Ann Thorac Surg 1996;61:711-713
© 1996 The Society of Thoracic Surgeons
Case Report
Posterior Dislocation of the Sternoclavicular Joint Leading to Mediastinal Compression
Jacques B. Jougon, MD,
Denis J. Lepront, MD,
Claire E. H. Dromer, MD
Thoracic Surgery Unit, Xavier Arnozan Hospital, Pessac, France
Accepted for publication August 3, 1995.
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Abstract
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Dislocations of the sternoclavicular joint are uncommon, and the posterior variety have a potential for considerable morbidity. We report a case with compression of the vital structures within the superior mediastinum. It was a rugby player getting run over by the scrum. The mechanism was an indirect force exerted forward and laterally against the shoulder. The patient complained of pain and dysphagia. A systolic right cervical murmur was heard. Angiography was normal and esophagography showed extrinsic esophageal compression. Surgical reduction was performed because there was a slight pneumomediastinum on the computed tomography. This case report demonstrates the mechanism, complications, and treatment of such a lesion.
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Introduction
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Dislocations of the sternoclavicular joint (SCJ) often are unrecognized because they are uncommon and are difficult to diagnose in a traumatic context. They account for less than 1% of all joint dislocations reported in traumatology [1]. The posterior variety is the most uncommon but the most dangerous because it can induce fatal mediastinal complications. It was first described in 1824 by Cooper [2]. Tricoire and associates [3] has reviewed six posterior varieties in 42 dislocations of sternoclavicular joint over a 6-year period. Nettles and Linscheid [4] reported only three posterior displacements of the clavicle in 60 cases of sternoclavicular dislocation. In 1967, when Worman and Leagus [5] reported 60 cases in a review of the literature, 16 patients (26%) had mediastinal complications resulting in death for 2 of them. We report a case of posterior dislocation of SCJ causing mediastinal injury.
The patient, a 17-year-old man, was brought to the hospital emergency room on December 11, 1994, with suspicion of right clavicle fracture during a rugby match. A sternoclavicular dislocation had been diagnosed, and the patient was soothed and admitted to be operated on 2 days after. One day later, he complained of dysphagia increasing with right shoulder moving and had slight discomfort. A computed tomographic scan (Fig 1
) assessed a posterior sternoclavicular dislocation and showed compression of the trachea, compression of the innominate artery, and a small pneumomediastinum. On December 12, 1994, the patient was transferred to the thoracic surgery department for management of the mediastinal injuries due to the posterior SCJ dislocation. Patient history specified the indirect mechanism of the trauma: while he was protecting the ball against the right part of his chest, he had been tackled, lying on his left shoulder with all the scrum against his right shoulder. He complained of pain over his right shoulder and dysphagia. Physical examination disclosed swelling of the overlying tissues over the right SCJ, and limited painful active range of motion of the right shoulder. The blood pressure was 120/70 mm Hg, equal at the two arms, but a systolic right cervical murmur was heard. Temperature was normal (37°C). There was no subcutaneous emphysema on physical examination or mediastinal emphysema on the chest roentgenogram. Injury of the innominate artery or one of its branches was ruled out by arteriography. The cervical murmur was due to the compression of the innominate artery. Tracheal extrinsic compression reducing the lumen to 50% of its normal size without tracheal or bronchial wound was shown by the bronchoscopy. Esophagography showed extrinsic esophageal compression without perforation injury (Fig 2). Intrinsic compression without mucosal wound was showed by the esophagoscopy. Diagnosis of posterior dislocation of the right SCJ with the internal end of the clavicle enclosed in the mediastinum leading to compression was then confirmed. The patient was quickly operated on, on December 12. A vertical manubriotomy permitted us to wedge out the clavicle and explore the mediastinum. After the meniscal joint was extracted, reduction was performed and the clavicle was fixed by a wire suture placed around a Kirchner pin crossing the joint. One month later, the patient had active and normal right shoulder motion, and the bronchoscopy was normal.
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Fig 1. . Computed tomogram of the chest showing a right posterior sternoclavicular joint dislocation with an innominate artery forced back, tracheal compression, and a small pneumomediastinum.
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Comment
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Dislocations of the SCJ are classified in three anatomic varieties: the traumatic anterior variety, the spontaneous atraumatic anterior variety, and the posterior variety. The posterior variety is usually secondary to trauma [1, 3], although a few spontaneous atraumatic posterior dislocations have been described [6]. Posterior SCJ dislocations are usually in relation to indirect trauma resulting from antepulsion and internal rotary motion of the arm combined with direct shoulder shock. This was the mechanism of injury in our patient. Tearing of all the retention articular system is always associated with this variety (articular capsule, sternoclavicular ligament, costoclavicular ligament, and interclavicular ligament). The sudden intrusion of the medial end of the clavicle into the thorax induce injuries of the vital structures of the superior mediastinum, lying immediately posterior to the joint: the great vessels of the neck, trachea, esophagus, vagus nerve, and dome of the pleurae. The sternohyoid and sternothyroid muscles supply the only protection between these vital structures and the joint. The complications may include simple compression as in our case report, or more serious injuries of the vital structures within the superior mediastinum.
Posterior SCJ dislocations are often difficult to diagnose, both clinically and roentgenographically. Pain and palpable deformation are alarming symptoms, but later swelling of the overlying tissues may conceal the deformation. Computed tomographic examination is the optimal method of displaying articular and mediastinal injuries, and a widened mediastinum is an indication for angiography [1].
The reduction of posterior SCJ dislocations is always required even if they do not cause functional discomfort. Indeed, late vascular complications have been described [3], such as a fatal tracheoesophageal fistula caused by a persistent pressure from an unreduced SCJ dislocation [7]. Removal of the mediastinal compression and restoration of the SCJ as much as possible are the two aims of the treatment. Close reduction, described by Buckerfield and Castle [8], must be performed within the first 72 hours after the injury [3]. Under general anesthesia and muscle relaxation, a bolster is placed between the scapulae and both shoulders are ``forced'' by direct pressure. A sterile towel clip may be percutaneously inserted into the medial end of the clavicle for direct manipulation to facilitate reduction. As soon as successful reduction is obtained, the shoulder must be immobilized in a figure-8 splint for 6 weeks. Close reduction implies the lack of mediastinal injuries. The use of ultrasound may provide real-time imaging to guide the manipulative efforts and control close reduction [9].
Surgical reduction is required if intrathoracic organ injury is suspected or if medical attempts for close reduction have failed. In our case report, we preferred open reduction to explore the mediastinum owing to the slight pneumediastinum on computed tomography. Historically, resection of the medial end of the clavicle has been one accepted mode of treatment, but now it must be avoided. Binding the clavicle against the first rib seems essential for stability of the reduction. Various fascial repairs such as sternal head of the sternocleidomastoid muscle and tendon of the subclavian muscle, have been described to procure dynamic stability [3]. Wire fixation across the joint must be a temporary solution to avoid wire migration, which has also been described [3].
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Footnotes
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Address reprint requests to Dr Jougon, Xavier Arnozan Hospital, 33604 Pessac Cedex, France.
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References
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- Cope R. Dislocations of the sternoclavicular joint. Skel Radiol 1993;22:233–8.[Medline]
- Cooper A. A treatise on dislocations and on fractures of the joints. In: Longman, Hurst, Orme, Brown, Green, eds. London, 1824:359.
- Tricoire JL, Colombier JA, Chiron P, Puget J, Utheza G. Les luxation sterno-claviculaires postérieures. A propos de 6 cas. Rev Chir Orthop 1990;76:39–44.[Medline]
- Nettles JL, Linscheid RL. Sternoclavicular dislocation. J Trauma 1968;8:158–64.[Medline]
- Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma 1967;7:416–23.[Medline]
- Martin SC, Altchek D, Erlanger S. Atraumatic posterior dislocation of the sternoclavicular joint. A case report and literature review. Clin Orthop Related Res 1993;292:159–64.[Medline]
- Wasylenko MJ, Busse EF. Posterior dislocation of the clavicle causing fatal tracheoesophageal fistula. Can J Surg 1981;24:626–7.[Medline]
- Buckerfield CT, Castle ME. Acute traumatic retrosternal dislocation of the clavicle. J Bone Joint Surg (Am) 1984;66:379–85.[Abstract/Free Full Text]
- Benson LS, Donaldson JS, Carrol NC. Use of ultrasound in management of posterior sternoclavicular dislocation. J Ultrasound Med 1991;10:115–8.[Medline]
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Abstract
Introduction
