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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 uncommonand usually present with anterior dislocation.2,20,21 PosteriorSCJ dislocations are relatively rare injuries in adults24,49 andare extremely rare in children.10,53,59 This injury can presentwith very subtle physical examination findings6 and plainradiographs are generally inconclusive.39,58 One in 3 casespresents with compression symptoms of retrosternal struc-tures, which can be life threatening43; there have also been5 deaths reported followingSCJ dislocation.5,15,17-19,30Whenmissed initially, they may present later with significantcomplications18,21,47 and can form basis of clinical negli-gence. Accurate diagnosis and prompt treatment is essentialfor a good functional outcome followingposterior dislocationof the SCJ.6,21 Furthermore, late presentation is more like toimpede closed reduction.6,21,32,47 There is debate in theliterature regarding treatment of these injuries,15,21,24,53

mainly because just over 120 cases have been reported inlast 75 years,31 out of which only very few have been reportedin children.5,6,9,10,13,17-19,30,35,41,43,44,50,51,53 Posterior dislo-cations of the SCJ in children should be treated as a separateentity due to ongoing growth at the epiphysis. While trueposterior dislocation can occur in children,53,56,59 themajority of the injuries are posteriorly displaced fracture (ofSalter-Harris 1 or 2) of the medial clavicular physis.20-22,26,32

This has been described by some authors as ‘‘pseudo-dislo-cation’’.47 Although the pathology is different, they stillpresent in the same way and require prompt treatment.

This report describes a rare case of posterior SCJdislocation of the clavicle metaphysis in a 12-year-old

uests: Zeiad A. Alshameeri, MBChB(Hons), MRCS, 22

, Birmingham B10 9EL, United Kingdom.

ss: Zeiad@doctors.org.uk (Z.A. Alshameeri).

ee front matter � 2012 Journal of Shoulder and Elbow Surgery

.2011.07.007

treated by attempted closed reduction proceeding to openreduction with repair of the growth plate and ligaments. Weaim to review the literature on posterior SCJ dislocation inlight of our experience, and provide an insight with regardsto diagnosis and management of posterior SCJ dislocationin children.

Case report

A 12-year-old boy fell down awkwardly onto his left shoulderwhile running. The patient took his body weight onto his leftshoulder and felt instant pain in the sternoclavicular area. Hewas seen at the accident and emergency department, wherea diagnosis of SCJ injury was not initially identified. The patientwas referred to the orthopaedics fracture clinic 1 week laterbecause of ongoing pain. Plain radiographs of the clavicle didnot show any injury (Fig. 1); however, the location of the painand tenderness in the region of the SCJ prompted the ortho-paedic team to order an immediate computer tomographic (CT)scan of SCJ with upper thorax. This showed a complete posteriordislocation of the medial end of the clavicle without any frac-tures (Figs. 2 and 3).

The patient was taken to the operating theater, and an openreduction of the dislocation was carried out 1 week post-injury.Closed reduction was attempted with the patient supine byapplying a towel clip to the medial end of the clavicle throughthe skin, with a sandbag placed in the mid-line under the upperthoracic spine. This failed and the SCJ was opened usinga ‘‘necklace’’ type transverse neck incision directly over thejoint. The joint was reduced using a towel clip. At this point, itbecame clear that the injury sustained had been a Salter-HarrisType 1 injury through the junction between the growth plate andmedial clavicular metaphysis. In addition, the growth plate hadbeen split into 2 main pieces and was only partially attached to

Board of Trustees.

Figure 1 Immediate post-injury x-ray showing no obvious injury.

Figure 2 Three-dimensional computer tomographic recon-struction showing complete posterior dislocation of left sterno-clavicular joint without any evidence of fracture to the medial endof clavicle.

Figure 3 Three-dimensional computer tomographic reconstruc-tion showing complete posterior dislocation of left sternoclavicularjoint without any evidence of fracture to the medial end of clavicle.

Figure 4 Magnetic resonance image showing well-reducedsternoclavicular joint.

e12 S. Garg et al.

the medial epiphysis of the clavicle. The growth plate wasreduced and sutured with absorbable No 1 Vicryl sutures. Theperiosteum with the sternoclavicular ligaments were repaired enmasse, using absorbable sutures through bony tunnels in themanubrium sternum and medial end of clavicle. Postoperatively,the arm was kept in a sling for 3 weeks and physiotherapy wascommenced with gentle passive exercises. Postoperatively,a magnetic resonance image was obtained 8 weeks following theinjury which confirmed that the reduction had been maintained(Fig. 4), the epiphysis was well located, and the growth plateremained in place between the metaphysis and epiphysis. Thebrachio-cephalic vein was seen lying closely adjacent to theremodeling bone; however, there were no symptoms of venousengorgement in the limb (Fig. 5). The boy made a remarkablerecovery with a Rockwood score48 of 15/15 at 3 months follow-up. No further follow-up was arranged because the child hadreturned to normal daily living activities.

Discussion

SCJ is a synovial gliding joint that links the upper extremityto the torso. The articular surface of clavicle is much largerthan the articular surface on sternum, making it inherentlyunstable and the most incongruous joint in the body;however, the joint is supported by a thick capsule rein-forced by strong ligaments (anterior and posterior sterno-clavicular, costoclavicular and interclavicular), making itstable to allow forward thrust and movements of the upperlimb.52

SCJ dislocation was first described by Cooper in 18248

and subsequently by various authors in the form of casereports and short series of cases. The largest series reported13 cases of posterior SCJ dislocation in children and

Figure 5 Magnetic resonance image 8 weeks post open reduc-tion and fixation showing the proximity of posterior aspect ofmedial clavicle epiphysis to brachiocephalic vein (arrow).

Posterior sternoclavicular joint dislocation e13

adolescents over a period of 10 years56; however, in theirseries, only 2 patients sustained true posterior SCJ dislo-cation. Yang et al described 4 cases of true dislocations,which were in children with joint laxities,59 and 1 furthercase was recently described by Sykes et al53 in a childwithout joint or liagmentous laxity. Laffosse et al describeda total of 17 cases of true dislocations, which were allin patients aged 17 years or over.32 They also described13 cases of posteriorly displaced physeal fractures, whichwere all in children and young adults. The high ratio ofposteriorly displaced physeal fracture to true dislocation ofthe SCJ in children and young adults arises because theepiphysis at the medial end of the clavicle does not ossifyuntil the age of 18-20, but does not fuse with the medial endof the clavicle until the age of 22-25.20,25 Until then, thegrowth plate remains the weakest point2 and more likely tosustain a fracture.22,24,26,34

As in our case, it is very difficult to distinguish betweentrue posterior dislocation and posterior displacement of themedial clavicle physeal fracture from conventional radio-graph or even CT scan.16,22,32 The true nature of the injurycan only be verified during open reduction16,22,32,33,53orretrospectively when new bone formation and boneremodeling is seen in follow-up CT scans.34 This is whymany of the reports do not make a clear distinction betweenthese 2 injuries, especially when managed nonoperatively,and are generally reported and treated as posterior dislo-cations 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

reported.43,56 Most dislocations occur as a result of anindirect twisting force from the clavicle that pivots on thefirst rib when the shoulder girdle is pushed back. Thisresults in anterior dislocation while the medial end ofclavicle is pushed out posteriorly when the shoulder girdleis pushed forwards. Atraumatic dislocations are rare;however, 3 cases of spontaneous posterior dislocation havebeen reported in the literature in patients with generalizedlaxity.12,37,38

Clinical presentation and investigation

Patients with posterior SCJ dislocations present with painlocalized to the joint, palpable gap, or swelling at the medialend of clavicle. The gap is often subtle and may remainunrecognized; hence, a high index of suspicion must bemaintained unless the injury is ruled out. One in 3 casesreported in the literature has presented with symptoms ofcompression from retrosternal structures. In a series of13 cases of posterior SCJ dislocation, authors56 reporteddysphagia at presentation in 4 cases (31%) and shortness ofbreath in 1 (8%). Nearly 10% of cases present withcompression or laceration of brachiocephalic vein, clinicallyevident by cyanosis in neck or upper limb with associatedswelling. Other serious presentations like traumatic pnue-mothorax42 and tracheal stenosis40 have also been reported.A case of tracheoeophageal fistula resulting in death of thepatient was reported when posterior displacement of claviclewas missed initially. Authors concluded that this wasa preventable cause of death.55 Brachial plexopathy withthoracic outlet syndrome requiring further surgery in form ofmedial clavicle excision have been reported after chronicposterior SCJ dislocation.46 Treating physicians must beaware of these potentially life threatening complications.There was 1 reported case presenting late due to subtlesymptoms, despite severe displacement of medial end ofclavicle.6 Some of these injuries can also be missed becausethey present in associationwithmid-clavicular fractures.27,33

Therefore, initial diagnosis can be difficult, as physicalfindings can be misleading and plain radiographs areusually inconclusive.1,6 Specialized views such as Hobbs’,Rockwood’s serendipity view, or Heinig’s20,22,24,25 may aidin diagnosis. CT scan is themost appropriate imagingmethodto confirm the diagnosis and evaluating the mediastinalstructures,11,22,24,25,59 and should be used whenever there issuspicion about SCJ dislocation. Angiography/venographyshould be carried out when there is suspicion of vascularinjury.

Classification and treatment

SCJ dislocation has been classified on the direction ofclavicle dislocation by Allman.3 Another classificationsystem has been proposed based on direction, mode, anddegree of displacement.29 This classification also provides

e14 S. Garg et al.

some guide towards treatment of these injuries. Currently,there is no classification system for posterior SCJdislocation.

Authors suggest that posterior displacement of claviclemust be seen as dislocationwith or without fracture ofmedialclavicle physis, as this will carry prognostic implica-tions.22,26,34 This is because some authors argue that manyasymptomatic physeal injuries will heal and remodel withoutintervention if not significantly displaced,20,34,57 while trueposterior dislocation usually leads to late onset of compli-cations24,47 and instability requiring adequate anatomicalreduction.21,32 However, clinically and radiologically, it canbe difficult to distinguish between the 2 injuries in children atpresentation, and they are, therefore, treated synonymouslyas dislocations requiring reduction.

Closed reduction

Traditionally, closed reduction has been accepted as treat-ment of choice and has been successful in many casesincluding physeal injuries in children.1,5,26,29,47,58,59 Yanget al managed all 4 cases of posterior dislocation in childrensuccessfully with closed reduction.59 This is attemptedunder general anaesthesia and carried out by placinga bolster (or sandbag) between the patient scapulae, whiletraction is applied to the abducted arm in line with theclavicle. The traction is gradually increased while the armis brought to extension.24,25

Another technique involves a combination of theabove and applying a pressure on the shoulder in anteriorposterior direction.25,53 If this is unsuccessful, then thesternclavicular area is surgically prepped and traction onthe abducted arm is applied with backward traction onthe ipsilateral shoulder. A sterile towel clap is appliedaround the medial end of the clavicle and pulled ante-riorly. The reduction is confirmed with an audible orpalpable snap. An x-ray is obtained to confirm thesatisfactory reduction of the joint, and a figure-of-8bandage is applied to keep the shoulder retracted for6-8 weeks.24,25,59

Open reduction and stabilization of the SCJ

Rockwood and Sanders49 have advised that, becausechronic instability of the SCJ has not been reported, openreduction of SCJ is not indicated. However, many otherauthors recommend open reduction when closed reductionfails, because of the complication associated with theposterior displacement of the medial clavicle end, such aserosion and compression of the retrosternal struc-tures.20,21,24-26,45,57

In their series of 13 cases of posterior SCJ dislocation inchildren, Waters et al56 reported instability after earlyclosed reduction. Two out of their initial 3 cases in theseries had to be taken back to theater for open reduction

and stabilization. Laffosse et al also described failure ofclosed reduction in all cases of posteriorly displacedphyseal fractures and in half of the cases with true posteriordislocation.32 This is consistent with our experience as wellas many reports in the literature that reported persistentdisplacement or failed reduction after initial closed reduc-tion in theater, requiring open reduction and internal fixa-tion as definitive treatment.14,21,23,28,36 Therefore, manyauthors recommend consenting patients for open reductionand stabilization of clavicle in all cases. Nettles41 reportednearly 20% chronic instability after closed reduction of14 cases of anterior SCJ dislocation. However, it has beenargued that, unlike posterior dislocation, there may be littleif any functional impact of chronic anterior dislocation.47

The success rate following closed reduction in posteriordislocations has been reported as 68%, if done early5; thetiming of closed reduction is, therefore, important. Grohet al suggested that closed reduction is more likely to besuccessful if treated within 10 days from injury,26 whileothers have warned that a delay of more than 5 days usuallyresults in irreducibility35 and that, in physeal injuries,fracture end adhesions to mediastinal structures mayform.6,57 A recent systemic review concluded that alldelayed dislocations needed open reduction after failedclosed reduction.21

Open reduction and stabilization of the clavicle allowshealing in anatomical position, avoiding complicationsfrom malunited fracture or chronic instability of the SCJ.14

The optimal method of stabilizing the SCJ has not yetbeen established. Reported methods included fixation withlarge cannulated screws, anterior plating, K-wire fixation,Steinmann pin fixation, external fixate, medial clavicleresection, and soft tissue procedures such as tendongrafts, facial loops, fiber wires, and synthetic liga-ments.4,6,9,16,21,24,26,32,38,45,57 A recent review showedoverall a good functional outcome using different modali-ties of treatments in adults.21 However, complication rateof hardware fixation has been unacceptably high, and someauthors do not support their use.7,21 In children, Waterset al, in their series of 13 cases, successfully used No.1polyester suture to repair costoclavicular and sternocla-vicular ligaments.56 We used a similar method and found itsafe and effective. Thomas et al described their ‘‘safe’’repair, using sutures to stabilize the clavicle to the manu-brium.54 At 15 months, the 3 described cases had full painfree function. Hofwegen et al also described a ‘‘safe’’repair of dislocated physeal injuries by suturing the end ofthe clavicle to the manuprium, using Fiberwires in 2patients. Both had good functional outcome at 2-½ yearsfollow-up.28 Laffosse et al used PDS for costcalvicularligament repair and costoclavicular cerclage.32 Severalother methods to stabilize the SCJ have been described inthe literature; however, we recommend the use of absorb-able sutures to stabilize the SCJ in children. Many authorswould also recommend the notification of a thoracicsurgeon when open reduction is attempted.6,45,47,56,57

Posterior sternoclavicular joint dislocation e15

Postoperatively, we left the shoulder in a sling for 3 weeksbefore commencing physiotherapy.

Conclusion

On the basis of the literature review and our limitedexperience, we recommend that all skeletally immaturepatients with suspected SCJ injury should be examinedvery carefully for associated symptoms and signs ofcompression from mediastinal structures. Neurovascularcompromise should be carefully noted and documented.A CT scan should be obtained in all cases, with suspi-cion of injury to SCJ, to confirm and define the exactpattern of injury. Treatment offered should be early andprompt, involving open reduction and stabilization ofsternoclavicular and costoclavicular ligaments. We feelthat the risks associated with an unreduced fracture,particularly in the presence of symptoms of mediastinalcompression, outweigh those of open reduction withinternal fixation. With this algorithm excellent func-tional outcome can be expected.

Disclaimer

None of the authors, their immediate families, and anyresearch foundation with which they are affiliatedreceived any financial payments or other benefits fromany commercial entity related to the subject of thisarticle.

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