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A 24-year-old man sustained a sporting accident which caused the contour of the proximal part of the right clavicle to disappear, due to a posterior sternoclavicular dislocation.
The authors report a case of posterior sternoclavicular dislocation, and discuss the diagnosis and treatment based on the relatively rare cases reported in the published literature. Therapy is described, which appears to be logical, even though a homogenous group of patients treated for this condition does not exist.
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A 24-year-old man severely injured in a motor vehicle accident was found to have, on the right side, a pneumothorax, extrapleural hematoma, acromioclavicular dislocation and fracture of the first three ribs and of the transverse processes of C7 and T1. Through a right thoracotomy, transection of the right main stem bronchus and a laceration of the left main stem bronchus were discovered. These were repaired. Twenty days after admission, posterior dislocation of the clavicle at the sternum was noted. A diagnosis of tracheoesophageal fistula was made on the 32nd day but the symptoms had been sternoclavicular and acromioclavicular dislocations. At autopsy the medial end of the clavicle was found to be torn from its articular discand and locked behind the manubrium. The fistula was behind the posterior capsule between the carina and esophagus. The authors conclude that continued pressure from the displaced clavicle may have led to delayed necrosis of the esophagus and that reduction of the dislocated clavicle might have saved the patient's life.
The authors describe two cases of the disease. They perform modified operation after Speed in which they use instead of a strip from fascia lata a 1 mm thick binding wire for the fixation of the medial end of the clavicle to the first rib. Immobilization in the Desault bandage takes three weeks and is followed by rehabilitation with the reduction of elevation above 90 degrees. After twelve weeks the upper extremity of the affected side can perform normal activity, however, with permanent exclusion of weightbearing of the extremity in the direction conductive to dislocation.
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The relationship between hyperparathyroid bone disorders and chronic renal diseases has been studied extensively for a long period of time. Zvaifler and Bywaters are the first to emphasize articular manifestations in hyperparathyroidism. Sundaram has found 30% in 80 hemodialysis patients presenting with articular disorders in hands. We reviewed routine radiographs of 258 uremia patients retrospectively and found that 36 patients had typical X-ray presentations of renal osteodystrophy. Sixteen among them (44.44%) were noted with articular involvement. Fourteen patients involved axial joints including sacroiliac, acromio-clavicular, sternoclavicular and symphysis pubis in decreasing order. Appendicular joints involvement were found in 6 patients, patellofemoral joints and small joints of hands involvement in 4 patients respectively and hip and shoulder joints in each one patient. None of the 16 patients complained joint pain. Diagnosis is easy because of the uncommon presentations of joint disorders in uremic patients. However, more knowledge about articular manifestations of renal osteodystrophy may eliminate the unnecessary investigations.
Ankylosing spondylitis (AS) is one of a group of disorders characterized by association with HLA-B27 histocompatibility complex, seronegativity for rheumatoid factor, and propensity for inflammation at entheses, synovial articulations, and cartilaginous articulations. The radiographic hallmark of the disease is ankylosis, and the principle sites of involvement are the sacroiliac joints and spine, with less frequent involvement of other joints, including the pubic symphysis, hips, shoulders, knees, hands, feet, and sternoclavicular, acromioclavicular, sternomanubrial, and temporomandibular joints. Following a brief discussion of the basic pathophysiology and typical clinical findings of AS, we describe the typical magnetic resonance imaging features of the disease as it is manifests in the axial skeleton. Finally, a brief mention of special considerations in the radiographic evaluation of the AS patient in the setting of trauma is made.
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Sternoclavicular stabilization using metal implants is associated with an unacceptably high complication rate. A simple and safe technique of sternoclavicular stabilization utilizing sutures and the clinical results thereof are described in this case of an 11-year-old boy with an unstable anterior sternoclavicular dislocation.
Scapulothoracic dissociation has been described as a "closed traumatic forequarter amputation" and is characterized by massive soft tissue swelling of the shoulder, lateral displacement of the scapula, neurovascular injuries (brachial plexus, subclavian artery), an osseous-ligamentous injuries. In addition to the lateral displacement of the scapula, an acromioclavicular separation, a displaced fracture of the clavicle or sternoclavicular separation can be identified on plain X-rays. This injury pattern has been infrequently reported. We present a patient who had a previously unreported combination of roentgenographic findings, and in whom the diagnosis was revealed by computed tomographic evaluation.
Scapulothoracic dissociation is an important and increasingly common clinical condition resulting from massive traction injury to the anterolateral shoulder girdle with disruption of scapulothoracic articulation. It frequently is accompanied by an acromioclavicular separation, displaced clavicular fracture, or sternoclavicular disruption. Vascular lesions have been reported in 88% of patients and severe neurologic injuries occur in 94% of patients. Many patients have a poor outcome with a flail extremity in 52%, early amputation in 21%, and death in 10%. Early recognition of this injury combined with a logical treatment protocol can help to decrease the substantial morbidity and mortality associated with this condition.
Twelve cases of posterior sternoclavicular dislocation were seen over 15 years at the Victoria General Hospital and the Izaak Walton Kiliam Hospital for Children in Halifax, NS. Two patients required open reduction of the dislocation but the rest were treated by closed reduction. One of the former group required threaded K wires for stability, but all other dislocations were deemed stable after reduction and application of a figure-of-eight bandage and an arm sling. There were no failures of reduction and no recurrent dislocations; the authors have been successful even in late closed reduction (up to 5 days) and therefore recommend it highly as the primary treatment. Open reduction is much more difficult and hazardous.
Posterior sternoclavicular dislocation is a relatively uncommon lesion, but must always be considered in the event of trauma to the scapulothoracic area in which initial radiology does not show signs of fracture. Its diagnosis and treatment must be carried out promptly because of the possible serious complications that may occur through the clavicle compressing nearby structures. The authors report two cases, which were diagnosed by CT-scan. In the first case, treatment consisted in orthopedic reduction, while in the second case open reduction and fixation with Kirschner wires was required. The result was satisfactory in both cases, and the patients remain asymptomatic three and five years after trauma.