Sternoclavicular dislocation: Difference between revisions
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==Background== | ==Background== | ||
[[File: | [[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.]] | [[File:PMC4481669 10.1177 1941738113502153-fig11.png|thumb|Mediastinal contents directly posterior to the sternoclavicular joint.]] | ||
*Very stable joint making a dislocation rare; majority of injuries are simple sprains | *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) | *Dislocations usually require severe force (MVC, sports injuries) | ||
**Mechanism either direct blow to the chest, or lateral compression | **Mechanism either direct blow to the chest, or lateral compression | ||
*Anterior dislocations are much more common than posterior | *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> | *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 | ||
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==Evaluation== | ==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) | ||
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*Serendipity view Xray | *Serendipity view Xray | ||
**Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.<ref name="Balcik"></ref> | **Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.<ref name="Balcik"></ref> | ||
==Management== | ==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. | *Symptoms of stridor, shortness of breath, or dysphagia, indicate aerodigestive tract injury and require immediate reduction. Also immediately reduce if evidence of vascular occlusion. | ||
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*May be associated with life-threatening injuries: | *May be associated with life-threatening injuries: | ||
**[[Pneumothorax]], compression/laceration of surrounding great vessels, trachea, or esophagus | **[[Pneumothorax]], compression/laceration of surrounding great vessels, trachea, or esophagus | ||
*Consult ortho for closed reduction (ideally performed in the OR or under [[ | *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 | **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. | **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 | **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> | **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== | ==Disposition== | ||
===Anterior=== | ===Anterior Dislocation=== | ||
*Ortho follow up within several days | |||
===Posterior=== | ===Posterior Dislocation=== | ||
*Immediate ortho consult, with potential transfer to facility with BOTH Ortho and CT surgery | *Immediate ortho consult, with potential transfer to facility with BOTH Ortho and CT surgery | ||
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