–2.