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East African Orthopaedic Journal Original article East African Orthopaedic Journal

be marvelous. This case displayed associated congenital 4. Boon JM: Potgieter D: Van Jaarsveld Z et al. Congential anomalies. The congenital cleft lip and palate that were Undescended Scapula (Sprengel Deformity): A case study. STABILISATION OF POSTERIOR STERNOCLAVICULAR Clinical Anatomy.2002.15.139-142 repaired in childhood have been reported as associated 5. Dilli A, Ayaz, U. Y., Damar, C., et al. Sprengel Deformity: DISLOCATION USING PALMARIS LONGUS before(4).The utilized modalities of investigating this Magnetic Resonance Imaging Findings in two Pediatric AUTOGRAFT: A CASE REPORT case were plain X-rays and a 3D CT scan. The information Cases. Journal of Clinical Imaging Sci. 2011. 1. 1. 17-20 6. Cavendish, M. E. Congenital Elevation of the Scapula. J. obtained from these was deemed adequate for the V.M. Mutiso*, MBChB(UON), MMed(Surg) (UON), Fellow ( and arthroplasty) (UK), Fellow AO-International (Ger), Bone joint Surg. Br. 1972. 54B. 3.395-408 V. M. Mutiso*, Department of Orthopaedic Surgery, College of Health Sciences, University of Nairobi, (P.O. Box FCS (ecsa), Department of Orthopaedic Surgery, College of Health Sciences, University of Nairobi, P.O. Box 19681 - 00202, treatment planning of this case. No new information 7. Green, W. T. The surgical correction of congenital elevation Nairobi,19681 – Kenya 00202, and Nairobi, J. Chigumbura, Kenya and MBChB J. Chigumbura (UK), GPST1 (UK), GPST1 - University – University Hospital Hospital of North of Stanffordshire, North Stafford UK shire, UK would have been availed by conducting an MRI of the scapula (Sprengel’s deformity). Journal of Bone and Joint Surgery AM. 1957. 39A. 6.1439. examination. Muscle anomalies have been documented Correspondence to: to: Dr. Dr. V.M. V. Mutiso, M. Mutiso, P.O. Box P.O. 19681 Box 19681- 00202, – Nairobi, 00202, Kenya.Nairobi, Email: Kenya. [email protected] Email: [email protected] 8. Grogan, D. P., Stanley, E. A. and Bobechko, W. P. The as part of the sprengel deformity but no mention of Congenital undescended scapula. Journal of Bone and *At the time of writing Dr. Mutiso was a Clinical Fellow ( Arthroplasty and Arthroscopy) in the Musculoskeletal the supraspinatus and infraspinatus atrophy noted in joint Surgery.Br.1983. 65B. 5. 598-605. Directorate of the University Hospital of North Staffordshire, UK. this case exists so far in the literature. The observed 9. Ross, D. M. and Cruess, R. L. The Surgical Correction of Congenital Elevation of the Scapula. Clinical Orthopaedics atrophy of the supraspinatus and infraspinatus Related Research.1977.125.17-23. would no doubt have a big role in determining the 10. Cho, T. J., Choi, I. H., Chung, C. Y., et al. The Sprengel SUMMARYABSTRACT postoperative outcome and gains of surgery. The choice deformity: Morphometric analysis using 3D-CT and its clinical relevance. Journal of Bone and Joint Surgery.Br. of the Woodwards procedure as treatment for this case Posterior dislocation is a rare . It is usually sustained acutely in activities 2000. 82B. 5. 711-718 such as contact sports eg. rugby and motorcycle accidents. Plain of the chest will often was arrived at by guidance from the literature as we 11. Petrie, J. G. Congenital elevation of the scapula. Journal miss the diagnosis and confirmation is by CT scans. However CT scans are often reported to miss of Bone and Joint Surgery-BR. 1973. 55B. 441 had no prior experience with Sprengel’s deformity. In epiphyseal . Management is by closed reduction and if the injury is unstable, by open reduction line with the practice of other surgeons, we are likely 12. Le Saout, J. Congenital elevation of the scapula (Sprengel’s deformity) In Professor Jacques Duparc (Ed) EFORT and stabilisation. A case is reported where palmaris longus tendon was used to stabilise the joint to offer future patients the same basic procedure, with Surgical Techniques In Orthopaedics and . following open reduction. modifications as the experience enlightens us. What Elsevier 2003. pg 55-210-C-10 we are left wondering is why the deformity 13. Leibovic, S. J., Ehrlich, M. E. and Zaleske, D. J. Sprengel INTRODUCTION CASE REPORT deformity. Journal of Bone and Joint Surgery.Am. 1990. was not addressed in childhood at the time of the cleft 72A. 2. 192-197 PosteriorINTRODUCTION Sternoclavicular joint dislocation is a relatively CASEA 19 year oldREPORT female was admitted with a history of injury lip and cleft palate repair. A similar scenario has been 14. Doita, M., Lio, H. and Mizuno, K. Surgical Management whilst playing with her friend. During the course of the rarePosterior injury sternoclavicular and is reported to joint have dislocation been first isdocumented a relatively reported before from Japan (14). Had the Sprengel of Sprengel’s Deformity in Adults. Clinical Orthopaedics A19game year he oldreportedly female waspulled admitted on her with right a forearmhistory ofwith in- byrare Sir injury Astley and Cooper is reported in 1824 to have (1, 2). been It is first a potentially documented life Related Research. 2000. 371. 119-124. jurythe whilst at approximatelyplaying with her 90 friend. degrees During of elevation the course and deformity been repaired in childhood it is possible the by Sir Astley Cooper in 1824 (1,2). It is a potentially 15. Carson, W. G., Lovell, W. W. and Whitesides, T. E. Congenital threatening injury due to the anatomical structures of45 thedegrees game of she adduction. reportedly She pulledwas upright on her at rightthe time. the outcome would have been better then. Earlier in the Elevation of the Scapula. Journal of Bone and Joint Surgery. life threatening injury due to the anatomical structures that lie immediately behind the joint in the thoracic armShe weighedat approximately approximately 90 degrees nine stoneof elevation and her and friend 45 postoperative period there were indications that the AM. 1981. 63A. 8. 1199-1207. that lie immediately behind the joint in the thoracic cavity. These include the great retrosternal vascular degreeswas of approximately of adduction. the She same was weight. upright She at feltthe rather time. 16. Siu, K. K., Ko, J. Y., Huang, C. C., et al. Woodward Procedure cavity. These include the great retrosternal vascular range of shoulder movement had improved. As of the Shethan weighed heard a ripping approximately sound closely nine stone followed and by her intense friend Improves Shoulder Function In Sprengel Deformity. Chang structures as well as thethe trachea,trachea, oesophagusoesophagus andand last review, the patient did not have an unsightly scar Gung Medical Journal. 2011. 34. 4. 403-408 waspain ofin approximatelythe region of her the right same sternoclavicular weight. She felt joint rath of- neural structures.structures. ComplicationsComplications includeinclude respiratory but there still persisted a disparity of the levels of the 17. Ahmad, A. A. Surgical Correction of Severe Sprengel erher than chest heard wall. She a ripping went to sound the accident closely andfollowed emergency by in- compromise, haemothorax, haemothorax, , pneumothorax, dysphagia, dyspha- deformity to allow greater postoperative range of tensedepartment pain in of the the region hospital of herwhere right chest sternoclavicular X-rays were scapulae. gia, brachial plexopathy and even death (3-5). Shoulder abduction. Journal of Paediatric Orthopaedics. brachial plexopathy and even death (3-5). jointdone ofand her some chest oral wall. analgesics She went administered. to the accident She wasand The capsule surrounding the joint is weakest 2010. 30. 6. 575-581 The capsule surrounding the joint is weakest emergencysubsequently department referred to ofthe the fracture hospital clinic where for review chest inferioriy with the other surfaces reinforced by REFERENCES 18. Borges, J. L., Shah, A., Torres, B. C., et al. Modified Woodward inferiorly with the other surfaces reinforced by the X-raysand follow were up. done and some oral analgesics adminis- procedure for Sprengel deformity of the Shoulder: Long the interclavicular, anterior and posterior sternocla- tered. SheOn reviewwas subsequently at the clinic referred there was to theno obviousfracture –term results. J. Paed. Orthopaed. 1996. 16. 508-513 interclavicular,vicular and costoclavicular anterior and posteriorligaments. sternoclavicular The posterior 1. DePalma, Anthony F. Surgery of the shoulder. 3rd Edition. clinicchest forbruising review or and deformity follow up. at the sternoclavicular 19. Gonen, E., Simsek, U., Solak, S., et al. Long-Term Results andsternociavicular costoclavicular joint capsule .The is the most posteriorimportant J.B.lippincott. Philadelphia. 1983.pg 24-25. joint.On It wasreview however at the tender clinic on there . was Theno armobvious had 2. Tachdjian MO. Congenital High Scapula (Sprengel’s of Modified Green Method in Sprengel’s Deformity. J. sternoclavicularstructure for preventing joint capsule both isanterior the most and important posterior Children Orthopaedics. 2010. 4. 309-314. chestgood circulationbruising or and deformity was neurologically at the sternoclavicular intact. Active Deformity). In Tachdjians Paediatric Orthopaedics. Vol translation of the stenoclavicuiar joint with the ante- structure for preventing both anterior and posterior joint.movement It was of however the limb tenderwas however on palpation. restricted The due arm to 1. 2nd Edition. 1990. Philadelphia. WB Saunders. pg 136- rior capsule acting as an important secondary stabi- translation of the stenoclavicular joint with the anterior hadpain. goodThus other circulation than the and tenderness was neurologically and the reluctance intact. 168 liser (4). The interclavicular is a continuation capsule acting as an important secondary stabiliser Activeto use movementthe right upper of the limb limb the was clinical however findings restricted were 3. Woodward, J. W. Congenital Elevation of the Scapula.J. of the deep cervical fascia and connects the medial Bone Joint Surg. AM. 1961. 43A.2.219-228 duerelatively to pain. unremarkable. Thus other than the tenderness and the (4).ends The of interclavicularthe two . ligament The costoclavicularis a continuation liga of- reluctance Plain toX-rays use of the the right chest upperwere also limb unremarkable. the clinical thement deep or rhomboid cervical fascia ligament and connects consists the of anteriormedial ends and findingsThe mechanism were relatively of injury and unremarkable. the history raised suspicion ofposterior the two laminae clavicles. connecting The costoclavicular the ligament to the first or of a sternoclavicularPlain X-rays of the joint were and also thus unremarkable CT scans were rib and the first costal cartilage (6). rhomboid ligament consists of anterior and posterior Therequested. mechanism These ofshowed injury a and posterior the history dislocation raised of sus her- laminae connecting the clavicle to the first rib and the picionright sternoclavicular of a sternoclavicular joint. joint injury and thus CT first costal cartilage (6). scans wereOnce requested. the diagnosis These had showed been a made, posterior it was dis locationrecommended of her right that sternoclavicularthe best course joint. of action was reductionOnce theof the diagnosis dislocation. had Thisbeen was made, discussed it was withrec- ommended that the best course of action was re- duction of the dislocation. This was discussed with

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the patient and her mother who was present. The plan Procedure: Under general anaesthesia the patient was was to do a closed reduction and assess stability and if placed supine on the operating table. Attempts were unstable progress to open reduction and stabilization. made to reduce the right sternoclavicular joint. The medial end of the clavicle was gripped by the pointed In view of the potential risk to intrathoracic structures ends of a surgical towel clamp and an anterior force interdisciplinary consultation was undertaken and the applied reducing the joint, however the joint repeatedly cardiothoracic surgeons were involved. Thus consent re-dislocated posteriorly and was thus found to be was taken for closed manipulation under general unstable. Having confirmed that the joint was unstable anaesthesia, to progress to open reduction and the team open reduction and internal fixation was stabilisation of the right sternoclavicular joint and also indicated and the team proceeded to undertake the for cardiothoracic surgical intervention should the need procedure. arise. Palmaris longus was harvested subcutaneously Pre operative history confirmed the mechanism from the of the same side using three small of injury. She was noted to be a 19 year old female longitudinal incisions to allow for cosmetically aesthetic of good general health. There was no history of scars. This was deemed important as the patient chronic illnesses and there was no clinical evidence was a 19 year old female. The sternoclavicular joint of generalized joint laxity. She was well orientated in was exposed using an L shape incision over it. The time, place and person. There were no other symptoms dislocation was reduced and two burr holes made at or physical signs specifically related to compression of the medial end of the right clavicle antero -superiorly intrathoracic structures. and antero-inferiorly. Similar burr holes were made in The patient was understandably a little bit the adjacent manubrium . anxious about surgery especially when during consent Palmaris longus tendon was threaded through taking the discussion centred on the potential to the holes in a figure of eight manner and stitched on damage to the great vessels. itself using fibrewire type sutures. The construct was stable on testing and the skin was closed in layers Figure 1 from periosteum outwards. The skin was closed with Plain AP radiograph of chest showing sternoclavicular subcuticular absorbable sutures. Post operatively the arm was supported in a sling. Post operative follow up was uneventful. The skin healed well and she was commenced on physiotherapy with good functional and cosmetic result.

DISCUSSION The sternoclavicular joint is the only linking the with the appendicular skeleton. It has an intra-articular disc and is classified as a sliding joint. It tends to be mobile in younger individuals. This injury is most common following acute trauma and Figure 2 is often associated with contact sports such as rugby, CT scan of chest showing Sternoclavicularsternoclavicular joint martial arts and with motorcycle accidents. All ligaments must be torn from the sternoclavicular joint for it to dislocate posteriorly (6). Pain over the sternoclavicular joint is an invariable symptom. There may be bruising and deformity over the region and variable loss of active movement of the upper limb. Standard AP views of the chest are often difficult to interpret and may not show the dislocation. Other views such as Serendipity views (Rockwood), Hobb, Kattan and Heinig may help (5). One should have a high index of suspicion. CT scanning will often clinch the diagnosis and gives an indication of the severity as well as the involvement of the mediastinal structures. As major vessels of the thoracic cavity may be involved some authors recommend angiography both pre and post reduction. However this has to be balanced against the

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the patient and her mother who was present. The plan Procedure: Under general anaesthesia the patient was invasive nature of these investigations. MRI angiography migrate (5). There is good long term expectation. In a was to do a closed reduction and assess stability and if placed supine on the operating table. Attempts were is ideal. paper by Nathan et al (3), a farmer with a similar injury unstable progress to open reduction and stabilization. made to reduce the right sternoclavicular joint. The The treatment of posterior sternoclavicular is reported to have regained full factory related activity medial end of the clavicle was gripped by the pointed within 6 months and at two years was problem free. In view of the potential risk to intrathoracic structures joint dislocation is varied owing to the rarity of the ends of a surgical towel clamp and an anterior force condition and the difficulty in diagnosis. Although a CT Mirza et al (1) reports stability at 8 months. interdisciplinary consultation was undertaken and the applied reducing the joint, however the joint repeatedly scan will often confirm the diagnosis epiphyseal injury cardiothoracic surgeons were involved. Thus consent re-dislocated posteriorly and was thus found to be may be missed. At the time of writing Lafosse et al (5) was taken for closed manipulation under general unstable. Having confirmed that the joint was unstable had the largest series comprising 30 cases of posterior ACKNOWLEDGEMENT anaesthesia, to progress to open reduction and the team open reduction and internal fixation was sternoclavicular joint dislocation. In his retrospective stabilisation of the right sternoclavicular joint and also The following two consultant orthopaedic surgeons are indicated and the team proceeded to undertake the study five of eight medial clavicle epiphyseal injuries for cardiothoracic surgical intervention should the need acknowledged, Mr. D. Griffiths, and surgeon and procedure. were missed by CT scan in his series and only diagnosed arise. Mr. D. McClelland, a shoulder surgeon.both at the Uni- Palmaris longus was harvested subcutaneously at open surgery (5). Pre operative history confirmed the mechanism versity Hospital of North Staffordshire. from the forearm of the same side using three small Singh et al (7) reports a case of posterior of injury. She was noted to be a 19 year old female longitudinal incisions to allow for cosmetically aesthetic dislocation in an 11 year old child whilst playing rugby of good general health. There was no history of REFERENCES scars. This was deemed important as the patient with successful treatment by closed reduction. A chronic illnesses and there was no clinical evidence was a 19 year old female. The sternoclavicular joint biomechanical study by Spencer et al (8) favours repair 1. Mirza, A.H., Alan, K. and Ali. A. Posterior sernoclavicular of generalized joint laxity. She was well orientated in dislocation in a rugby player as a cause of silent vascular was exposed using an L shape incision over it. The by semitendinosus tendon grafts with figure of eight time, place and person. There were no other symptoms compromise. A case report. Br. J. Sports Med. 2005;39: dislocation was reduced and two burr holes made at stabilisation threaded through burr holes at the medial or physical signs specifically related to compression of pages?e28. the medial end of the right clavicle antero -superiorly end of the clavicle and adjacent manubrium sternum. intrathoracic structures. 2. Wirth, M.A. and Rockwood, C.A. Acute and chronic and antero-inferiorly. Similar burr holes were made in He reports that these have higher tensile strength The patient was understandably a little bit traumatic injury of the sternoclavicular joint. J. AM. Acad. the adjacent manubrium sternum. than intramedullary ligaments as well as subclavius Orthop. Surg. 1996; 4: 268-278. anxious about surgery especially when during consent Palmaris longus tendon was threaded through tendon repairs. Repairs can also be undertaken using 3. Nathan, H., Michael, T., Mark, A., Stephen, D. and Cassivi, taking the discussion centred on the potential to the holes in a figure of eight manner and stitched on costo-clavicular cerclage with non- absorbable sutures. M.D. MSc Posterior sternoclavicular joint dislocation. Can damage to the great vessels. itself using fibrewire type sutures. The construct was of subclavius and use of medial head of J. Surg. 2008;2006; 5151:(1): pages e19-e20. stable on testing and the skin was closed in layers stenocleidomastoid muscle has been advocated by 4. Gunther, W. A. Posterior dislocation of the sternoclavicular joint: Report of a case. J. Bone JointJoint Surg. Surg. 1949; 1949; 31 878M-: 878- Figure 1 from periosteum outwards. The skin was closed with some authors. Plain AP radiograph of chest showing sternoclavicular subcuticular absorbable sutures. M879.879. Volume? Complications: These are related to the intrathoracic 5. Laffosse, J. J.M., M., Espie,Espie, A.,A., Bonnevialle, Bonnevialle, N., N., Tricoire, et al posterior J. L., & joints Post operatively the arm was supported in a structures that may be affected by the posterior translation dislocational, e. Posterior of the dislocation sternoclavicular of the sternoclavicular joint and epiphyseal joint sling. Post operative follow up was uneventful. The skin of the medial clavicle in cases of posterior dislocation disruptionand epiphyseal of the disruption medial clavicleof the medialwith posterior clavicle withdis- healed well and she was commenced on physiotherapy of the sternoclavicular joint. These include dyspnoea, placementposterior displacement in sports participants. in sports participants. J. Bone Joint 2010; (BR). 2010 103: with good functional and cosmetic result. respiratory obstruction, haemopneumothorax, truncal Pages? damage, great vessel injury, laryngeal damage, vocal 6. Rajanathan, S., Kering, M. and Apthup, L. Posterior cord palsy, and dysphagia. Possible late complications dislocation of the sternoclavicular joint: A case report DISCUSSION include possible oesophageal rupture, respiratory and review of the clinical anatomy of the region. Clinical Anatomy. 2002; 15: 108-111. The sternoclavicular joint is the only synovial joint compromise, pneumothorax, dysphagia, brachial 7. Singh, V. K., Singh, P. K., Mishra, A., and Tomar, J. linking the upper limb with the appendicular skeleton. plexopathy and even death. Asymptomatic traumatic posterior dislocation of It has an intra-articular disc and is classified as a sliding Management: Reduction is advised in all cases and sternoclavicular joint in a child: A case report.report J. Orthopaed. joint. It tends to be mobile in younger individuals. This should be closed where possible. Open reduction is 2007; e14.4 (3): Pages? e14. injury is most common following acute trauma and recommended if the joint is unstable or the reduction 8. Spencer, Jnr, E. E., and Kuhn, J. E. Biomechanical analysis fails. Stability can be achieved by various methods of reconstructions for sternoclavicular joint instability. J. Figure 2 is often associated with contact sports such as rugby, martial arts and with motorcycle accidents. of fixation such as palmaris longus tendon as in this BoneJ. Bone Joint Joint Surg. Surg. Am AM.. 2004: 2004: 86 86: 98-105.: 98-105. CT scan of chest showing Sternoclavicular joint 9. Samba, G.H. and Sidoffi, E. Stenoclavicular dislocation All ligaments must be torn from the case, various suture types and if all else fails resection of the proximal clavicle (9). There may be a problem (letter). J. Cardiothoracic Surg. 1990; 99 (6:) 1114-11145.1114-1115. sternoclavicular joint for it to dislocate posteriorly 10. Bicos, J. and Nicholson, J. P. Treatment and results of (6). Pain over the sternoclavicular joint is an invariable with reduction of the dislocated joint in patients sternoclavicular joint injury. Clin. Sports Med. 2003;22: symptom. There may be bruising and deformity over seen 48 hours after injury (3, 10). Use of wire fixation 359-370. the region and variable loss of active movement of the is discouraged because of a potential for the wire to upper limb. Standard AP views of the chest are often difficult to interpret and may not show the dislocation. Other views such as Serendipity views (Rockwood), Hobb, Kattan and Heinig may help (5). One should have a high index of suspicion. CT scanning will often clinch the diagnosis and gives an indication of the severity as well as the involvement of the mediastinal structures. As major vessels of the thoracic cavity may be involved some authors recommend angiography both pre and post reduction. However this has to be balanced against the

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