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Ingoe HMA, Mohammed K, Malone AA, Beadle G, Sharpe T, Cockfield A, Lloyd R, Singh H, Colgan F. Traumatic posterior sternoclavicular joint dislocation - Current aspects of management. Injury 2023; 54:110983. [PMID: 37634999 DOI: 10.1016/j.injury.2023.110983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/19/2023] [Accepted: 08/05/2023] [Indexed: 08/29/2023]
Abstract
The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.
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Affiliation(s)
- Helen M A Ingoe
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand.
| | - Khalid Mohammed
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Alex A Malone
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Gordon Beadle
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Thomas Sharpe
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Allen Cockfield
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Richard Lloyd
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345, Christchurch, 8140, New Zealand; Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Harsh Singh
- Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand; Dept of Cardiothoracic Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Frances Colgan
- Christchurch Hospital, Riccarton Avenue, Christchurch, 8140, New Zealand; Department of Interventional Radiology, Christchurch Hospital, Christchurch, 8011 New Zealand
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Wahal N, Kendirci AS, Abondano C, Tauber M, Martetschläger F. Acromioclavicular Joint Lesions in Adolescents-A Systematic Review and Treatment Guidelines. J Clin Med 2023; 12:5650. [PMID: 37685716 PMCID: PMC10488848 DOI: 10.3390/jcm12175650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
True acromioclavicular joint (ACJ) injuries are rare in children and adolescents due to the strength of ligaments in this age group. However, a standardized management guideline for these injuries is currently lacking in the literature. This systematic review aims to provide an organized overview of associated injuries and propose a management algorithm for pediatric ACJ injuries. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted. Two independent observers searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases for ACJ injuries in children and adolescents. The extracted data were analyzed (due to the limited number of publications and inhomogeneity of data, no formal statistical analysis was conducted), and cases were categorized based on injury frequency and pattern, leading to the formulation of a treatment algorithm. The risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 77 articles were identified, and 16 articles (4 case series and 12 case reports) met the inclusion criteria. This study included 37 cases in 36 patients (32 males, 4 females) with a mean age of 13 years (9-17 years). Six injury categories were described. Surgical management was performed in 27 ACJ injuries (25 open, 2 arthroscopic). Various surgical implants were used including K wires, polydioxanone sutures (PDS), screws, hook plates, suture anchors, and suture button devices. Most cases achieved good to excellent outcomes, except for one case of voluntary atraumatic dislocation of the ACJ. This systematic review provides the first comprehensive analysis of ACJ injury management in adolescents with open physis. It categorizes injury patterns and presents a treatment algorithm to enhance the understanding of these injuries. The review's findings contribute valuable insights for clinicians dealing with pediatric ACJ injuries.
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Affiliation(s)
- Naman Wahal
- Deutsches Schulterzentrum, ATOS Klinik, 81925 Munich, Germany
| | - Alper Sukru Kendirci
- Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, 34093 Istanbul, Turkey;
| | - Carlos Abondano
- Deutsches Schulterzentrum, ATOS Klinik, 81925 Munich, Germany
| | - Mark Tauber
- Deutsches Schulterzentrum, ATOS Klinik, 81925 Munich, Germany
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Kraal T, Struijs PAA, Langenberg LC, van Bergen CJA. Fractures around the shoulder in the skeletally immature: A scoping review. World J Orthop 2023; 14:604-611. [PMID: 37662664 PMCID: PMC10473910 DOI: 10.5312/wjo.v14.i8.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.
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Affiliation(s)
- Tim Kraal
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Peter AA Struijs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Lisette C Langenberg
- Department of Orthopedic Surgery, NoordWest Ziekenhuisgroep, Alkmaar 1815 JD, Netherlands
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
| | - Christiaan JA van Bergen
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
- Department of Orthopedic Surgery, Amphia, Breda 4818 CK, Netherlands
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Yoshida Y, Matsumura N, Yamada Y, Yamada M, Yokoyama Y, Miyamoto A, Oki S, Nakamura M, Nagura T, Jinzaki M. Dynamic evaluation of the sternoclavicular and acromioclavicular joints using an upright four-dimensional computed tomography. J Biomech 2023; 157:111697. [PMID: 37406603 DOI: 10.1016/j.jbiomech.2023.111697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/27/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
In the analysis of the shoulder complex, the sequential changes occurring in the sternoclavicular and acromioclavicular joints during active shoulder motion are challenging to track. This study aimed to investigate the in vivo sternoclavicular and acromioclavicular joint motions during active elevation, including the sequential changes in these joint spaces using upright four-dimensional computed tomography (4DCT). Bilateral shoulders of 12 healthy volunteers upright 4DCT were obtained during active elevation similar to a "hands up" motion. The sternoclavicular and acromioclavicular rotation angles, joint distances, and closest points on the clavicle relative to the thorax and scapula were evaluated during 10°-140° of humerothoracic elevation. During humerothoracic elevation, the clavicle elevated, retracted, and rotated posteriorly relative to the thorax, whereas the scapula rotated upwardly, internally, and posteriorly relative to the clavicle. All the sternoclavicular and acromioclavicular joint rotation angles were significantly different at ≥ 30°-50° of humerothoracic elevation compared with 10° of humerothoracic elevation. The mean sternoclavicular and acromioclavicular joint distances were 2.2 ± 1.1 mm and 1.6 ± 0.9 mm, respectively. The closest points were located on the anteroinferior part of the medial and lateral clavicle in the sternoclavicular and acromioclavicular joints, respectively. Significant differences were observed in the acromioclavicular joint distance and anterior/posterior movements of the closest points in the sternoclavicular and acromioclavicular joints compared with 10° of humerothoracic elevation. Our sternoclavicular and acromioclavicular closest point results indicate that the impingement tends to occur at the anteroinferior part of the medial and lateral aspects of the clavicle and may be related to osteoarthritis.
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Affiliation(s)
- Yuki Yoshida
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Yoshitake Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Yokoyama
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Azusa Miyamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Oki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takeo Nagura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
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Sandler AB, Baird MD, Scanaliato JP, Harris ALW, Raiciulescu S, Green CK, Dunn JC, Parnes N. Incidence of sports-related sternoclavicular joint dislocations in the United States over the last two decades. World J Orthop 2023; 14:427-435. [PMID: 37377996 PMCID: PMC10292055 DOI: 10.5312/wjo.v14.i6.427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/01/2023] [Accepted: 05/08/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Epidemiological understanding of acute sternoclavicular (SC) dislocations secondary to sports across the United States is poorly defined.
AIM To identify and assess epidemiological trends of SC dislocations occurring secondary to sports-related mechanisms across United States over the past two decades.
METHODS This cross-sectional, descriptive epidemiological study evaluates epidemiological trends of SC dislocations from sports that present to emergency departments (EDs) across the United States. Data were obtained from the National Electronic Injury Surveillance System database spanning two decades. Data on incidence, patient demographics, mechanisms of injury, dislocation types, incident locales, and patient dispositions were collected.
RESULTS 1622 SC dislocations occurred nationwide from 2001 to 2020 [incidence = 0.262/1000000 people, confidence interval (CI) = 0.250-0.275], comprising 0.1% of shoulder/upper trunk dislocations. Most patients were male (91%, n = 1480) and aged 5-17 (61%, n = 982). Football, wrestling, and biking were the most frequently implicated sports, with contact sports responsible for 59% of athletic injuries (n = 961). Recreational vehicle-related sports injuries, such as all-terrain vehicles, dirt bikes, and mopeds accounted for 7.8% of all injuries (n = 126), with dirt bikes specifically comprising 3.7% (n = 61). Ultimately, 82% were discharged from the ED (n = 1337), 12% were admitted (n = 194), and 6% were transferred (n = 90). All recorded posterior dislocations were admitted or transferred from the ED. Patients sustaining SC dislocations from contact sports had a significantly increased risk of hospital admission or transfer rather than discharge from the ED as compared to patients whose injuries were from non-contact sports (incidence rate ratio = 1.46, CI: = 1.32-1.61, P < 0.001).
CONCLUSION SC dislocations from sports continue to be rare with a stably low incidence over the past two decades, likely comprising a smaller proportion of shoulder dislocations than previously thought. Contact sports are a frequent source of injury, especially among school-aged and teenage males. Most patients are discharged directly from the ED; however, a substantial number are hospitalized, many of which had documented posterior dislocations. Ultimately, understanding the epidemiology and mechanism-related trends of acute SC dislocations is important given the potential severity of these injuries, concentration in a specific population, and uncertainty linked to rare presentation.
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Affiliation(s)
- Alexis B Sandler
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, United States
| | - Michael D Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20307, United States
| | - John P Scanaliato
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, United States
| | - Ayden LW Harris
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20307, United States
| | - Sorana Raiciulescu
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20307, United States
| | - Clare K Green
- School of Medicine and Health Sciences, The George Washington University, Washington, DC 20001, United States
| | - John C Dunn
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, United States
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, NY 13619, United States
- Department of Orthopaedic Surgery, Claxton-Hepburn Medical Center, Ogdensburg, NY 13669, United States
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Kelley N, Tuttle M, Sylvia SM, Dragoo JL, Khodaee M. Acromioclavicular Joint Injuries in Sport. Curr Sports Med Rep 2023; 22:91-99. [PMID: 36866952 DOI: 10.1249/jsr.0000000000001046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
ABSTRACT Sport-related shoulder injuries, including disruptions to the acromioclavicular joint (ACJ), are common. An ACJ injury is classified by the degree and direction of the clavicle displacement. Although the diagnosis can be made clinically, standard radiographic views are important to determine the severity of the ACJ disruption and assess for concurrent injuries. The majority of ACJ injuries can be managed nonoperatively; however, surgical treatment is indicated in some cases. Long-term outcomes are generally favorable for most ACJ injuries, and athletes generally return to sport without functional limitations. This article provides an in-depth discussion regarding all aspects of ACJ injuries, including clinically relevant anatomy, biomechanics, evaluation, treatment, and complications.
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Affiliation(s)
- Naomi Kelley
- University of Colorado School of Medicine, Aurora, CO
| | - Matthew Tuttle
- Head of Soccer Medicine and Performance, New York Red Bulls, Harrison, NJ
| | - Stephen M Sylvia
- University of Colorado School of Medicine, Department of Orthopedics, Division of Sports Medicine, Englewood, CO
| | - Jason L Dragoo
- University of Colorado School of Medicine, Department of Orthopedics, Division of Sports Medicine, Englewood, CO
| | - Morteza Khodaee
- University of Colorado School of Medicine, Department of Family Medicine and Orthopedics, Division of Sports Medicine, Denver, CO
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Carius BM, Long B, Gottlieb M. Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department. J Emerg Med 2021; 61:499-506. [PMID: 34511297 DOI: 10.1016/j.jemermed.2021.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries. OBJECTIVE This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician. DISCUSSION SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification. CONCLUSIONS SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.
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Affiliation(s)
| | - Brit Long
- Brooke Army Medical Center, Joint Base San Antonia, Fort Sam Houston, Texas, and.
| | - Michael Gottlieb
- Department of Emergent Medicine, Rush University Medical Center, Chicago, Illinois
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