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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 47-50

A rare case of anterior sternoclavicular joint dislocation with clavicle fracture with subclavian artery thrombosis


Department of Orthopaedics, JSS Hospital, Mysore, Karnataka, India

Date of Web Publication20-Mar-2019

Correspondence Address:
Dr. Supreeth Nekkanti
Department of Orthopaedics, JSS Hospital, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajt.ajt_3_18

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  Abstract 


Sternoclavicular (SC) joint injuries are rare. These usually follow violent injuries or high-velocity trauma events. These injuries can be either anterior or posterior dislocations. Anterior dislocations may be left alone, but posterior dislocations could cause complication by compressing the posterior structures including major vessels, airway esophagus, and larynx. We report a 17-year-old boy who fell from his two-wheeler sideways and injured his left shoulder. He presented to the emergency department with an open fracture of the clavicle. A detailed evaluation revealed an associated anterior SC joint dislocation, and there was an injury to the subclavian artery. The patient was planned for an emergency surgery, and the clavicle fracture was fixed following thrombectomy of the subclavian artery. The patient was successfully treated and had a good functional range of movement of his shoulder at 1 year follow-up. Anterior SC joint dislocations with concomitant open clavicle fracture are an unusual injury pattern. We report a complex injury pattern of the clavicle associated with traumatic vascular injury. We report this case for its complexity and the technical challenge it poses to the treating surgeons.

Keywords: Clavicle fracture, complex injury, sternoclavicular joint dislocation, subclavian vessel injury, vascular injury


How to cite this article:
Chandru V, Nekkanti S, Abhilash B, Ravishankar R, Kuniyil S. A rare case of anterior sternoclavicular joint dislocation with clavicle fracture with subclavian artery thrombosis. Afr J Trauma 2017;6:47-50

How to cite this URL:
Chandru V, Nekkanti S, Abhilash B, Ravishankar R, Kuniyil S. A rare case of anterior sternoclavicular joint dislocation with clavicle fracture with subclavian artery thrombosis. Afr J Trauma [serial online] 2017 [cited 2019 Nov 19];6:47-50. Available from: http://www.afrjtrauma.com/text.asp?2017/6/2/47/254633




  Introduction Top


Dislocations of the sternoclavicular (SC) joint may occur following a fall on the outstretched hand or a direct blow to the shoulder.[1] Sporting injuries and motor vehicle accidents account for most causes of SC joint dysfunction.[1],[2] The direction in which the shoulder is driven determines the type of dislocation.[1],[2] When overwhelming compression propels the shoulder forward, the force directed toward the clavicle produces a posterior dislocation of the SC joint. If the shoulder is pressed and rotated backward, the force directed down the clavicle produces an anteroinferior dislocation of the SC joint.[2],[3],[4]


  Case Report Top


We report a rare case of an open fracture of clavicle with anteroinferior dislocation of the left SC joint. A 17-year-old boy presented to the emergency department with an open fracture of his left clavicle 2 h after injury. He claimed to have fallen from a bike with his entire body weight falling on his left shoulder. On clinical examination, the patient was conscious and well oriented. We observed a laceration of approximately 6 cm × 5 cm extending from his neck to the left shoulder. The distal brachial, radial, and ulnar pulsations were feebly felt. Strong pulsations were palpable in the corresponding vessels of the contralateral upper limb. The patient's airway was patent. He was able to breathe spontaneously, and his vitals were stable.

Sensing a vascular injury, we rushed the patient for radiographic investigations. X-ray and computerized tomography scans [Figure 1] demonstrated an anteroinferior dislocation of the left SC joint with an oblique minimally displaced mid third clavicle fracture. Arterial Doppler suggested an injury to the subclavian artery. Arterial Doppler of the contralateral subclavian artery showed good flow and velocity with no evidence of injury or thrombosis. The patient was immediately planned for surgery.
Figure 1: Preoperative radiograph

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Under general anesthesia, the clavicle was directly approached with a horizontal incision over the clavicle which was palpable subcutaneously. The fracture site was exposed, and the bone fragments were separated to gain entry to the subclavian artery. The vascular surgeon identified the subclavian vessel to be thrombosed. A second incision was made in the axilla to approach the axillary artery, and small nick was made, and Fogarty catheter was passed through it to the subclavian artery [Figure 2]. A thrombectomy was attempted, but the distal pulse was still feebly palpable. A third incision was made in the cubital region to gain access to the cubital artery. A second attempt of thrombectomy was made using the Fogarty catheter. As the catheter passed to the subclavian artery, a successful thrombectomy procedure was completed. The distal pulse was clinically felt over the radial artery. Following the vascular repair, the clavicle was reduced and fixed with a precontoured locking plate and six screws. The SC dislocation automatically relocated into position once the fracture was reduced. The wound was then closed in two layers. Postoperatively, antibiotics were administered for 10 days till suture removal. The postoperative period was uneventful. Postoperative radiographs showed a good reduction of the clavicle fracture with locking plate in situ [Figure 3]. Postoperative Doppler studies on the 7th day and after 3 weeks showed improved flow volume and velocity.
Figure 2: Intraoperative photographs

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Figure 3: Postoperative radiograph

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Pendulum exercises were started from the 6th postoperative week. Functional range-of-movements were achieved by 8 weeks. He had resumed his regular daily activities and employment by 3 months' postoperatively [Figure 4]. The patient was successfully followed up for 1 year with no complaints of instability of the acromioclavicular joint.
Figure 4: Range of movements at 6 months

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  Discussion Top


Traumatic SC dislocations are extremely rare injuries. They constitute <3% of all traumatic joint injuries.[1],[2] Patients commonly present with pain and swelling in the proximal sternum and SC region. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing, or coughing. In our patient, the injury was an open injury with a concomitant clavicle fracture, and hence, our patient had an extremely painful deformed left shoulder.[1] Patients often laterally flex their neck towards the affected side to relieving pressure on the SC joint which was the case with our patient too.[1]

Anterior dislocation of the SC joint is more common.[1],[2] Patients are usually asymptomatic. However, some patients may develop chronic anterior instability and may continue to have symptoms. In these cases, surgical treatment is indicated.[2],[3],[4]

Many techniques for reconstructing the SC joint have been described, such as intramedullary suturing, medial resection of the clavicle, fixation using a plate, reinforcement using the subclavian tendon, and reinforcement using the semitendinosus tendon.[5],[6],[7]

Closed reduction of an anterior SC joint dislocation is usually easy to achieve. The patient is placed supine on the table, with a small sandbag between the shoulders. In this position, the joint may reduce with direct gentle pressure over the anteriorly displaced clavicle. In our patient, since there was an open clavicle fracture along with the vascular injury, the vascular repair was addressed initially, and then the clavicle was reduced and plated. When the clavicle was reduced anatomically, the SC joint automatically relocated back to its position. The mechanism of injury in our patient could be explained by a posteriorly directed force on the clavicle rendering it fractured. The posteriorly directed fractured ends of the clavicle possibly injured the subclavian artery due to the force of the impact. Consequent to the posterior angulation of the fracture fragments due to the trauma, the medial end of the clavicle was probably was levered out anteriorly, leading to an anterior dislocation of the SC joint which was relocated once the clavicle was anatomically reduced.

Following trauma, the first two-thirds of the subclavian artery is most commonly injured. Around 1% of subclavian artery thrombosis following trauma present with symptoms such as claudication, cold extremities, and lack of palpable upper limb pulse.[8] Our patient did not have any symptoms except for a feeble brachial radial and ulnar artery pulse. Subclavian steal syndrome could present with visual disturbances, vertigo and hemisensory dysfunction, none of which were present in our patient.[9]

Thrombosis of the subclavian artery if left untreated could lead to stroke and embolism and eventual death.[9] There is also the potential complication of irreversible ischemic damage to the upper limb. Hence, the timing and priority of vascular repair take utmost importance. The treatment of subclavian artery thrombosis includes both medical and surgical approaches. Medical treatment includes anticoagulation therapy and surgical intervention includes bypass of obstructed artery, thrombectomy, venous grafting, angioplasty depending on the degree of vascular damage.[8] In our patient, thrombectomy was performed along with anticoagulation therapy.

A definite controversy exists regarding the timing of vascular surgery versus orthopedic surgery. When there is a concomitant fracture, Cakir et al. suggested vascular repair takes precedence over orthopedic reconstruction as it would decrease the duration and degree of ischemia to the upper limb.[10] On the other hand, Boulis and Samad recommended orthopedic repair first as it would stabilize the limb first.[11] Further manipulation of the limb while fixing the fracture would lead to a compromise of the vascular repair if done first.[11] In our patient, we proceeded to perform vascular repair initially as clavicle fracture was a two-part fracture which would not require much manipulation of the upper limb during fixation. Furthermore, the complications of ischemia and embolism were life-threatening.

According to Savastano and Stutz,[12] closed reduction of the SC joint should not be performed in an acute setting because the stability of the SC joint is not necessary to ensure normal function of the involved limb. De Jong and Sukul[13] reported on ten patients with acute SC dislocations who were treated conservatively without closed reduction. The results of treatment were good in seven patients, fair in two patients, and poor in one patient. Others attempted closed reduction with varying success. They had recurrence rates between 21% and 100%.[14],[15],[16] Eskola described the results achieved in eight patients treated with closed reduction.[10] Redislocation occurred in five of them and was painful in three patients, two of whom were operated on. Nettles and Linscheid[16] obtained better results: of sixteen patients treated with closed reduction, eleven had no recurrence and no pain. Three had a redislocation, and two were lost to follow-up. If closed reduction is successful, cosmesis is improved.[1]

If closed reduction fails, some authors propose surgical treatment.[17],[18],[19] It consists of open anatomical reduction and internal fixation either by nonabsorbable suture material, as proposed by Simurda[18] or by a Vicryl sling placed around the first rib.[17] The functional results are excellent, with a full range of motion, unrestricted sports activity, and no pain. Alternatively, transarticular K-wire fixation to fortify the periosteal suture has been proposed[19] but is no longer recommended. The only significant disadvantage of operative treatment is a potentially disfiguring hypertrophic scar. After treatment, a figure-of-eight sling is recommended for 3–4 weeks in closed[13] and open reduction.[1]


  Conclusion Top


Anterior SC joint dislocations in combination with clavicle fractures are rare injuries. This report portrays a complex injury involving the anterior dislocation of the SC joint associated with clavicle fracture and injury to the subclavian vessels. A successful vascular repair was also made during surgery. The timing of vascular surgery versus orthopedic reconstruction is a surgical controversy. This complex injury pattern of the shoulder joint poses an academic and technical challenge to the treating surgeon.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg 2011;19:1-7.  Back to cited text no. 1
    
2.
Bae DS, Kocher MS, Waters PM, Micheli LM, Griffey M, Dichtel L, et al. Chronic recurrent anterior sternoclavicular joint instability: Results of surgical management. J Pediatr Orthop 2006;26:71-4.  Back to cited text no. 2
    
3.
Rockwood CA Jr., Groh GI, Wirth MA, Grassi FA. Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg Am 1997;79:387-93.  Back to cited text no. 3
    
4.
Groh GI, Wirth MA, Rockwood CA Jr. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg 2011;20:107-13.  Back to cited text no. 4
    
5.
Abiddin Z, Sinopidis C, Grocock CJ, Yin Q, Frostick SP. Suture anchors for treatment of sternoclavicular joint instability. J Shoulder Elbow Surg 2006;15:315-8.  Back to cited text no. 5
    
6.
Armstrong AL, Dias JJ. Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle. J Bone Joint Surg Br 2008;90:610-3.  Back to cited text no. 6
    
7.
Singer G, Ferlic P, Kraus T, Eberl R. Reconstruction of the sternoclavicular joint in active patients with the figure-of-eight technique using hamstrings. J Shoulder Elbow Surg 2013;22:64-9.  Back to cited text no. 7
    
8.
Fatimi SH, Anees A, Muzaffar M, Hanif HM. Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis. Chin J Traumatol 2010;13:255-6.  Back to cited text no. 8
    
9.
Wang KQ, Wang ZG, Yang BZ, Yuan C, Zhang WD, Yuan B, et al. Long-term results of endovascular therapy for proximal subclavian arterial obstructive lesions. Chin Med J (Engl) 2010;123:45-50.  Back to cited text no. 9
    
10.
Boulis S, Samad S. Subclavian artery injury following isolated clavicle fracture, which to repair first? Internet J Orthop Surg 2006;3:2.  Back to cited text no. 10
    
11.
Cakir O, Subasi M, Erdem K, Eren N. Treatment of vascular injuries associated with limb fractures. Ann R Coll Surg Engl 2005;87:348-52.  Back to cited text no. 11
    
12.
Savastano AA, Stutz SJ. Traumatic sternoclavicular dislocation. Int Surg 1978;63:10-3.  Back to cited text no. 12
    
13.
de Jong KP, Sukul DM. Anterior sternoclavicular dislocation: A long-term follow-up study. J Orthop Trauma 1990;4:420-3.  Back to cited text no. 13
    
14.
Eskola A. Sternoclavicular dislocation. A plea for open treatment. Acta Orthop Scand 1986;57:227-8.  Back to cited text no. 14
    
15.
Salvatore JE. Sternoclavicular joint dislocation. Clin Orthop Relat Res 1968;58:51-5.  Back to cited text no. 15
    
16.
Nettles JL, Linscheid RL. Sternoclavicular dislocations. J Trauma 1968;8:158-64.  Back to cited text no. 16
    
17.
Gobet R, Meuli M, Altermatt S, Jenni V, Willi UV. Medial clavicular epiphysiolysis in children: The so-called sterno-clavicular dislocation. Emerg Radiol 2004;10:252-5.  Back to cited text no. 17
    
18.
Simurda MA. Retrosternal dislocation of the clavicle: A report of four cases and a method of repair. Can J Surg 1968;11:487-90.  Back to cited text no. 18
    
19.
Rang M. Children's Fractures. Philadelphia: J.B. Lippincott Company; 1974.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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