Sternoclavicular dislocation: Difference between revisions
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==Background== | ==Background== | ||
*Very stable joint; majority of injuries are simple sprains | [[File:PMC3898097 1754-9493-7-38-1.png|thumb|Sternoclavicular anatomy with ligaments.]] | ||
*Dislocations usually require severe force (MVC, sports injuries) | [[File:PMC4481669 10.1177 1941738113502153-fig11.png|thumb|Mediastinal contents directly posterior to the sternoclavicular joint.]] | ||
**Anterior dislocations are much more common than posterior | *Sternoclavicualr joint is only true articulation between the upper extremity and the axial skeleton | ||
**Very stable joint making a dislocation rare; majority of injuries are simple sprains | |||
*Dislocations usually require severe force (MVC, sports injuries) | |||
**Mechanism either direct blow to the chest, or lateral compression | |||
*Anterior dislocations are much more common than posterior | |||
*Due to both force and anatomic location, damage to the brachial plexus, subclavian, trachea, and esophagus may occur<ref name="Balcik">Balcik BJ et al. Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries. Prim Care Clin Office Pract 40 (2013): 911-923. PMID: 24209725</ref> | |||
*Atraumatic subluxation possible in younger patients | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:PMC3867956 CRIM.ORTHOPEDICS2013-386089.002.png|thumb|Photo showing right-sided sternoclavicular displacemnt.]] | |||
*Severe pain that is exacerbated by arm motion and lying supine | *Severe pain that is exacerbated by arm motion and lying supine | ||
*Shoulder appears shortened and rolled forward | *Shoulder appears shortened and rolled forward | ||
*Anterior dislocation: prominent medial clavicle end is visible/palpable ant to sternum | *Anterior dislocation: prominent medial clavicle end is visible/palpable ant to sternum | ||
*Posterior dislocation: Medial end is less visible and often not palpable | *Posterior dislocation: Medial end is less visible and often not palpable | ||
**If there is delay in presentation, edema may have developed making depression of the medial head less obvious | |||
==Diagnosis== | ==Differential Diagnosis== | ||
{{Thoracic trauma DDX}} | |||
==Evaluation== | |||
[[File:PMC3867956 CRIM.ORTHOPEDICS2013-386089.001.png|thumb|Xray with sternoclavicular dislocation (floating clavicle), as well as fracture lateral clavicle fracture (right).]] | |||
*CT | *CT | ||
**Study of choice (plain films may not be diagnostic) | **Study of choice (plain films may not be diagnostic) | ||
**Consider IV contrast if concern for injury to mediastinal structures | **Consider IV contrast if concern for injury to mediastinal structures | ||
*Serendipity view Xray | |||
**Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.<ref name="Balcik"></ref> | |||
==Management== | |||
*Symptoms of stridor, shortness of breath, or dysphagia, indicate aerodigestive tract injury and require immediate reduction. Also immediately reduce if evidence of vascular occlusion. | |||
===Anterior Dislocation=== | ===Anterior Dislocation=== | ||
*May | *May discharged without attempted reduction (no impact on function) | ||
*Clavicular splinting, ice, analgesics | *Clavicular splinting, ice, analgesics | ||
*Ortho referral | *Ortho referral within several days | ||
===Posterior Dislocation=== | |||
*May be associated with life-threatening injuries: | |||
**[[Pneumothorax]], compression/laceration of surrounding great vessels, trachea, or esophagus | |||
*Consult ortho for closed reduction (ideally performed in the OR or under [[procedural sedation]]) | |||
**Reduction must be performed with Cardiothoracic Surgery on-call or nearby due to potential for great vessel injury during reduction / manipulation | |||
**Create a sterile field with appropriate skin prep. | |||
**A metal towel clip is inserted percutaneously and is used to grasp the medial clavicle, pulling anteriorly until reduction is complete | |||
**May be observed afterwards due to severity of trauma and risk for vascular injury<ref>Deren ME et al. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthopedic Reviews 2014; 6: 5245. PMID: 24744842</ref> | |||
==Disposition== | |||
===Anterior Dislocation=== | |||
*Ortho follow up within several days | |||
===Posterior Dislocation=== | ===Posterior Dislocation=== | ||
* | *Immediate ortho consult, with potential transfer to facility with BOTH Ortho and CT surgery | ||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Orthopedics]] | ||
Latest revision as of 20:35, 13 June 2020
Background
- Sternoclavicualr joint is only true articulation between the upper extremity and the axial skeleton
- Very stable joint making a dislocation rare; majority of injuries are simple sprains
- Dislocations usually require severe force (MVC, sports injuries)
- Mechanism either direct blow to the chest, or lateral compression
- Anterior dislocations are much more common than posterior
- Due to both force and anatomic location, damage to the brachial plexus, subclavian, trachea, and esophagus may occur[1]
- Atraumatic subluxation possible in younger patients
Clinical Features
- Severe pain that is exacerbated by arm motion and lying supine
- Shoulder appears shortened and rolled forward
- Anterior dislocation: prominent medial clavicle end is visible/palpable ant to sternum
- Posterior dislocation: Medial end is less visible and often not palpable
- If there is delay in presentation, edema may have developed making depression of the medial head less obvious
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
- CT
- Study of choice (plain films may not be diagnostic)
- Consider IV contrast if concern for injury to mediastinal structures
- Serendipity view Xray
- Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.[1]
Management
- Symptoms of stridor, shortness of breath, or dysphagia, indicate aerodigestive tract injury and require immediate reduction. Also immediately reduce if evidence of vascular occlusion.
Anterior Dislocation
- May discharged without attempted reduction (no impact on function)
- Clavicular splinting, ice, analgesics
- Ortho referral within several days
Posterior Dislocation
- May be associated with life-threatening injuries:
- Pneumothorax, compression/laceration of surrounding great vessels, trachea, or esophagus
- Consult ortho for closed reduction (ideally performed in the OR or under procedural sedation)
- Reduction must be performed with Cardiothoracic Surgery on-call or nearby due to potential for great vessel injury during reduction / manipulation
- Create a sterile field with appropriate skin prep.
- A metal towel clip is inserted percutaneously and is used to grasp the medial clavicle, pulling anteriorly until reduction is complete
- May be observed afterwards due to severity of trauma and risk for vascular injury[2]
Disposition
Anterior Dislocation
- Ortho follow up within several days
Posterior Dislocation
- Immediate ortho consult, with potential transfer to facility with BOTH Ortho and CT surgery
References
- ↑ 1.0 1.1 Balcik BJ et al. Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries. Prim Care Clin Office Pract 40 (2013): 911-923. PMID: 24209725
- ↑ Deren ME et al. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthopedic Reviews 2014; 6: 5245. PMID: 24744842