Posterior Sternoclavicular Dislocation Presenting with Upper-Extremity Deep Vein Thrombosis

n Case Report

Posterior Sternoclavicular Dislocation Presenting With Upper-extremity Deep Vein Thrombosis

Pranit N. Chotai, MD; Nabil A. Ebraheim, MD

abstract Full article available online at Healio.com/Orthopedics. Search: 20120919-27

Posterior sternoclavicular dislocation is an uncommon injury and often remains initially 1 undiagnosed due to variable clinical presentation and inadequate visualization of the Figure 1: Axial chest computed tomography scan joint on plain radiographs. It is frequently associated with serious and life-threatening showing posterior sternoclavicular dislocation on injuries involving the trachea, esophagus, or great vessels. the left, with the medial end of the clavicle com- pressing the brachiocephalic vein.

A 15-year-old boy was knocked to the ground during wrestling and landed on his left shoulder. He presented 6 days after trauma with increasing arm swelling and pain. A Doppler ultrasound revealed deep vein thrombosis involving the left shoulder and arm. Contrast-enhanced computed tomography of the chest confirmed the diagnosis of left posterior sternoclavicular dislocation with the medial end of left clavicle compress- ing the underlying brachiocephalic vein. Venous duplex scan confirmed acute venous thrombosis of the left jugular and subclavian veins. Open reduction of the left posterior sternoclavicular dislocation was performed under general anesthesia with cardiothoracic surgery backup. The reduced joint was stable, negating the need for internal fixation. Postoperatively, the pain and arm swelling gradually subsided, and patient recovered well with no complications.

Deep vein thrombosis has not been reported as a presenting symptom for posterior ster- 2 noclavicular dislocation. Orthopedic, trauma, and thoracic surgeons should be aware Figure 2: Three-dimensional reconstruction of the of this presentation and obtain a chest computed tomography scan with 3-dimensional axial chest computed tomography scan demon- reconstruction to confirm the diagnosis. In cases of posterior sternoclavicular dislocation strating posterior sternoclavicular dislocation on the left. with vascular compromise, patients should immediately undergo open reduction with or without internal fixation.

Drs Chotai and Ebraheim are from the Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio. Drs Chotai and Ebraheim have no relevant financial relationships to disclose. Correspondence should be addressed to: Nabil A. Ebraheim, MD, Department of Orthopedic Surgery, University of Toledo Medical Center, 3065 Arlington Ave, Toledo, OH 43614 (nabil.ebraheim@ utoledo.edu). doi: 10.3928/01477447-20120919-27

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ternoclavicular joint dislocations tal pulsations. The neck veins were not are uncommon and represent 3% of distended. Smajor injuries to the shoulder girdle Ultrasound examination of upper- and less than 1% of all dislocations.1,2 extremity swelling demonstrated DVT. Anterior dislocations are more common The vascular service was consulted, and and have a less complicated presentation; heparin infusion was initiated. Contrast- 1 however, posterior sternoclavicular dis- enhanced computed tomography (CT) Figure 1: Axial chest computed tomography scan locations present with serious injuries to scans of the neck and chest confirmed showing posterior sternoclavicular dislocation on the mediastinal structures.1,3-5 They often the diagnosis of posterior dislocation of the left, with the medial end of the clavicle com- pressing the brachiocephalic vein. result from trauma secondary to contact the left clavicle with brachiocephalic vein sports (up to 85%, commonly football, compression (Figures 1, 2). No contrast rugby, and wrestling) or motor vehicle ac- was identified in the left subclavian and cidents.2,6-8 Since Sir Astley Cooper first axillary veins, and a filling defect was described this injury in 1824,9 approxi- found below the level of C4 in the left mately 130 cases have been reported in internal jugular vein. Venous duplex scan English literature; however, none of these confirmed acute DVT of the left jugular presented with upper-extremity deep vein and left subclavian veins. thrombosis (DVT) secondary to brachio- The patient’s family gave informed cephalic vein compression.9,10 consent for surgery. The cardiothoracic This describes reports a case of a pa- surgery team was available as backup. tient with a left shoulder girdle injury who Under general anesthesia and adequate presented 6 days after trauma with upper- muscle relaxation, a 4-cm horizontal inci- extremity DVT. The patient was managed sion was made on the skin overlying the 2 with open reduction without internal fixa- left sternoclavicular joint. After meticu- Figure 2: Three-dimensional reconstruction of the tion and recovered well with no neurovas- lous dissection, the posteriorly lying me- axial chest computed tomography scan demon- cular complications at last follow-up. dial clavicle was identified. Under contin- strating posterior sternoclavicular dislocation on uous left upper-extremity traction, it was the left. Case Report atraumatically reduced with a towel clip. During a wrestling match, a 15-year- Reduction was ascertained to be stable The sternoclavicular joint is inherently old-boy was slammed to ground by his under direct examination, and no inter- unstable and incongruent because less opponent and landed on his left shoulder. nal fixation was required. The wound was than half of the medial end of the clavicle At a primary clinic, a straight anteroposte- thoroughly irrigated and closed in layers, articulates with the sternum. An intra- rior chest radiograph was read as normal. and the patient recovered uneventfully. articular disk partially compensates for The patient was discharged in a sling and Postoperatively, the arm swelling and the incongruence, and much of the joint returned with increasing arm swelling and pain resolved, and the joint was pro- stability relies on periarticular ligament pain on postinjury day 6. He was then re- tected in a sling for 6 weeks. At 12-week (intra-articular disk ligament, interclavic- ferred to the authors for further evaluation follow-up; he was doing well and had ini- ular ligament, and capsular ligaments) and and management. tiated gradual shoulder range of motion extra-articular ligaments (costoclavicular At presentation, he reported increas- exercises. He reported no discomfort or ligament). The posterior capsular liga- ing arm swelling with pain and no his- pain over the left sternoclavicular joint. ment is sturdier than the anterior capsular tory of dysphagia, dyspnea, stridor, voice Participations in contact sports was re- ligament, and greater force is required to change, neck pain, facial swelling and stricted until 6-month follow-up. dislocate the joint posteriorly than ante- paresthesias, or upper-extremity weak- riorly. The costoclavicular ligament pro- ness. Examination revealed swelling of Discussion vides the strongest support and connects his left arm that also involved the left Anatomy and Mechanism of Injury the medial end of the clavicle to the first hand. Asymmetric swelling existed over The sternoclavicular joint links the rib and its corresponding costal cartilage. the left sternoclavicular joint. His left upper extremity with the axial skeleton. Vital mediastinal structures lie in close shoulder movements were limited due to Anatomically, it is a saddle-type synovial proximity posterior to each sternoclavicu- pain. He had bilaterally equal hand grips, joint, but functionally, its range of motion lar joint. On the right, the brachiocephalic normal capillary refill, and palpable dis- is comparable to a ball-and-socket joint.6 vein and artery, and on the left, the bra-

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chiocephalic vein, subclavian vein, common carotid artery, and, more posteriorly, Table 1 the left subclavian artery, are related to the Secondary Clinical Features of Posterior Sternoclavicular Dislocation sternoclavicular joint. In addition, the trachea, esophagus, lungs apices, and roots Mediastinal Structure Compressed by of the brachial plexus (C5-T1) lie deep Posteriorly Dislocated Medial Clavicle Clinical Manifestation next to the mediastinal vessels.11 Subclavian artery brachiocephalic Acute limb ischemia; pulses may diminish 5,8,20 Medial clavicular epiphysis does not artery (on the right side) on arm abduction ; systolic cervical murmur2; cerebrovascular stroke21 ossify until 18 to 20 years of age and does Innominate or subclavian vein Edema and cyanosis of the arm8,11,18,22; not fuse with the clavicular shaft until 23 compression or laceration DVT of arm; death4 7,12 to 25 years of age. It is believed that in Tracheal compression/stenosis lung Difficulty breathing; tachypnea; patients younger than 23 years, a poste- parenchymal injury stridor23,24; pneumothorax25 rior sternoclavicular dislocation should be Esophageal compression Dysphagia2,26,27 considered as having a Salter-Harris type Brachial plexus (C5-T1, anterior rami) Brachial plexopathy5,28 I/II clavicular physeal fracture as well.12,13 Recurrent laryngeal nerve compression Hoarseness of voice; voice changes5 However, not all posterior sternoclavicu- Abbreviation: DVT, deep vein thrombosis. lar dislocation cases present with physeal fracture, and they are usually diagnosed intraoperatively. Also, when present, they do not modify the management plan in the Presentation and Diagnosis festing as cyanosis or upper limb swelling acute stage. Notably, physeal injuries may A high index of suspicion is necessary was approximately 10%.7 Twelve cases heal and remodel if not displaced signifi- for diagnosing posterior sternoclavicular are reported with brachiocephalic vein in- cantly.9,11,12,14 dislocation because the clinical findings volvement, but none presented with upper- Sternoclavicular dislocation may be are often subtle.15-17 The typical presenta- extremity DVT (Table 2).* Four of 12 cases secondary to a direct blow to the medial tion of posterior sternoclavicular disloca- presented with laceration of the vein, of clavicle or secondary to an indirect force- tion is with pain and swelling around the which 2 were repaired19,30 and 1 resulted ful blow on the ipsilateral shoulder, with sternoclavicular joint following a fall and in death.4 A presentation with laceration 70% of injuries resulting from the lat- trauma to the shoulder. At presentation, the of the innominate vein–subclavian vein ter.13 A significant compressive force is arm is usually fixed in adduction and inter- junction was reported, which was repaired required to dislocate this joint; this may in nal rotation. The patient may favor the in- using a bovine pericardial patch.22 Partial part explain the rarity of this injury. If the jured joint by flexing and holding the head to complete compression may manifest, arm is anterior to the trunk at the time of toward the side of injury.9,11 The presence ranging from asymptomatic to cyanosis shoulder injury, the sternoclavicular joint of swelling over the joint often precludes and swelling of the involved upper ex- dislocates posteriorly, and if the arm is satisfactory palpation, and differentiation tremity.6,15,17,18,23,26,29,31 Following venous posterior to the trunk, the sternoclavicular between an anterior and posterior disloca- obstruction, collateral drainage develops joint dislocates anteriorly.11 Ninety-five tion is difficult. Mediastinal compression via the jugular veins and superior intercos- percent of sternoclavicular dislocations may be present in up to 30% of all poste- tal veins.18 In the current case, presentation are anterior, mainly attributable to the rior sternoclavicular dislocations and may was delayed by 6 days after injury, which stronger posterior support. Traumatic in- present with variable symptoms second- may be long enough to develop DVT but juries to the sternoclavicular joint are gen- ary to compression of the brachiocephalic may not be long enough for the collaterals erally classified based on damage to liga- vein or artery, subclavian vein or artery, to develop. Arm swelling and pain usually ments and joint alignment. Most common and trachea and esophagus (Table 1).7,18,19 disappear after open reduction and decom- are first-degree injuries, which are simple In the current patient, painful arm swelling pression of the brachiocephalic vein. If the strains of the ligaments. Second-degree raised the possibility of DVT secondary to patient is asymptomatic after reduction, injuries present as subluxation with com- compression and stasis, which was con- postoperative venograms are seldom nec- plete breach of the sternoclavicular liga- firmed on duplex ultrasound. essary to confirm the venous patency.17,18 ment only, and third-degree injuries, as In the largest case series of 13 pediatric Anteroposterior radiographs of the ster- seen in the current patient, present with and adolescent patients with posterior sternoclavicular joint are commonly obtained complete rupture of the sternoclavicular noclavicular dislocation, the incidence of and costoclavicular ligaments. brachiocephalic vein compression mani- *References 4, 6, 15, 17-19, 22, 23, 26, 29-31.

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Table 2 Posterior Sternoclavicular Dislocation Presenting With Brachiocephalic Vein Involvement

Patient Mechanism Study Sex/Age, y of Injury BCV Injury Presentation/Diagnosis Management Worman & M/18 MVA Compression/ Left PSCD with right pneumothorax, Thoracotomy, venous ligation Leagus19 laceration mediastinal hematoma/upright chest radiograph Southworth M/16 MVA Compression Asymptomatic complete right BCV CR with towel clip; restoration of & Merritt17 obstruction/CT scan and venogram flow on repeat venogram Cooper et al30 M/38 Fall from Laceration/tear Left hydropneumothorax, fractured Open reduction, resection of height left 1-3 ribs, transected left internal anterior end of first rib, sutured mammary artery/intraoperative tear, Pennig external fixator Ono et al18 M/41 MVA Compression Prominent neck veins, 2-6 rib fractures, CR 6 h after trauma; cyanosis cyanosis and swelling of left upper disappeared but asymptomatic arm, right lung contusion/AP chest venous occlusion persisted radiograph, venogram, and CT scan Thomas et al26 M/23 Rugby Compression Venous engorgement of right arm, pain, Open reduction swelling/CT scan 6 wk after injury Ege et al23 F/36 No trauma Compression Effort dyspnea for 2 y, congestion and Bilateral resection of clavicular mild cyanosis of left arm for 6 mo, heads; resolution of arm venous collaterals on left arm/CT scan congestion and swelling, BCV and duplex ultrasound patent at postoperative wk 6 Mirza et al6 M/19 Rugby Compression Deformity and tenderness over left ORIF using nonabsorbable suture sternoclavicular joint/CT scan Bennett et al29 M/20 Field hockey Compression Pain, swelling, elevated JVP, cyanosis of ORIF using transarticular sutures arm/CT scan, USG confirmed venous with ligament repair compression Buckley & M/16 Football Partial Pain and tenderness over left Nonemergent open reduction Hayden15 compression sternoclavicular joint/CT scan without internal fixation Hoekzema M/41 Bull attack Compression Pain, right upper limb paresthesias, ORIF using polydioxanone suture, et al31 dyspnea/CT scan ligament reconstruction Kang et al22 M/67 Machinery Laceration of Pain, slight tracheal deviation, widened Laceration repair using bovine accident innominate mediastinum/CT scan pericardial patch, open reduction vein–SCV junction Fenig et al4 M/16 Wrestling Laceration Death due to right hemothorax/autopsy N/A Chotai & M/15 Wrestling Compression UEDVT, arm swelling, pain/duplex Open reduction without internal Ebraheim scan, CT scan fixation; resolution of arm edema and pain Abbreviations: AP, anteroposterior; BCV, brachiocephalic vein; CR, closed reduction; CT, computed tomography; JVP, jugular venous pressure; MVA, motor vehicle accident; N/A, not applicable; ORIF, open reduction and internal fixation; PSCD, posterior sternoclavicular dislocation; SCV, subclavian vein; UEDVT, upper-extremity deep vein thrombosis; USG, ultrasonography.

but frequently fail to identify the injury. radiographs, but this is often too subtle to and popular.1,8 However, contrast CT scan This is attributed to the oblique orienta- establish the diagnosis. Specialized pro- (with 3-dimensional reconstruction, when tion of the sternoclavicular joint and the jections (serendipity, Heinig, Hobbs, and available) remains the imaging modality overlapping of ribs and vertebrae on the Kattan views) for better visualization of of choice because it allows excellent vi- joint. In a review of 30 cases of posterior the sternoclavicular joint have been de- sualization of both sternoclavicular joints, sternoclavicular dislocation, an erroneous scribed in the literature. The serendipity helps evaluate injuries to the surrounding initial diagnosis was made in 50% of cas- view, with 400 to 450 cephalad angulation mediastinal structures, and detects cla- es.20 Asymmetry of the 2 sternoclavicular of the radiograph beam, clearly shows vicular fractures.10,12,27,29 Occasionally, joints may be evident on anteroposterior both sternoclavicular joints and is useful angiography may be indicated to evalu-

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ate the vascular damage when a widened with gentle extension of the arm. At this with a subacute or chronic presentation, mediastinum is present.9,19 Magnetic point, the medial end of the clavicle is re- resection of the medial 1 to 1.5 inches of resonance imaging is rarely necessary but duced with a pop. If this fails, the medial clavicle is indicated. The medial clavicle may help determine ligament injuries and clavicle is grasped using a towel clip and is then secured to the first rib through differentiate true posterior sternoclavicu- pulled anteriorly into anatomic reduction the costoclavicular ligament.21,23,24 This lar dislocation from a physeal injury in under sterile precautions.11 Alternatively, decompresses any mediastinal compres- young patients.1,32 Ultrasound examina- the patient is positioned supine with the sion; however, it will not preserve the tion satisfactorily visualizes the sterno- arm in adduction; traction is applied to the sternoclavicular joint. Postoperatively, a clavicular joint and may diagnose a dis- arm caudally while anteroposterior pres- repeat CT scan is obtained to confirm ad- location, especially in an unstable patient. sure is applied to the shoulders bilaterally equate reduction and rule out subluxation. It also helps detect vascular compression to achieve sternoclavicular joint reduction.3 Rehabilitation of these patients is guarded, or mediastinal hematoma.29,32 Ultrasound Cases with suspected or proven me- and patients should be immobilized in an examination of arm swelling may detect diastinal injury or cases with delayed arm sling for at least 6 weeks to allow for DVT of the arm veins and indicate bra- presentation or diagnosis require open ligament healing, followed by gradual mo- chiocephalic or subclavian venous com- reduction and internal fixation.1,9,11,16 A bilization exercises. pression, as in the current case. Rarely, horizontal incision placed parallel to the bronchoscopy or esophagography may be shaft of the clavicle adequately exposes Conclusion performed to evaluate tracheal or esopha- the sternoclavicular joint and medial cla- Posterior sternoclavicular dislocation geal compression, respectively.2,24 vicular metaphysis. Care should be taken is a rare injury and may present with vari- to preserve as much anterior capsule as able mediastinal compression symptoms. Management possible. The posteriorly dislocated clavi- In a patient presenting after a fall or trau- Management begins with clinical sus- cle can then be reduced back under direct ma to the shoulder, the presence of arm picion of injury and obtaining CT scans to vision. Postreduction, the stability of the swelling and pain should raise suspicion confirm the diagnosis and rule out medi- joint should be determined on palpation for DVT secondary to venous compres- astinal injury. If posterior sternoclavicular or using a towel clip. The sternoclavicu- sion posterior to the sternoclavicular joint. dislocation is confirmed, vigilant monitor- lar joint is usually stable after reduction, Plain radiographs often fail to diagnose ing of upper-extremity perfusion and neu- and no internal fixation is required.1,11,14,15 the injury, and immediate CT scans should rological functions should be performed, However, if the joint is unstable or sub- be obtained. If posterior sternoclavicular and prompt reduction should be sched- luxates after reduction, internal fixation is dislocation with vascular injury is con- uled. A delay in reduction may lead to vas- necessary to prevent redislocation. firmed, the patient should undergo surgery cular compromise or thoracic outlet syn- Numerous stabilization methods have at the earliest opportunity to prevent fur- drome.1,5,6,19,20 Closed reduction is usually been described.1,7,33 Commonly, a costo- ther complications. All physicians dealing tried initially, especially in the absence of clavicular cerclage with a nonabsorbable with trauma patients should be aware of mediastinal injury and if presentation is suture or a semitendinosus graft tied in this presentation for posterior sternocla- within 48 hours of injury. However, closed a figure-8 fashion is used to stabilize the vicular dislocation. reduction has been performed successfully reduction.1,33 Costoclavicular tenodesis as late as 7 to 10 days after injury.8,13,14 In using the subclavius muscle and sternocla- References a few cases, a blind attempt at closed re- vicular tenodesis using the sternal head of 1. Groh GI, Wirth MA. Management of trau- duction may release the tamponade effect the sternocleidomastoid muscle have also matic sternoclavicular joint injuries. J Am Acad Orthop Surg. 2011; 19(1):1-7. on great vessels and could be catastroph- been described.27 While stabilizing the 21,30 2. Jougon JB, Lepront DJ, Dromer CE. Posterior ic. Also, a risk of vascular tear or tra- joint, it is important to avoid injury to the dislocation of the sternoclavicular joint lead- cheal and/or esophageal perforation exists; joint surfaces and to the physis in young ing to mediastinal compression. Ann Thorac hence, reduction should be performed un- patients. In all instances, metal implants, Surg. 1996; 61(2):711-713. der general anesthesia with cardiothoracic including cannulated screws and K-wires, 3. Buckerfield CT, Castle ME. Acute traumatic retrosternal dislocation of the clavicle. J 1,11,21 34 surgery backup. should not be used. Costoclavicular liga- Bone Joint Surg Am. 1984; 66(3):379-385. The most popular technique is the ments should not be damaged and, if rup- 4. Fenig M, Lowman R, Thompson BP, Shayne abduction–traction technique, where the tured, must be repaired before closure.7,11 PH. Fatal posterior sternoclavicular joint dis- patient is positioned supine with a sandbag In cases where the anterior capsular liga- location due to occult trauma. Am J Emerg Med. 2010; 28(3):e385-e388. placed between the shoulders. The arm is ment is injured or exposure to underly- 5. Gangahar DM, Flogaites T. Retrosternal abducted to 90°, and traction is applied ing vasculature is inadequate and in cases dislocation of the clavicle producing tho-

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