Asymptomatic Traumatic Posterior Dislocation Of Sternoclavicular Joint In A Child: A Case Report

 Singh VK*, Singh PK*, Mishra A*, Tomar J*

* James Paget University Hospital , Great Yarmouth , UK

Address for Correspondence:

Mr. V.K Singh, MRCS.
Department of Trauma & Orthopaedics Surgery, 
James Paget University Hospital, Great Yarmouth, U.K. NR31 6LA
Email : we.publish@googlemail.com

Abstract:

Injury to Sternoclavicular joint is uncommon but may be a life threatening if the diagnosis is not made acutely. Posterior sternoclavicular joint dislocation is associated with a number of complications including trachea  tear or trauma to the great vessels. Diagnosis by conventional radiography is difficult. Even experienced examiners may miss the diagnosis unless a high level of suspicion exists and the appropriate imaging studies are ordered. We report a case of traumatic dislocation of Seternoclavicular joint in an 11-year-old child post rugby injury, successfully treated by closed reduction.

J.Orthopaedics 2007;4(3)e14

 Keywords:
Sternoclavicular joint; bilateral; dislocation; child; sports injury.
Introduction:
Sternoclavicular joint (SCJ) is a synovial diarthrodial joint that links upper extremity to Torso. It participates in all the movements of upper extremity by providing free movement of clavicle in virtually all directions. Stability of this joint is imperative for ability to thrust the arm and shoulder forwards. Articular surface of clavicle is much larger than articular surface of sternum   hence only 50% of the medial end of the clavicle articulates with sternum. SCJ has little inherent stability. Most of the strength and stability originates from the joint capsule and supporting ligaments. The capsule surrounding the joint is weakest inferiorly, while it is reinforced on the superior, anterior, and posterior aspects by the various ligaments. These include the interclavicular, anterior and posterior sternoclavicular and costoclavicular ligaments. Sternoclavicular joint dislocations are rare injuries1, 2 accounting for <1% of all traumatic joint dislocations. It was first described in 1824 by Cooper3 and since then only around 100 cases of posterior dislocation of SCJ have been reported in literature. Anterior dislocation is more common4 than posterior dislocation (9:1). Most of these injuries have been described in adults. We report a case of asymptomatic traumatic posterior dislocation of sternoclavicular joint in an 11year old child post sporting injury.

Case Report :

An 11-year-old enthusiastic rugby player was injured while playing rugby. He was involved in a bad tackle and fell awkwardly on his right shoulder and another player fell on top of his chest. He had to discontinue playing because of pain. He was assessed by the physical trainer who advised him to visit casualty for assessment. 

In casualty child was comfortable with minimal pain and had restricted range of right upper limb movements. He had swelling, minimal tenderness and a subtle palpable dip in right sternoclavicular area. He had no other symptoms and was neurovascularly intact. Child was sent for a chest X-ray to look for possible sternoclavicular dislocation, which was inconclusive (Fig 1).

Specialist opinion was sought because of clinical suspicion. Child was admitted under the care of orthopaedic team for observation and CT scan to rule out dislocation. There was no change in patient’s symptoms and CT scan  was done next day, which revealed posterior  dislocation of both sternoclavicular joints  (Fig 2). Once the diagnosis is confirmed he  was urgently taken to theatre. Successful  closed reduction was performed under general anaesthetic using fluoroscopic guidance (Fig 3). His symptom resolved post manipulation and was subsequently discharged home. Follow up in clinic in showed normal examination and complete resolution of symptoms.

Discussion :

Injuries to the sternoclavicular joint are uncommon, but can be life-threatening if not diagnosed and treated adequately. Nearly 25% of patient with SCJ dislocation have associated injuries5 such as pneumothorax, injury to brachial plexus, laceration of the superior vena cava, occlusion of the subclavian artery or vein, and disruption of the trachea. All of these complications can cause significant disability and even death. Prompt diagnosis and treatment is necessary to avoid complications.

High index of suspicion in needed in case of high velocity road traffic injuries or high impact sporting injuries. Children playing contact sports are particularly at risk. Chest X-ray may help in diagnosis but should not be used to rule out SCJ dislocation. Specific view of SCJ dislocation such as Rockwood (serendipity), Hobb, Kattan6 and Heinig views may be requested to help diagnosis but CT scan is the imaging modality of choice. It is imperative to make the diagnosis early, as delay may be life threatening, and closed reduction is best accomplished during the first 48 hours.

When diagnosis is not clear patient should be admitted for adjunctive imaging (CT scan) to rule out the diagnosis. Reduction of posterior dislocation must only be done in theatres under general anesthetic7 in view of the possibility of compression of mediastinal structures8 with cardiothoracic team on standby.

Reference :

1. Cope R, Riddervold HO, Shore JL, Sistrom CL. Dislocation of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis Orthop Trauma1991; 5:379–384.

2. Denham RH, Jr., and Dingley AF, Jr.: Epiphyseal Separation of the medial end of the clavicle.J.Bone And Joint Surg., 49-A: 1179-1183, Sept.1967.

3. Cooper A: A Treatise on Dislocations and on Fractures of the Joints, Ed 3, p 559. London, Longman, 1824.

4. Rockwood CA, Wirth MA. Injuries to the sternoclavicular joints. In: Rockwood CA, Green DP, Bucholtz RW, Heckman JD, eds. Fractures in adults, 4thed. Philadelphia: Lippincott-Raven, 1996:1415–1471.

5. Atraumatic posterior dislocation of the sternoclavicular joint, Clin Orthop Relat Res.1993 Jul;(292): 159-64.

6. Kattan KR. Modified view for use in roentgen examination of the sternoclavicular joints Radiology.1973; 108:8.

7. Selesnick FH, Jablon M, Frank C, Post M. Retrosternal dislocation of the clavicle: report of four cases. J Bone Joint Surg. 1984; 66A: 287–291.

8. Sanders JO, Lyons FA, Rockwood CA. Management of dislocations of both ends of the clavicle. J Bone Joint Surg. 1990; 72A: 399–402.
   
   

This is a peer reviewed paper 

Please cite as : Singh VK : Asymptomatic Traumatic Posterior Dislocation Of Sternoclavicular Joint In A Child: A Case Report  

J.Orthopaedics 2007;4(3)e14

URL: http://www.jortho.org/2007/4/3/e14

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