1 Introduction
Because of the protection of strong ligaments, it often requires greater forces to cause sternoclavicular joint (SCJ) dislocation. Compared with all injuries of the shoulder girdle, SCJ dislocation is a rare injury and can be classified into 2 types namely posterior and anterior dislocation. Anterior SCJ dislocation accounts for about 3% of all injuries to the shoulder girdle[1–3] [2] [4–6] [7]
Because posterior SCJ dislocation is a very rare injury and there was no obvious findings on physical examination. Therefore, the orthopedist may not be aware of this injury promptly. Besides, there are some important thoracic structures behinding the SCJ, such as great vessels, nerves, esophagus, trachea. Therefore, if not been diagnosed timely and accurately, posterior SCJ dislocation can be life-threatening.
The diagnosis of SCJ dislocation relies on a careful physical examination and evaluation. In suspected SCJ dislocations, computed tomography (CT) scan with a three-dimensional reconstruction has become the imaging study of choice.[1,6,8,9]
We experienced a patient who has a potentially life-threatening posterior dislocation of right SCJ and anterior dislocation on the left SCJ combined with bilateral clavicular fracture and this case acquired a satisfactory result. After reviewing the literature, we found there were no similar cases reported in the world.
2 Case report
We acquired the informed written consent for publication of this case report and accompanying images from the patient. Because this is a case report, ethics committee approval was waived.
A 28-year-old woman was driving a motorcycle alongside the truck. The truck swerved to the right suddenly and ran over her. She lost consciousness when paramedics arrived on the scene and was rapidly sent to the emergency department. Multiple abrasions to the chest and abdomen were seen and there was no obvious deformity on both side of SCJ.
A full-body CT scan was done for further treatment after establishing respiratory and systemic circulation, which revealed comminuted fracture of pelvis, hemopneumothorax, multiple rib fractures, bilateral lung contusion. A CT scan with three-dimensional reconstructions of SCJ showed potentially life-threatening posterior dislocation of right SCJ and anterior dislocation on the left SCJ combined with bilateral clavicular fracture (Fig. 1 ). She was brought to the intensive care unit (ICU) and discharged in stable condition a few dates later.
Figure 1: A computed tomography (CT) scan with three-dimensional reconstructions of sternoclavicular joint (SCJ) showed potentially life-threatening posterior dislocation of right SCJ and anterior dislocation on the left SCJ combined with bilateral clavicular fracture. CT = computed tomography, SCJ = sternoclavicular joint .
Because of failed attempts at closed reduction, electively surgical intervention was made. We repaired the ruptured joint capsule and ligaments and fixed bilateral SCJ by Kirschner wire during the operation. Three-dimensional CT scans confirmed bilateral SCJ reduction and alignment after operation 1 week (Fig. 2 ) as well as at the 2-month follow-up.
Figure 2: Three-dimensional computed tomography (CT) scans confirmed bilateral sternoclavicular joint (SCJ) reduction and alignment after operation 1 week. CT = computed tomography, SCJ = sternoclavicular joint .
3 Discussion
There are many joints and bones surrounding shoulder girdle, which receive more energy from blunt trauma. Meantime the SCJ's stability derived from well reinforced ligamentous structures (costoclavicular ligament, interclavicular ligament, posterior and anterior sternoclavicular ligaments, capsular) surrounding the joint.[10] [11] [4–6] [7,9,12,13] [3,13]
There was often no obvious findings on physical examination for patients in a coma with posterior SCJ dislocation which is an extremely rare injury. The orthopedist may not be aware of this injury promptly. But here are some important thoracic structures behind the SCJ, such as great vessels, nerves, esophagus, trachea. If not been diagnosed timely and accurately, posterior SCJ dislocation can be life-threatening.
The diagnosis of SCJ dislocation relies on a careful physical examination and evaluation. In suspected SCJ dislocations, CT scan with a three-dimensional reconstruction has become the first choice of imaging examination.[1,6,8,9]
Closed reduction under general anesthetic or with sedation should be attempted in the operating room for patients with acute anterior and posterior SCJ dislocation (within 7–10 d). However, some life-threatening complications during the closed reduction of posterior SCJ dislocation have been reported in the literature,[4,14–16] [4,17,18]
If closed reduction is unsuccessful, recurrent dislocation or persistent symptomatic SCJ instability, open reduction should be adopted. To date there is no uniform operative procedure. The aim of the operation is to repair the ruptured joint capsule and its ligaments and to fix the dislocated joints using wire suture, internal fixation, allograft or autograft tendon, myotendonous transfer, fascia lata, and so on.[19–25] [26]
In our case report, we used Kirschner wires to fix bilateral SCJ dislocation and anatomical plates to fix bilateral fracture of clavicle. During the 2-month follow-up after the operation, the patient did not report discomfort symptoms and acquired good shoulder motion. To our knowledge, this is the first case of a potentially life-threatening posterior dislocation of right SCJ and anterior dislocation on the left SCJ combined with bilateral clavicular fracture.
Author contributions
Writing – original draft: Hai feng Wang, Jian wei Ruan.
Writing – review & editing: Wei qian Wu, Chong yang Wang.
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