Manubriosternal Dislocation with Spinal Fracture: a Rare Cause for Delayed Haemothorax

Chinese Journal of Traumatology 18 (2015) 245e248

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Chinese Journal of Traumatology

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Case report Manubriosternal dislocation with spinal fracture: A rare cause for delayed haemothorax

* Manish Kothari , Pramod Saini, Sunny Shethna, Samir Dalvie

Spine Room 1408, Hinduja Clinic, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra 400016, India article info abstract

Article history: Type 2 manubriosternal dislocations with concomitant spinal fracture are rare and may be associated Received 9 October 2014 with thoracic visceral injuries. The complication of delayed haemothorax has not been reported yet. We Received in revised form report a case of a young male who suffered manubriosternal dislocation with chance type thoracic spine 11 November 2014 fracture due to fall of a tree branch over his back. The haemothorax presented late on day three. The Accepted 3 December 2014 possible injury mechanism is discussed along with review of literature. We conclude that a lateral chest Available online 30 October 2015 radiograph is indicated in spinal fracture patients complaining of midsternal pain. Computerized axial tomography scan of chest with contrast is indicated to rule out visceral injuries and a chest radiograph Keywords: Manubriosternal dislocation should be repeated before the patient is discharged to look for delayed haemothorax. © Spinal fractures 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Haemothorax Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Manubriosternal dislocation with spinal fracture is a rare injury and can be associated with concomitant internal chest injuries. The cause usually, is a hyperﬂexion injury following indirect trauma. Only a few reports have described this injury, due to various mechanisms, like road trafﬁc accidents and trampolining.1,2 How- ever, there are no reports of this injury causing a delayed haemothorax. We report a case of a 20-year-old male who had spine fracture with manubriosternal dislocation and delayed haemothorax in the absence of any rib fractures or mediastinal chest injuries.

2. Case report

Our patient was a 20-year-old man who was hit by a falling tree branch over his back. After this injury, he could not sit or stand by himself, neither could he move both his lower limbs and he had no sensations below the waist. There was no history of head injury or accompanied symptoms. At presentation, the patient had stable vital signs. He had complete paraplegia with sensory level at the

* Corresponding author. Tel.: þ91 9833302899. E-mail address: [email protected] (M. Kothari). Peer review under responsibility of Daping Hospital and the Research Institute Fig. 1. CAT scan of dorsal spine on presentation. The sagittal image showing three of Surgery of the Third Military Medical University. column injury. http://dx.doi.org/10.1016/j.cjtee.2014.12.001 1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 246 M. Kothari et al. / Chinese Journal of Traumatology 18 (2015) 245e248

patient was propped up comfortably and allowed side turning. On post operation day 3, he was asked to sit with legs dangling, following which he complained of severe anterior chest pain which was without radiating and aggravated on coughing and gets better in supine position. He complained of sweating and giddiness but did not have any respiratory distress. Local exami- nation revealed a step at the manubriosternal junction which was acutely tender. A lateral chest radiograph (Fig. 5) was taken which showed posterior dislocation of the manubrium on the sternum (Type 2). Immediate CAT scan of chest conﬁrmed the dislocation (Fig. 6) and revealed a large right haemothorax of about 800 cc. Contrast study did not show any vascular or mediastinal injury. Right side chest drain was inserted, which drained 850 cc of blood in one hour. There was less than 50 cc output over next 48 h, following which the chest drain was removed. Chest X-ray taken one and three days later did not show any recurrence of haemothorax. The patient was discharged following an uneventful further course.

Fig. 2. CAT scan axial image showing pre and paravertebral soft tissue collection along ﬂ with mild hyperdense uid collection in bilateral pleural cavity. 3. Discussion

Manubriosternal dislocations are rare. They are seen in high- umbilicus. X rays of dorsolumbar spine revealed wedging of the D8 energy trauma. Anatomically manubriosternal joint are of three and D9 vertebral bodies and interspinous separation. Chest X-ray types; 1) hyaline 2) synchondrosis and 3) synostosis. Synchrondosis did not reveal any abnormality. There were no rib fractures. and synostosis more commonly have fractures, whereas disloca- Computerized axial tomography scan (CAT scan) of the dorso- tions are seen in the hyaline type of manubriosternal joints. Thir- lumbar spine confirmed the spine fracture with paravertebral upathi and Husted3 described two types of dislocation based on the haematoma bilaterally (Figs. 1 and 2). There were also fractures of mechanism of injury. Type 1 includes dorsal dislocation of the the right transverse process of D7 and D8 with horizontal fracture of sternum over manubrium, usually seen with direct impact in D8 spinous process along with fracture of right transverse process vehicular accidents. Type 2 involves in ventral dislocation of the of D10. Injection of Methylprednisolone was started in view of the sternum over manubrium. It is usually associated with a flexion neurological deficit. Magnetic Resonance imaging showed a chance compression upper thoracic spine fractures. Type 2 injuries may be fracture pattern with extruded D8-9 disc material attached to the associated with injuries to aorta, other great vessels, trachea and 4 fractured endplate, compressing the spinal cord (Fig. 3). The D8 oesophagus, which are potentially life threatening. Diagnosis can spinous process was transversely split along with compete be readily made on a lateral chest radiograph. A CAT scan of chest disruption of the posterior longitudinal ligament, interspinous and must be done to rule out other injuries. Gopalakrishnan et al5 supraspinous ligament. commented that in the absence of any clinical signs, mediastinal The patient was taken immediately for fracture spine fixation widening is not due to aortic injury, but due to paravertebral and spinal cord decompression (Fig. 4). After operation, the haematoma.

Fig. 3. A: Axial T2W MRI image showing cord compression. B: Sagittal T2W MRI image showing 8e9 disc extrusion compressing the cord. PLC disruption is also seen. M. Kothari et al. / Chinese Journal of Traumatology 18 (2015) 245e248 247

Fig. 4. Postoperative anteroposterior (A) and lateral (B) X ray images.

In our patient, the initial spine CAT scan showed a mild paravertebral haematoma. We detected the sternomanubrial dislocation later, on day 3 after spine fracture ﬁxation surgery. Fortunately, he did not have any life-threatening mediastinal injuries. However, the patient had an enlarged right sided haemothorax which was absent at presentation. The contrast CT did not show any vascular injury. This kind of delayed haemothorax associated with manubriosternal dislocation and spinal fracture has not been described in literature. Delayed haemothorax itself is uncommon and an entity unique to multiple rib fractures.6 Most of the English literature involves in case series/reports. Sharma et al7 reported 7 cases in an 8 year retrospective analysis of 167 patients with haemothorax. Simon et al6 reported that delayed haemothorax presented at 18 h to 6 days after injury. Risk factors for delayed haemothorax following blunt chest trauma include multiple rib fractures, diaphragmatic injuries and internal mammary artery injuries. Our patient did not have any of these injuries. We believe this patient had a circumferential separation of upper half of the thorax from the lower half, hinging at the manubriosternal junction, more on the right side as compared to the left side. The fractures of only right side of posterior elements of the D7,D8 and D10 stand testimony to this. This separation, we believe, has lead to the delayed haemothorax. In conclusion, we have reported an unusual cause of delayed haemothorax caused by indirect manubriosternal dislocation along with a Chance-type fracture of the spine. A lateral chest radiograph should be done in patients with spinal fracture complaining of midsternal pain. A CAT scan of chest with contrast should be per- formed to spot the occurrence of mediastinal injuries. Repeat chest X ray should be ordered to exclude the delayed haemothorax before Fig. 5. Lateral X ray of the chest showing posterior displacement of the manubrium the patient is discharged. over sternum. 248 M. Kothari et al. / Chinese Journal of Traumatology 18 (2015) 245e248

Fig. 6. CAT scan of chest. A: Sagittal view showing the dislocation. B: Axial view showing the worsened large haemothorax.

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