Sternoclavicular dislocation: Difference between revisions
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*Very stable joint making a dislocation rare; majority of injuries are simple sprains | *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 | |||
*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> | ||
*Trivia - SC joint is only true articulation of the upper extremity and the axial skeleton | |||
==Clinical Features== | ==Clinical Features== | ||
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*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 | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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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> | ||
*MRI is a consideration, though less likely to be practical | |||
==Management== | ==Management== | ||
*Symptoms of stridor | *Symptoms of stridor, shortness of breath, or dysphagia, indicate aerodigestive tract injury and require immediate reduction. Also immediately reduce if evidence of vascular occlusion. | ||
===Sprain=== | ===Sprain=== | ||
*Rice, sling, analgesics | *Rice, sling, analgesics | ||
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*May discharged without attempted reduction (no impact on function) | *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=== | ===Posterior Dislocation=== | ||
*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 [[Procedural Sedation]]) | *Consult ortho for closed reduction (ideally performed in the OR or under [[Procedural Sedation]]) | ||
*A towel clip | **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> | *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> | ||
Revision as of 06:23, 17 November 2015
Background
- 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]
- Trivia - SC joint is only true articulation of the upper extremity and the axial skeleton
Clinical Features
Sprain
- Pain and swelling are localized to the joint
Dislocation
- 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
Diagnosis
- 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]
- MRI is a consideration, though less likely to be practical
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.
Sprain
- Rice, sling, analgesics
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
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