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Posterior sternoclavicular joint dislocation in a child: a case report with review of literature
J Shoulder Elbow Surg (2012) 21, e11-e16
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Posterior sternoclavicular joint dislocation in a child: a case report with review of literature Sunil Garg, FRCS(Orth), Zeiad A. Alshameeri, MBChB(Hons), MRCS*, W. Angus Wallace, FRCS, FRCS Ed(Orth) Nottingham Shoulder and Elbow Unit, City Hospital Campus, Nottingham, UK Sternoclavicular joint (SCJ) dislocations are uncommon and usually present with anterior dislocation.2,20,21 Posterior SCJ dislocations are relatively rare injuries in adults24,49 and are extremely rare in children.10,53,59 This injury can present with very subtle physical examination findings6 and plain radiographs are generally inconclusive.39,58 One in 3 cases presents with compression symptoms of retrosternal structures, which can be life threatening43; there have also been 5 deaths reported following SCJ dislocation.5,15,17-19,30 When missed initially, they may present later with significant complications18,21,47 and can form basis of clinical negligence. Accurate diagnosis and prompt treatment is essential for a good functional outcome following posterior dislocation of the SCJ.6,21 Furthermore, late presentation is more like to impede closed reduction.6,21,32,47 There is debate in the literature regarding treatment of these injuries,15,21,24,53 mainly because just over 120 cases have been reported in last 75 years,31 out of which only very few have been reported in children.5,6,9,10,13,17-19,30,35,41,43,44,50,51,53 Posterior dislocations of the SCJ in children should be treated as a separate entity due to ongoing growth at the epiphysis. While true posterior dislocation can occur in children,53,56,59 the majority of the injuries are posteriorly displaced fracture (of Salter-Harris 1 or 2) of the medial clavicular physis.20-22,26,32 This has been described by some authors as ‘‘pseudo-dislocation’’.47 Although the pathology is different, they still present in the same way and require prompt treatment. This report describes a rare case of posterior SCJ dislocation of the clavicle metaphysis in a 12-year-old *Reprint requests: Zeiad A. Alshameeri, MBChB(Hons), MRCS, 22 Somerville Road, Birmingham B10 9EL, United Kingdom. E-mail address: [email protected] (Z.A. Alshameeri).
treated by attempted closed reduction proceeding to open reduction with repair of the growth plate and ligaments. We aim to review the literature on posterior SCJ dislocation in light of our experience, and provide an insight with regards to diagnosis and management of posterior SCJ dislocation in children.
Case report A 12-year-old boy fell down awkwardly onto his left shoulder while running. The patient took his body weight onto his left shoulder and felt instant pain in the sternoclavicular area. He was seen at the accident and emergency department, where a diagnosis of SCJ injury was not initially identified. The patient was referred to the orthopaedics fracture clinic 1 week later because of ongoing pain. Plain radiographs of the clavicle did not show any injury (Fig. 1); however, the location of the pain and tenderness in the region of the SCJ prompted the orthopaedic team to order an immediate computer tomographic (CT) scan of SCJ with upper thorax. This showed a complete posterior dislocation of the medial end of the clavicle without any fractures (Figs. 2 and 3). The patient was taken to the operating theater, and an open reduction of the dislocation was carried out 1 week post-injury. Closed reduction was attempted with the patient supine by applying a towel clip to the medial end of the clavicle through the skin, with a sandbag placed in the mid-line under the upper thoracic spine. This failed and the SCJ was opened using a ‘‘necklace’’ type transverse neck incision directly over the joint. The joint was reduced using a towel clip. At this point, it became clear that the injury sustained had been a Salter-Harris Type 1 injury through the junction between the growth plate and medial clavicular metaphysis. In addition, the growth plate had been split into 2 main pieces and was only partially attached to
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Figure 3 Three-dimensional computer tomographic reconstruction showing complete posterior dislocation of left sternoclavicular joint without any evidence of fracture to the medial end of clavicle. Figure 1
Immediate post-injury x-ray showing no obvious injury.
Figure 2 Three-dimensional computer tomographic reconstruction showing complete posterior dislocation of left sternoclavicular joint without any evidence of fracture to the medial end of clavicle.
the medial epiphysis of the clavicle. The growth plate was reduced and sutured with absorbable No 1 Vicryl sutures. The periosteum with the sternoclavicular ligaments were repaired en masse, using absorbable sutures through bony tunnels in the manubrium sternum and medial end of clavicle. Postoperatively, the arm was kept in a sling for 3 weeks and physiotherapy was commenced with gentle passive exercises. Postoperatively, a magnetic resonance image was obtained 8 weeks following the injury which confirmed that the reduction had been maintained (Fig. 4), the epiphysis was well located, and the growth plate remained in place between the metaphysis and epiphysis. The brachio-cephalic vein was seen lying closely adjacent to the remodeling bone; however, there were no symptoms of venous engorgement in the limb (Fig. 5). The boy made a remarkable recovery with a Rockwood score48 of 15/15 at 3 months followup. No further follow-up was arranged because the child had returned to normal daily living activities.
Figure 4 Magnetic resonance image showing well-reduced sternoclavicular joint.
Discussion SCJ is a synovial gliding joint that links the upper extremity to the torso. The articular surface of clavicle is much larger than the articular surface on sternum, making it inherently unstable and the most incongruous joint in the body; however, the joint is supported by a thick capsule reinforced by strong ligaments (anterior and posterior sternoclavicular, costoclavicular and interclavicular), making it stable to allow forward thrust and movements of the upper limb.52 SCJ dislocation was first described by Cooper in 18248 and subsequently by various authors in the form of case reports and short series of cases. The largest series reported 13 cases of posterior SCJ dislocation in children and
Posterior sternoclavicular joint dislocation
e13 reported.43,56 Most dislocations occur as a result of an indirect twisting force from the clavicle that pivots on the first rib when the shoulder girdle is pushed back. This results in anterior dislocation while the medial end of clavicle is pushed out posteriorly when the shoulder girdle is pushed forwards. Atraumatic dislocations are rare; however, 3 cases of spontaneous posterior dislocation have been reported in the literature in patients with generalized laxity.12,37,38
Clinical presentation and investigation
Figure 5 Magnetic resonance image 8 weeks post open reduction and fixation showing the proximity of posterior aspect of medial clavicle epiphysis to brachiocephalic vein (arrow).
adolescents over a period of 10 years56; however, in their series, only 2 patients sustained true posterior SCJ dislocation. Yang et al described 4 cases of true dislocations, which were in children with joint laxities,59 and 1 further case was recently described by Sykes et al53 in a child without joint or liagmentous laxity. Laffosse et al described a total of 17 cases of true dislocations, which were all in patients aged 17 years or over.32 They also described 13 cases of posteriorly displaced physeal fractures, which were all in children and young adults. The high ratio of posteriorly displaced physeal fracture to true dislocation of the SCJ in children and young adults arises because the epiphysis at the medial end of the clavicle does not ossify until the age of 18-20, but does not fuse with the medial end of the clavicle until the age of 22-25.20,25 Until then, the growth plate remains the weakest point2 and more likely to sustain a fracture.22,24,26,34 As in our case, it is very difficult to distinguish between true posterior dislocation and posterior displacement of the medial clavicle physeal fracture from conventional radiograph or even CT scan.16,22,32 The true nature of the injury can only be verified during open reduction16,22,32,33,53or retrospectively when new bone formation and bone remodeling is seen in follow-up CT scans.34 This is why many of the reports do not make a clear distinction between these 2 injuries, especially when managed nonoperatively, and are generally reported and treated as posterior dislocations of the SCJ.21
Mechanism of injury The mechanism of injury is usually sports related; however, falls from height and road traffic accidents have also been
Patients with posterior SCJ dislocations present with pain localized to the joint, palpable gap, or swelling at the medial end of clavicle. The gap is often subtle and may remain unrecognized; hence, a high index of suspicion must be maintained unless the injury is ruled out. One in 3 cases reported in the literature has presented with symptoms of compression from retrosternal structures. In a series of 13 cases of posterior SCJ dislocation, authors56 reported dysphagia at presentation in 4 cases (31%) and shortness of breath in 1 (8%). Nearly 10% of cases present with compression or laceration of brachiocephalic vein, clinically evident by cyanosis in neck or upper limb with associated swelling. Other serious presentations like traumatic pnuemothorax42 and tracheal stenosis40 have also been reported. A case of tracheoeophageal fistula resulting in death of the patient was reported when posterior displacement of clavicle was missed initially. Authors concluded that this was a preventable cause of death.55 Brachial plexopathy with thoracic outlet syndrome requiring further surgery in form of medial clavicle excision have been reported after chronic posterior SCJ dislocation.46 Treating physicians must be aware of these potentially life threatening complications. There was 1 reported case presenting late due to subtle symptoms, despite severe displacement of medial end of clavicle.6 Some of these injuries can also be missed because they present in association with mid-clavicular fractures.27,33 Therefore, initial diagnosis can be difficult, as physical findings can be misleading and plain radiographs are usually inconclusive.1,6 Specialized views such as Hobbs’, Rockwood’s serendipity view, or Heinig’s20,22,24,25 may aid in diagnosis. CT scan is the most appropriate imaging method to confirm the diagnosis and evaluating the mediastinal structures,11,22,24,25,59 and should be used whenever there is suspicion about SCJ dislocation. Angiography/venography should be carried out when there is suspicion of vascular injury.
Classification and treatment SCJ dislocation has been classified on the direction of clavicle dislocation by Allman.3 Another classification system has been proposed based on direction, mode, and degree of displacement.29 This classification also provides
e14 some guide towards treatment of these injuries. Currently, there is no classification system for posterior SCJ dislocation. Authors suggest that posterior displacement of clavicle must be seen as dislocation with or without fracture of medial clavicle physis, as this will carry prognostic implications.22,26,34 This is because some authors argue that many asymptomatic physeal injuries will heal and remodel without intervention if not significantly displaced,20,34,57 while true posterior dislocation usually leads to late onset of complications24,47 and instability requiring adequate anatomical reduction.21,32 However, clinically and radiologically, it can be difficult to distinguish between the 2 injuries in children at presentation, and they are, therefore, treated synonymously as dislocations requiring reduction.
Closed reduction Traditionally, closed reduction has been accepted as treatment of choice and has been successful in many cases including physeal injuries in children.1,5,26,29,47,58,59 Yang et al managed all 4 cases of posterior dislocation in children successfully with closed reduction.59 This is attempted under general anaesthesia and carried out by placing a bolster (or sandbag) between the patient scapulae, while traction is applied to the abducted arm in line with the clavicle. The traction is gradually increased while the arm is brought to extension.24,25 Another technique involves a combination of the above and applying a pressure on the shoulder in anterior posterior direction.25,53 If this is unsuccessful, then the sternclavicular area is surgically prepped and traction on the abducted arm is applied with backward traction on the ipsilateral shoulder. A sterile towel clap is applied around the medial end of the clavicle and pulled anteriorly. The reduction is confirmed with an audible or palpable snap. An x-ray is obtained to confirm the satisfactory reduction of the joint, and a figure-of-8 bandage is applied to keep the shoulder retracted for 6-8 weeks.24,25,59
Open reduction and stabilization of the SCJ Rockwood and Sanders49 have advised that, because chronic instability of the SCJ has not been reported, open reduction of SCJ is not indicated. However, many other authors recommend open reduction when closed reduction fails, because of the complication associated with the posterior displacement of the medial clavicle end, such as erosion and compression of the retrosternal structures.20,21,24-26,45,57 In their series of 13 cases of posterior SCJ dislocation in children, Waters et al56 reported instability after early closed reduction. Two out of their initial 3 cases in the series had to be taken back to theater for open reduction
S. Garg et al. and stabilization. Laffosse et al also described failure of closed reduction in all cases of posteriorly displaced physeal fractures and in half of the cases with true posterior dislocation.32 This is consistent with our experience as well as many reports in the literature that reported persistent displacement or failed reduction after initial closed reduction in theater, requiring open reduction and internal fixation as definitive treatment.14,21,23,28,36 Therefore, many authors recommend consenting patients for open reduction and stabilization of clavicle in all cases. Nettles41 reported nearly 20% chronic instability after closed reduction of 14 cases of anterior SCJ dislocation. However, it has been argued that, unlike posterior dislocation, there may be little if any functional impact of chronic anterior dislocation.47 The success rate following closed reduction in posterior dislocations has been reported as 68%, if done early5; the timing of closed reduction is, therefore, important. Groh et al suggested that closed reduction is more likely to be successful if treated within 10 days from injury,26 while others have warned that a delay of more than 5 days usually results in irreducibility35 and that, in physeal injuries, fracture end adhesions to mediastinal structures may form.6,57 A recent systemic review concluded that all delayed dislocations needed open reduction after failed closed reduction.21 Open reduction and stabilization of the clavicle allows healing in anatomical position, avoiding complications from malunited fracture or chronic instability of the SCJ.14 The optimal method of stabilizing the SCJ has not yet been established. Reported methods included fixation with large cannulated screws, anterior plating, K-wire fixation, Steinmann pin fixation, external fixate, medial clavicle resection, and soft tissue procedures such as tendon grafts, facial loops, fiber wires, and synthetic ligaments.4,6,9,16,21,24,26,32,38,45,57 A recent review showed overall a good functional outcome using different modalities of treatments in adults.21 However, complication rate of hardware fixation has been unacceptably high, and some authors do not support their use.7,21 In children, Waters et al, in their series of 13 cases, successfully used No.1 polyester suture to repair costoclavicular and sternoclavicular ligaments.56 We used a similar method and found it safe and effective. Thomas et al described their ‘‘safe’’ repair, using sutures to stabilize the clavicle to the manubrium.54 At 15 months, the 3 described cases had full pain free function. Hofwegen et al also described a ‘‘safe’’ repair of dislocated physeal injuries by suturing the end of the clavicle to the manuprium, using Fiberwires in 2 patients. Both had good functional outcome at 2-½ years follow-up.28 Laffosse et al used PDS for costcalvicular ligament repair and costoclavicular cerclage.32 Several other methods to stabilize the SCJ have been described in the literature; however, we recommend the use of absorbable sutures to stabilize the SCJ in children. Many authors would also recommend the notification of a thoracic surgeon when open reduction is attempted.6,45,47,56,57
Posterior sternoclavicular joint dislocation Postoperatively, we left the shoulder in a sling for 3 weeks before commencing physiotherapy.
Conclusion On the basis of the literature review and our limited experience, we recommend that all skeletally immature patients with suspected SCJ injury should be examined very carefully for associated symptoms and signs of compression from mediastinal structures. Neurovascular compromise should be carefully noted and documented. A CT scan should be obtained in all cases, with suspicion of injury to SCJ, to confirm and define the exact pattern of injury. Treatment offered should be early and prompt, involving open reduction and stabilization of sternoclavicular and costoclavicular ligaments. We feel that the risks associated with an unreduced fracture, particularly in the presence of symptoms of mediastinal compression, outweigh those of open reduction with internal fixation. With this algorithm excellent functional outcome can be expected.
Disclaimer None of the authors, their immediate families, and any research foundation with which they are affiliated received any financial payments or other benefits from any commercial entity related to the subject of this article.
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S. Garg et al. 46. Rayan GM. Compression brachial plexopathy caused by chronic posterior dislocation of the sternoclavicular joint. J Okla State Med Assoc 1994;87:7-9. 47. Robinson C, Jenkins P, Markham P, Beggs I. Disorders of the sternoclavicular joint. J Bone Joint Surg [Br] 2008;90-B:685-96. doi:10. 1302/0301-620X.90B6 48. Rockwood CA, Groh Gl, Wirth MA, Grassi FA. Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg [Am] 1997;79-A:387-93. 49. Sanders J, Rockwood C, Curtis RJ. Fractures and dislocations of the humeral shaft and shoulder. In: Rockwood C, Wilkins K, Beaty J, editors. Fractures in children. Philadelphia: WB Saunders; 1996. p. 961-70 (ISBN13: 9780397515127). 50. Savastano AA, Stutz SJ. Traumatic sternoclavicular dislocation. Int Surg 1978;63:10. 51. Southworth SR, Merritt TR. Asymptomatic innominate vein tamponade with retromanubrial clavicular dislocation: a case report. Orthop Rev 1988;17:789. 52. Spencer EE, Kuhn JE, Huston LJ, Carpenter JE, Hughes RE. Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-7. doi:10.1067/ mse.2002.119394 53. Sykes JA, Ezetendu C, Sivitz A, Lee J Jr, Desai H, Norton K, et al. Posterior dislocation of sternoclavicular joint encroaching on ipsilateral vessels in 2 pediatric patients. Pediatr Emer Care 2011;27:327-30. doi:10.1097/PEC.0b013e318217b58f 54. Thomas DP, Davies A, Hoddinott HC. Posterior sternoclavicular dislocations - a diagnosis easily missed. Ann R Coll Surg England 1999;81:201-4. 55. Wasylenko MJ, Busse EF. Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula. Can J Surg 1981;24:626-7. 56. Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop 2003;23:464-9. 57. Wirth MA, Rockwood CA. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268-78. 58. Worrell J, Fernandez GN. Retrosternal dislocation of the clavicle: An important injury easily missed. Arch Emergency Med 1986;3:133-5. 59. Yang J, al-Etani H, Letts M. Diagnosis and treatment of posterior sternoclavicular joint dislocations in children. Am J Orthop 1996;25:565-9.
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Posterior sternoclavicular joint dislocation in a child: a case report with review of literature Sunil Garg, FRCS(Orth), Zeiad A. Alshameeri, MBChB(Hons), MRCS*, W. Angus Wallace, FRCS, FRCS Ed(Orth) Nottingham Shoulder and Elbow Unit, City Hospital Campus, Nottingham, UK Sternoclavicular joint (SCJ) dislocations are uncommon and usually present with anterior dislocation.2,20,21 Posterior SCJ dislocations are relatively rare injuries in adults24,49 and are extremely rare in children.10,53,59 This injury can present with very subtle physical examination findings6 and plain radiographs are generally inconclusive.39,58 One in 3 cases presents with compression symptoms of retrosternal structures, which can be life threatening43; there have also been 5 deaths reported following SCJ dislocation.5,15,17-19,30 When missed initially, they may present later with significant complications18,21,47 and can form basis of clinical negligence. Accurate diagnosis and prompt treatment is essential for a good functional outcome following posterior dislocation of the SCJ.6,21 Furthermore, late presentation is more like to impede closed reduction.6,21,32,47 There is debate in the literature regarding treatment of these injuries,15,21,24,53 mainly because just over 120 cases have been reported in last 75 years,31 out of which only very few have been reported in children.5,6,9,10,13,17-19,30,35,41,43,44,50,51,53 Posterior dislocations of the SCJ in children should be treated as a separate entity due to ongoing growth at the epiphysis. While true posterior dislocation can occur in children,53,56,59 the majority of the injuries are posteriorly displaced fracture (of Salter-Harris 1 or 2) of the medial clavicular physis.20-22,26,32 This has been described by some authors as ‘‘pseudo-dislocation’’.47 Although the pathology is different, they still present in the same way and require prompt treatment. This report describes a rare case of posterior SCJ dislocation of the clavicle metaphysis in a 12-year-old *Reprint requests: Zeiad A. Alshameeri, MBChB(Hons), MRCS, 22 Somerville Road, Birmingham B10 9EL, United Kingdom. E-mail address: [email protected] (Z.A. Alshameeri).
treated by attempted closed reduction proceeding to open reduction with repair of the growth plate and ligaments. We aim to review the literature on posterior SCJ dislocation in light of our experience, and provide an insight with regards to diagnosis and management of posterior SCJ dislocation in children.
Case report A 12-year-old boy fell down awkwardly onto his left shoulder while running. The patient took his body weight onto his left shoulder and felt instant pain in the sternoclavicular area. He was seen at the accident and emergency department, where a diagnosis of SCJ injury was not initially identified. The patient was referred to the orthopaedics fracture clinic 1 week later because of ongoing pain. Plain radiographs of the clavicle did not show any injury (Fig. 1); however, the location of the pain and tenderness in the region of the SCJ prompted the orthopaedic team to order an immediate computer tomographic (CT) scan of SCJ with upper thorax. This showed a complete posterior dislocation of the medial end of the clavicle without any fractures (Figs. 2 and 3). The patient was taken to the operating theater, and an open reduction of the dislocation was carried out 1 week post-injury. Closed reduction was attempted with the patient supine by applying a towel clip to the medial end of the clavicle through the skin, with a sandbag placed in the mid-line under the upper thoracic spine. This failed and the SCJ was opened using a ‘‘necklace’’ type transverse neck incision directly over the joint. The joint was reduced using a towel clip. At this point, it became clear that the injury sustained had been a Salter-Harris Type 1 injury through the junction between the growth plate and medial clavicular metaphysis. In addition, the growth plate had been split into 2 main pieces and was only partially attached to
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Figure 3 Three-dimensional computer tomographic reconstruction showing complete posterior dislocation of left sternoclavicular joint without any evidence of fracture to the medial end of clavicle. Figure 1
Immediate post-injury x-ray showing no obvious injury.
Figure 2 Three-dimensional computer tomographic reconstruction showing complete posterior dislocation of left sternoclavicular joint without any evidence of fracture to the medial end of clavicle.
the medial epiphysis of the clavicle. The growth plate was reduced and sutured with absorbable No 1 Vicryl sutures. The periosteum with the sternoclavicular ligaments were repaired en masse, using absorbable sutures through bony tunnels in the manubrium sternum and medial end of clavicle. Postoperatively, the arm was kept in a sling for 3 weeks and physiotherapy was commenced with gentle passive exercises. Postoperatively, a magnetic resonance image was obtained 8 weeks following the injury which confirmed that the reduction had been maintained (Fig. 4), the epiphysis was well located, and the growth plate remained in place between the metaphysis and epiphysis. The brachio-cephalic vein was seen lying closely adjacent to the remodeling bone; however, there were no symptoms of venous engorgement in the limb (Fig. 5). The boy made a remarkable recovery with a Rockwood score48 of 15/15 at 3 months followup. No further follow-up was arranged because the child had returned to normal daily living activities.
Figure 4 Magnetic resonance image showing well-reduced sternoclavicular joint.
Discussion SCJ is a synovial gliding joint that links the upper extremity to the torso. The articular surface of clavicle is much larger than the articular surface on sternum, making it inherently unstable and the most incongruous joint in the body; however, the joint is supported by a thick capsule reinforced by strong ligaments (anterior and posterior sternoclavicular, costoclavicular and interclavicular), making it stable to allow forward thrust and movements of the upper limb.52 SCJ dislocation was first described by Cooper in 18248 and subsequently by various authors in the form of case reports and short series of cases. The largest series reported 13 cases of posterior SCJ dislocation in children and
Posterior sternoclavicular joint dislocation
e13 reported.43,56 Most dislocations occur as a result of an indirect twisting force from the clavicle that pivots on the first rib when the shoulder girdle is pushed back. This results in anterior dislocation while the medial end of clavicle is pushed out posteriorly when the shoulder girdle is pushed forwards. Atraumatic dislocations are rare; however, 3 cases of spontaneous posterior dislocation have been reported in the literature in patients with generalized laxity.12,37,38
Clinical presentation and investigation
Figure 5 Magnetic resonance image 8 weeks post open reduction and fixation showing the proximity of posterior aspect of medial clavicle epiphysis to brachiocephalic vein (arrow).
adolescents over a period of 10 years56; however, in their series, only 2 patients sustained true posterior SCJ dislocation. Yang et al described 4 cases of true dislocations, which were in children with joint laxities,59 and 1 further case was recently described by Sykes et al53 in a child without joint or liagmentous laxity. Laffosse et al described a total of 17 cases of true dislocations, which were all in patients aged 17 years or over.32 They also described 13 cases of posteriorly displaced physeal fractures, which were all in children and young adults. The high ratio of posteriorly displaced physeal fracture to true dislocation of the SCJ in children and young adults arises because the epiphysis at the medial end of the clavicle does not ossify until the age of 18-20, but does not fuse with the medial end of the clavicle until the age of 22-25.20,25 Until then, the growth plate remains the weakest point2 and more likely to sustain a fracture.22,24,26,34 As in our case, it is very difficult to distinguish between true posterior dislocation and posterior displacement of the medial clavicle physeal fracture from conventional radiograph or even CT scan.16,22,32 The true nature of the injury can only be verified during open reduction16,22,32,33,53or retrospectively when new bone formation and bone remodeling is seen in follow-up CT scans.34 This is why many of the reports do not make a clear distinction between these 2 injuries, especially when managed nonoperatively, and are generally reported and treated as posterior dislocations of the SCJ.21
Mechanism of injury The mechanism of injury is usually sports related; however, falls from height and road traffic accidents have also been
Patients with posterior SCJ dislocations present with pain localized to the joint, palpable gap, or swelling at the medial end of clavicle. The gap is often subtle and may remain unrecognized; hence, a high index of suspicion must be maintained unless the injury is ruled out. One in 3 cases reported in the literature has presented with symptoms of compression from retrosternal structures. In a series of 13 cases of posterior SCJ dislocation, authors56 reported dysphagia at presentation in 4 cases (31%) and shortness of breath in 1 (8%). Nearly 10% of cases present with compression or laceration of brachiocephalic vein, clinically evident by cyanosis in neck or upper limb with associated swelling. Other serious presentations like traumatic pnuemothorax42 and tracheal stenosis40 have also been reported. A case of tracheoeophageal fistula resulting in death of the patient was reported when posterior displacement of clavicle was missed initially. Authors concluded that this was a preventable cause of death.55 Brachial plexopathy with thoracic outlet syndrome requiring further surgery in form of medial clavicle excision have been reported after chronic posterior SCJ dislocation.46 Treating physicians must be aware of these potentially life threatening complications. There was 1 reported case presenting late due to subtle symptoms, despite severe displacement of medial end of clavicle.6 Some of these injuries can also be missed because they present in association with mid-clavicular fractures.27,33 Therefore, initial diagnosis can be difficult, as physical findings can be misleading and plain radiographs are usually inconclusive.1,6 Specialized views such as Hobbs’, Rockwood’s serendipity view, or Heinig’s20,22,24,25 may aid in diagnosis. CT scan is the most appropriate imaging method to confirm the diagnosis and evaluating the mediastinal structures,11,22,24,25,59 and should be used whenever there is suspicion about SCJ dislocation. Angiography/venography should be carried out when there is suspicion of vascular injury.
Classification and treatment SCJ dislocation has been classified on the direction of clavicle dislocation by Allman.3 Another classification system has been proposed based on direction, mode, and degree of displacement.29 This classification also provides
e14 some guide towards treatment of these injuries. Currently, there is no classification system for posterior SCJ dislocation. Authors suggest that posterior displacement of clavicle must be seen as dislocation with or without fracture of medial clavicle physis, as this will carry prognostic implications.22,26,34 This is because some authors argue that many asymptomatic physeal injuries will heal and remodel without intervention if not significantly displaced,20,34,57 while true posterior dislocation usually leads to late onset of complications24,47 and instability requiring adequate anatomical reduction.21,32 However, clinically and radiologically, it can be difficult to distinguish between the 2 injuries in children at presentation, and they are, therefore, treated synonymously as dislocations requiring reduction.
Closed reduction Traditionally, closed reduction has been accepted as treatment of choice and has been successful in many cases including physeal injuries in children.1,5,26,29,47,58,59 Yang et al managed all 4 cases of posterior dislocation in children successfully with closed reduction.59 This is attempted under general anaesthesia and carried out by placing a bolster (or sandbag) between the patient scapulae, while traction is applied to the abducted arm in line with the clavicle. The traction is gradually increased while the arm is brought to extension.24,25 Another technique involves a combination of the above and applying a pressure on the shoulder in anterior posterior direction.25,53 If this is unsuccessful, then the sternclavicular area is surgically prepped and traction on the abducted arm is applied with backward traction on the ipsilateral shoulder. A sterile towel clap is applied around the medial end of the clavicle and pulled anteriorly. The reduction is confirmed with an audible or palpable snap. An x-ray is obtained to confirm the satisfactory reduction of the joint, and a figure-of-8 bandage is applied to keep the shoulder retracted for 6-8 weeks.24,25,59
Open reduction and stabilization of the SCJ Rockwood and Sanders49 have advised that, because chronic instability of the SCJ has not been reported, open reduction of SCJ is not indicated. However, many other authors recommend open reduction when closed reduction fails, because of the complication associated with the posterior displacement of the medial clavicle end, such as erosion and compression of the retrosternal structures.20,21,24-26,45,57 In their series of 13 cases of posterior SCJ dislocation in children, Waters et al56 reported instability after early closed reduction. Two out of their initial 3 cases in the series had to be taken back to theater for open reduction
S. Garg et al. and stabilization. Laffosse et al also described failure of closed reduction in all cases of posteriorly displaced physeal fractures and in half of the cases with true posterior dislocation.32 This is consistent with our experience as well as many reports in the literature that reported persistent displacement or failed reduction after initial closed reduction in theater, requiring open reduction and internal fixation as definitive treatment.14,21,23,28,36 Therefore, many authors recommend consenting patients for open reduction and stabilization of clavicle in all cases. Nettles41 reported nearly 20% chronic instability after closed reduction of 14 cases of anterior SCJ dislocation. However, it has been argued that, unlike posterior dislocation, there may be little if any functional impact of chronic anterior dislocation.47 The success rate following closed reduction in posterior dislocations has been reported as 68%, if done early5; the timing of closed reduction is, therefore, important. Groh et al suggested that closed reduction is more likely to be successful if treated within 10 days from injury,26 while others have warned that a delay of more than 5 days usually results in irreducibility35 and that, in physeal injuries, fracture end adhesions to mediastinal structures may form.6,57 A recent systemic review concluded that all delayed dislocations needed open reduction after failed closed reduction.21 Open reduction and stabilization of the clavicle allows healing in anatomical position, avoiding complications from malunited fracture or chronic instability of the SCJ.14 The optimal method of stabilizing the SCJ has not yet been established. Reported methods included fixation with large cannulated screws, anterior plating, K-wire fixation, Steinmann pin fixation, external fixate, medial clavicle resection, and soft tissue procedures such as tendon grafts, facial loops, fiber wires, and synthetic ligaments.4,6,9,16,21,24,26,32,38,45,57 A recent review showed overall a good functional outcome using different modalities of treatments in adults.21 However, complication rate of hardware fixation has been unacceptably high, and some authors do not support their use.7,21 In children, Waters et al, in their series of 13 cases, successfully used No.1 polyester suture to repair costoclavicular and sternoclavicular ligaments.56 We used a similar method and found it safe and effective. Thomas et al described their ‘‘safe’’ repair, using sutures to stabilize the clavicle to the manubrium.54 At 15 months, the 3 described cases had full pain free function. Hofwegen et al also described a ‘‘safe’’ repair of dislocated physeal injuries by suturing the end of the clavicle to the manuprium, using Fiberwires in 2 patients. Both had good functional outcome at 2-½ years follow-up.28 Laffosse et al used PDS for costcalvicular ligament repair and costoclavicular cerclage.32 Several other methods to stabilize the SCJ have been described in the literature; however, we recommend the use of absorbable sutures to stabilize the SCJ in children. Many authors would also recommend the notification of a thoracic surgeon when open reduction is attempted.6,45,47,56,57
Posterior sternoclavicular joint dislocation Postoperatively, we left the shoulder in a sling for 3 weeks before commencing physiotherapy.
Conclusion On the basis of the literature review and our limited experience, we recommend that all skeletally immature patients with suspected SCJ injury should be examined very carefully for associated symptoms and signs of compression from mediastinal structures. Neurovascular compromise should be carefully noted and documented. A CT scan should be obtained in all cases, with suspicion of injury to SCJ, to confirm and define the exact pattern of injury. Treatment offered should be early and prompt, involving open reduction and stabilization of sternoclavicular and costoclavicular ligaments. We feel that the risks associated with an unreduced fracture, particularly in the presence of symptoms of mediastinal compression, outweigh those of open reduction with internal fixation. With this algorithm excellent functional outcome can be expected.
Disclaimer None of the authors, their immediate families, and any research foundation with which they are affiliated received any financial payments or other benefits from any commercial entity related to the subject of this article.
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