Difference between revisions of "Sternoclavicular dislocation"

(Created page with "==Background== SC joint is freely movable synovial joint Allows movement in nearly all planes Very strong/stable due to connective tissue stabilizers - dislocation is UNCOMMO...")
 
(Management)
 
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==Background==
 
==Background==
 +
[[File:PMC3898097 1754-9493-7-38-1.png|thumb|Sternoclavicular anatomy with ligaments.]]
 +
[[File:PMC4481669 10.1177 1941738113502153-fig11.png|thumb|Mediastinal contents directly posterior to the sternoclavicular joint.]]
 +
*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==
 +
[[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
 +
*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
  
SC joint is freely movable synovial joint
+
==Differential Diagnosis==
 +
{{Thoracic trauma DDX}}
  
Allows movement in nearly all planes
+
==Evaluation==
 
+
[[File:PMC3867956 CRIM.ORTHOPEDICS2013-386089.001.png|thumb|Xray with sternoclavicular dislocation (floating clavicle), as well as fracture lateral clavicle fracture (right).]]
Very strong/stable due to connective tissue stabilizers - dislocation is UNCOMMON
+
*CT
 
+
**Study of choice (plain films may not be diagnostic)
Requires substantial force to dislocate
+
**Consider IV contrast if concern for injury to mediastinal structures
 
+
*Serendipity view Xray
Anterior dislocation:posterior ratio 9:1
+
**Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.<ref name="Balcik"></ref>
 
 
 
 
 
==Mechanism==
 
 
 
 
 
Anterior: anterior blow to lateral shoulder levers medial clavicle out
 
 
 
Poster: usually direct blow to medial clavicle
 
  
 +
==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
  
==Presentation==
+
===Posterior Dislocation===
 
+
*May be associated with life-threatening injuries:
 
+
**[[Pneumothorax]], compression/laceration of surrounding great vessels, trachea, or esophagus
Anterior
+
*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
-usually not subtle
+
**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
-can happen in elderly without significant trauma
+
**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>
 
 
-minimal potential for resultant morbidity
 
 
 
 
 
 
Posterior
 
 
 
Associated with sig force
 
 
 
25% incidence of mediastinal injury
 
 
 
-tracheal rupture
 
 
 
-PTX
 
 
 
-SVC lac
 
 
 
-Subclavian occlusion
 
 
 
-Vocal cord palsy
 
 
 
 
 
 
==Imaging==
 
 
 
 
 
Rountine Xray may appear nl
 
 
 
Serendipity View: 40˚ from vertical, direct cephalad
 
 
 
CT modality of choice
 
 
 
-can demonstrate co-injuries
 
 
 
MRI/MRA if necessary
 
 
 
 
 
 
==Treatment==
 
 
 
 
 
Anterior
 
 
 
-Reduction if you desire
 
 
 
-Bolster between shoulder blades, abduct arm to 90˚, press medial clavicle posteriorly and inferiorly
 
 
 
-May not reduce 2/2 interposed ligaments
 
 
 
-May not stay reduced 2/2 loss of ligament support
 
 
 
-Sling
 
 
 
-Ortho f/u
 
 
 
 
 
 
Posterior
 
 
 
-Difficult to reduce
 
 
 
-Prep, place towel clips, pull anteriorly while (assistant) placing traction and abduction to ipsilateral arm
 
 
 
-Sling
 
 
 
-Ortho f/u
 
 
 
-Admit if other mediastinal injury
 
 
 
 
 
 
==Source==
 
 
 
 
 
Perron (ACEP '09)
 
 
 
 
 
 
 
  
 +
==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==
 +
<references/>
  
[[Category:Ortho]]
+
[[Category:Orthopedics]]

Latest revision as of 20:35, 13 June 2020

Background

Sternoclavicular anatomy with ligaments.
Mediastinal contents directly posterior to the sternoclavicular joint.
  • 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

Photo showing right-sided sternoclavicular displacemnt.
  • 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

Evaluation

Xray with sternoclavicular dislocation (floating clavicle), as well as fracture lateral clavicle fracture (right).
  • 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. 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
  2. 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