The Posterior Sternoclavicular Dislocation

Orthopaedics & Traumatology: Surgery & Research (2010) 96, 816—820

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CLINICAL REPORT Variants of the shoulder side impact syndrome: The posterior sternoclavicular dislocation

J.-M. Laffosse a,∗, N. Reina a,b, J.-L. Tricoire a,b, P. Chiron a, J. Puget a

a Musculoskeletal Institute, Orthopaedic Surgery Department, Toulouse-Rangueil Teaching Hospital Center, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France b Anatomy Research Laboratory, Toulouse-Rangueil Teaching Hospital Center, 31059 Toulouse cedex 9, France

Accepted: 14 June 2010

KEYWORDS Summary Side impact syndrome of the shoulder is rare and usually associated with conco- Shoulder; mitant mid-shaft clavicle, rib and scapular fractures. Visceral complications involve pleural Side-impact shoulder cavity and/or lung injuries. The authors report two rare instances of posterior sternoclavicular injury; dislocations with this entity. This association is rare and diagnosis can be overlooked in multi- Sternoclavicular trauma patients especially when blunt thoracic lesions can be life threatening. The absence of dislocation; a fracture of the clavicle after a high-energy side impact to the shoulder should suggest this Mediastinal diagnosis, which can be facilitated by systematic total body CT scan with 3D reconstruction. structures injuries; Management is surgical. Multiple injuries; © 2010 Elsevier Masson SAS. All rights reserved. Polytrauma

Introduction the sternoclavicular joint [2]. In the large majority of cases, a fracture of the medial clavicle is found, and any associ- Lateral impaction syndrome of the shoulder or scapular- ated visceral injuries are pleuropulmonary (pneumothorax, clavicular-thoracic syndrome associates fractures of the hemothorax, pulmonary contusion). Mediastinal injuries are scapula, the clavicle and several ribs [1]. It occurs after a extremely rare in this situation [1,2]. high impact trauma with direct impact delivered to the lat- We show that in very rare cases the fracture of the clavi- eral shoulder [1,2]. It is frequently associated with thoracic cle during a lateral impaction syndrome of the shoulder can injuries and other neurovascular damage, in particular to be replaced by a posterior sternoclavicular dislocation which the brachial plexus [2]. During the trauma, the impaction can be life threatening to the patient. The diagnosis is some- force can be broken down into a posterior-inferior compo- times difﬁcult and delayed. Two cases are reported here. nent causing the scapular fracture and an anterior-superior component which cases the fracture to the anterior shoulder arch which can extend from the acromioclavicular joint to Clinical case no. 1

Mr D, a 35-year-old right-handed man presented after a car ∗ Corresponding author. accident where he ran into a tree on the left side of the E-mail address: [email protected] (J.-M. Laffosse). road. He was not wearing a seat belt and had a concussion,

Figure 3 Patient 1. CT Scan centered on the sternoclavicular region shows posterior dislocation of the left clavicle.

dyspnea, no dysphagia or signs of vascular compression, and Figure 1 Patient 1. Standard AP view X-ray of the left shoul- Mr D underwent surgery 4 days later. Because of the delay der showing a slightly displaced fracture of the neck of the (over 48 hours) and associated homolateral bone injuries (rib scapula. The sternoclavicular joint cannot be seen in this view. and scapular fractures), no closed reduction was attempted. The dislocation was surgically reduced then stabilized with a costoclavicular cerclage or tenodesis with a PDSTM suture had lost consciousness, an open fracture of the left tibia, associated with a costoclavicular ligament suture and on the injury to the left shoulder and fracture of the scapular neck anterior capsular plane. Stability seemed satisfactory during (Figs. 1 and 2) as well as fractures of the third to sixth ribs. surgery, and no other procedures seemed to be necessary. Initial CT Scan of the chest did not show any injuries to Conservative treatment of the scapular fracture was con- the abdomen or thorax. Mr. D therefore underwent emer- tinued. Mr D was immobilized for 6 weeks with the elbow gency surgery for the open tibial fracture, and conservative splinted to the body, rehabilitation was begun at the end treatment was decided for the scapular fracture. Five days of the third week. At 15 months of follow-up, recovery was after admission, due to pain and discomfort in the left ster- excellent with a Constant score of 97/100 without pain or noclavicular region, CT Scan of this region showed posterior reduction in range of motion [3]. The patient was able to sternoclavicular dislocation (Fig. 3). There was no marked begin his previous activities at the same level as before. The Single Assessment Numeric Evaluation (SANE) [4] was 95/100.

Clinical case no. 2

Mr C, a 49-year-old right-handed man was a passenger in a helicopter accident. He presented with multiple injuries associating a severe craniofacial injury with unconscious- ness, crushing of the right glenoid fossa, injury to the cervical spine without bone lesions and injury to the right shoulder and right thorax. Standard X-ray and emergency CT Scan showed a fracture of the diaphyseal neck of the scapula, multiple rib fractures, posterior and superior sternoclavicular dislocation associated with a posterior chondrosternal dislocation of the first rib (Fig.4et5). Hemopneumothroax with only a slight fluid accumulation and which was well tolerated clinically was also identified and Mr C underwent surgery the day after admission. No closed reduction was attempted. The sternoclavicular and chondrosternal dislocations were treated by open reduction and because of persistent instability, stabilization was obtained with sternoclavicular and chondrosternal wire Figure 2 Patient 1. Emergency CT Scan centered on the cerclage (Fig. 6). Tenodesis was performed on the subclav- scapula. It confirms the fractures, but no diagnosis of stern- ius ligament due to severe injuries to the costoclavicular oclavicular dislocation can be made. ligament by the Burrows technique [5] as well as a capsular 818 J.-M. Laffosse et al.

Figure 4 Patient 2. Standard AP chest X-ray with the patient lying in the emergency room. A fracture of the scapula is visible Figure 6 Patient 2. Standard AP chest X-ray showing sta- (arrow) but not the pneumothorax with minimal ﬂuid collection bilization by sternocostal and costoclavicular cerclage during or the sternoclavicular and chondrosternal dislocation. postoperative follow-up.

fore it is extremely rare for them to occur together. Zucman et al. [7] reported the case of a 30 old stonemason who presented after falling from a high place, with a scapular body fracture and a sternoclavicular dislocation without mention- ing the direction. The patient did not undergo surgery and was lost to follow-up. Féry et Sommelet [8] reported a series of 49 sternoclavicular dislocations (40 were anterior, nine posterior, and one with multidirectional instability). Stern- oclavicular dislocations were found to be associated with rib and scapular fractures in nine patients, but the direction of the dislocation was not mentioned. Our team has already reported two separate series of posterior sternoclavicular

Figure 5 Patient 2. 3D CT Scan reconstruction showing posterior sternoclavicular and sternochondral dislocations (white arrow) compared to the contralateral joints. suture. Mr C was immobilized for 6 weeks postoperatively in a splint, rehabilitation with pendular exercises was begun on the fourth week, and the patient gradually began his regular activities four months after surgery. Eight years after the accident, the clinical results are excellent. Range of motion of the shoulder is normal and there is no pain. The Constant score was 95/100 and the SANE 90/100. The sternoclavicular joint appears stable. X-ray at the ﬁnal follow-up (Fig. 7) shows that the wire has broken but has not broken skin.

Discussion Figure 7 Patient 2. Standard AP chest X-ray at 8 years of follow-up showing union of the scapular fracture without sec- Lateral impaction syndrome of the shoulder, like posterior ondary displacement as well as a break but no migration of the sternoclavicular dislocations are very rare. [1,2,6], there- cerclage wire. Side impact syndrome of the shoulder with posterior sterno-clavicular dislocation 819 dislocations: one series of 30 cases which occurred during of the medial clavicle behind the sternum. In the presence sports accidents [9] and another six cases from various trau- of anterior sternoclavicular dislocation, surgical treatment mas (three rugby accidents and three road accidents) [10]. can be considered because of the disruption of the supe- We have never encountered this association of injuries in our rior shoulder suspensory complex, especially if the fracture experience, and we did not find any other cases reported in of the scapula is to be treated conservatively. If the latter the literature. is treated by open reduction and stabilization, simultane- Because anterior sternoclavicular dislocations are much ous reduction of the anterior sternoclavicular dislocation is more frequent [6], their association with scapular and rib indicated, once internal fixation of the scapula has been fractures should also be more frequent, even if dislocations performed, although the surgical risks inherent in the close occur during lower impact traumas. Thus, to our knowledge, anatomical relationship to the trachea, the esophagus and the cases reported here are the first reports in the literature the neurovascular elements behind the sternum should be of this very rare association of injuries. carefully evaluated [6,19]. This is a severe injury, for the mechanism of lateral impaction syndrome of the shoulder is the result of a violent impact and the presence of posterior sternoclavicular dislo- Conflict of interest statement cation is always associated with a high impact posterolateral trauma. The sternoclavicular joint is one of the most stable The authors have no conflict of interest. and resistant joints of the locomotor system [6,11].Itcan therefore cause severe displacement of the medial clavicle, which can result in severe mediastinal injuries, in particular References vascular injuries [12], which may be life threatening to the patient [12—15]. However, when there are signs of mediasti- [1] Sommelet J, Fery A, Sommelet JF. 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