Ann Thorac Surg 2007;83:685-687
© 2007 The Society of Thoracic Surgeons
Case Reports
Tracheal Stenosis Caused by Retrosternal Dislocation of the Right Clavicle
Ei Nakayama, MDa,
Toru Tanaka, MDa,
Tetsuo Noguchi, MDb,
Jun-ichi Yasuda, MDb,
Yasuji Terada, MDa,*
a Department of Thoracic Surgery, Nagahama City Hospital, Nagahama, Japan
b Department of Respiratory Medicine, Nagahama City Hospital, Nagahama, Japan
Accepted for publication June 5, 2006.
* Address correspondence to Dr Terada, Department of Thoracic Surgery, Nagahama City Hospital, 313 Oinui-cho, Nagahama 526-8580, Japan. (Email: yaterada{at}ex.biwa.ne.jp).
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Abstract
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A 17-year-old woman was admitted to our institution because of tracheal stenosis. She had undergone tracheostomy after a traffic accident, but the stenosis had persisted. Chest computed tomography showed retrosternal dislocation of the right sternoclavicular joint and compression of the trachea by the medial head of the right clavicle. To relieve the tracheal compression, 3 cm of the medial head of the clavicle was resected. The dyspnea disappeared completely, allowing closure of the tracheostomy. Posterior dislocation of the sternoclavicular joint and tracheal stenosis due to compression by the dislocated clavicle is rare.
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Introduction
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Blunt chest trauma causes very complex syndromes because of damage to adjacent organs or structures, but tracheobronchial injury is an uncommon complication. We describe a rare case of retrosternal dislocation of the right clavicle that led to compression of the trachea. The patient was treated successfully by resection of medial head of the clavicle.
A 17-year-old woman was in a traffic accident in July 2005. She received conservative treatment for cerebral contusion and mechanical ventilation with tracheostomy at another hospital. After being weaned from the ventilator, the patient began rehabilitation, but exertional stridor made it difficult to remove the tracheostomy tube. The dyspnea gradually worsened, and bronchoscopy showed narrowing of the trachea with granulation tissue, which was thought to have been induced by the tracheostomy tube. The patient underwent argon plasma coagulation twice, but her dyspnea did not improve.
In November, she was admitted to our hospital, and administration of tranilast (300 mg/day) was started for treatment of the granulation. She was able to speak with a speech cannula, and required gait rehabilitation for spasticity of the left extremities. The movement of her right shoulder joint was limited to 90° of abduction. No abnormalities were evident in laboratory data or the lung field on chest roentgenogram.
Bronchoscopy revealed tracheal stenosis with granulation tissue located at the end of tracheostomy tube (Fig 1A). Chest computed tomography (CT) and three-dimensional CT showed retrosternal dislocation of the right sternoclavicular joint (Fig 2), and magnetic resonance imaging (MRI) without the tracheostomy tube indicated compression of the trachea by the right clavicle head (Fig 3). We considered that the granulation of the mucosa had been due to compression by the dislocated clavicle and the tracheostomy tube.
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Fig 1. (A) Bronchoscopy shows tracheal stenosis and granulation tissue inside the trachea. (B) Two weeks after the operation, tracheal stenosis is improved and the granulation decreased. (C) The tracheal stenosis and granulation disappeared completely 3 months after the operation, but deformity of the cartridge remains.
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Fig 2. (A) Chest computed tomography shows that the medial head of the right clavicle is located posterior of the sternum. The airway was maintained in this slice just inferior to the end of the tracheostomy tube. (B) Three-dimensional computed tomography shows prominent shift of the right clavicle head rearward to the sternum.
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Fig 3. Chest magnetic resonance image shows compression of the trachea by the right clavicle head. White arrowhead indicates the head of the right clavicle and white arrow shows the area of tracheal stenosis.
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With the assistance of our institution’s orthopedists, 3 cm of the medial head of the clavicle was resected to relieve the tracheal compression. We then removed the tracheostomy tube after confirming that the trachea was sufficiently patent (Fig 1B), and the tracheostomy was closed.
Three months after the operation, the granulation tissue disappeared completely (Fig 1C), and the administration of tranilast was withdrawn. Currently, the patient has no movement limitation in the right shoulder joint, and 180° of abduction is possible. She is also completely free of dyspnea.
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Comment
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Dislocation of the sternoclavicular joint is a relatively rare injury, and posterior dislocation is especially rare. Cave [1] found only one such injury among 1600 cases of trauma to the shoulder. Rowe and Marble [2] reported 10 injuries to the sternoclavicular joint in their series of 1603 shoulder-girdle injuries, and there was only one retrosternal dislocation.
The sternoclavicular joint is very stable because it is maintained by a capsule and various ligaments such as the costoclavicular, interclavicular, and sternoclavicular ligaments. Because the posterior sternoclavicular ligament is thicker than the anterior one, posterior dislocation of the sternoclavicular joint is much rarer than anterior dislocation [3, 4]. Clinical manifestations include local tenderness, swelling, absence of the normal protuberance over the injured sternoclavicular joint, and apparent depression of the skin. However, our patient was unable to describe any symptoms immediately after the accident because she had cerebral contusion.
The great vessels and other organs in the superior mediastinum may be damaged by this injury, causing pneumothorax or compression of a great vessel or the esophagus. Ege and colleagues [5] reported a case of bilateral retrosternal dislocation of the sternoclavicular joints that resulted in exertional dyspnea and venous congestion of the left arm due to compression of the trachea and the brachiocephalic vein. We report tracheal stenosis due to compression by a dislocated clavicle with granulation tissue.
This type of dislocation can be treated by closed reduction within 48 hours. In our patient, we had to resect the medial head of the clavicle because 4 months had passed after the injury. The outcome was good, however, with no limitation of shoulder joint movement and complete disappearance of the symptoms. The effectiveness of tranilast for treatment of airway granulation has been widely reported [6] and was also effective in the present case.
Although tracheal stenosis caused by clavicular dislocation is rare, patients presenting with dyspnea after injury should be assessed carefully for airway obstruction and possible injury to surrounding structures using CT and MRI.
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References
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- Cave AJE. The nature and morphology of the costoclavicular ligament J Anat 1961;95:170-179.[Medline]
- Rowe CR, Marble HC. Sternoclavicular dislocationsIn: Cave EF, editor. Fractures and other injuries. Chicago: Year Book Medical; 1958. pp. 258.
- Nettles JL, Linscheid RL. Sternoclavicular dislocations J Trauma 1968;8:158-164.[Medline]
- Selesnick FH, Jablon M, Frank C, Post M. Retrosternal dislocation of the clavicleReport of four cases. J Bone Joint Surg Am 1984;66:287-291.[Medline]
- Ege T, Canbaz S, Pekindil G, Duran E. Bilateral retrosternal dislocation and hypertrophy of medial clavicular heads with compression to brachiocephalic vein Int Angiol 2003;22:325-327.[Medline]
- Sato M, Terada Y, Nakagawa T, Li M, Wada H. Successful use of argon plasma coagulation and tranilast to treat granulation tissue obstructing the airway after tracheal anastomosis Chest 2000;118:1829-1831.[Medline]
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