ipsilateral sternoclavicular joint dislocation and fracture of the medial end of the clavicle

CASE REPORT

Ipsilateral sternoclavicular joint dislocation andfracture of the medial end of the clavicle

James Beastall a,*, Alan Johnstone b

Injury Extra (2006) 37, 476—478

www.elsevier.com/locate/inext

a Positional MRI Centre, Woodend Hospital, Eday Road, Aberdeen AB15 6XS, United KingdombDepartment of Orthopaedic Surgery, Woodend Hospital, Eday Road, Aberdeen AB15 6XS,United Kingdom

Accepted 21 June 2006

Introduction

Medial clavicular fractures account for approxi-mately 5% of all clavicular fractures and are usuallytreated conservatively when occurring in isolation.3

Sternoclavicular joint (SCJ) injuries comprise 3% ofall injuries around the shoulder girdle and likewiseconservative measures are most frequentlyemployed in the acute phase.2,8 Surgical optionsare more commonly reserved for chronically painfulSCJ dislocations.8

Case report

A 30-year-old male on holiday abroad, fell from hismountain bike whilst travelling at speed, injuring hisright shoulder. Admission radiographs confirmed thepresence of a medial clavicular fracture and he wastreated conservatively using a broad arm sling(Fig. 1).

Three weeks later, on his return from holiday,further radiographs were taken due to ongoing painand swelling. In addition to the fracture, a disloca-

* Corresponding author. Tel.: +44 1224 556705;fax: +44 1224 556098.

E-mail address: james.beastall@nhs.net (J. Beastall).

1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.06.111

tion of the sternoclavicular joint was identified. Acomputed tomography (CT) scan of the SCJs demon-strated lateral displacement of the right clavicleand associated fractures of the transverse process ofthe first thoracic vertebra and the first rib (Fig. 2).The senior author elected to stabilise the clavicularfracture and the SCJ surgically.

Due to the small size of the medial fracturefragment and the need to reconstruct the SCJ,the clavicular fracture was fixed using a six-holesmall fragment reconstruction plate. This gave suf-ficient space for the SCJ to be stabilised using a freepalmaris longus graft harvested from the patient’sipsilateral arm. The graft was taken through a seriesof small stab incisions, and fed through holes madein the medial end of the clavicle and the anteriortable of the manubrium. The graft was secured in afigure of eight configuration using absorbablesutures, in effect reconstructing the anterior jointcapsule (Fig. 3).

The patient was discharged from hospital thefollowing day and his shoulder was immobilised ina broad arm sling for 6 weeks. Thereafter he wasencouraged to gently mobilise his shoulder and by 3months following the procedure he had regained asymptom free full range of movement. At this stagehe was permitted to carry loads in his right handwithout restriction (Fig. 4).

rved.

Ipsilateral sternoclavicular joint dislocation and fracture of the medial end of the clavicle 477

Figure 1 Plain radiograph showing medial clavicularfracture and abnormality at SCJ.

Figure 3 Graphic representation of the technique usedto stabilise the SCJ with a free palmaris longus graft.

During the following months however, he devel-oped increasing pain and anterior bowing over themedial end of the clavicle. Radiographs taken 6months following his initial surgery confirmed thatthe plate had bent and that there was looseningaround the two most medial screws, consistent withnon-union of the fracture (Fig. 5).

The senior author elected to revise the clavicularfixation using a six-hole dynamic compression plateand to bone graft the non-union using morselisedauto graft. At operation the SCJ was stable. Threemonths following revision, including a further 6-week period of immobilisation, he once againregained a full pain free range of shoulder move-ments. By 4 months following the revision platingprocedure, radiographs confirmed that the claviclehad united (Fig. 6).

Discussion

The combination of a clavicular fracture withan ipsilateral SCJ injury is very uncommon and

Figure 2 CT scan showing lateral displacemen

only five similar adult cases have been documen-ted.1,4—7 Of these cases, the clavicular fracturewas situated in the distal third in two cases6,7 andthe middle third in one case.5 Information regard-ing the exact location of the clavicular fracturecould not be found in the remaining two casesalthough in one instance, the SCJ injury was aposterior dislocation.4

The decision to use a small fragment recon-struction plate in the first operation was dictatedby the size of the medial fracture fragment. Thesmall medial fragment was just large enough toenable the senior author to gain a reasonable holdusing two screws without compromising the spacerequired for insertion of the free tendon graft,although in hindsight it might have been better tohave lagged the small posteroinferior butterflyfragment onto the medial fragment to give addi-tional fracture stability. However, due to both thedelay in surgery and associated soft tissue scarringas well as the potential disruption to cortical bloodsupply through dissection, this was not done. As aresult, the fixation failed before the fracture could

t of right SCJ and fracture of right clavicle.

478 J. Beastall, A. Johnstone

Figure 4 Radiographic appearances post operatively.

Figure 5 The plate has bent explaining it’s prominenceclinically and there remains lucency at the fracture site 6months following injury.

Figure 6 Appearances 3 months following re-plating.

heal. At the second procedure the butterfly frag-ment had healed onto the medial fragment whichmade it possible to obtain a stable fixation using alarger plate and screws.

Conclusion

As far as we are aware, the combination of a dis-placed medial clavicular fracture in association witha displaced ipsilateral SCJ dislocation has neverpreviously been reported. Despite problemsencountered with fixation of the fracture, stabilisa-tion of the SCJ using a free palmaris tendon graftwould appear to be a simple, safe and effectivemethod of treating these injuries.

References

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2. Calve EF. Fractures and Other Injuries Chicago: Year BookMedical Publishers; 1958.

3. Housner J, Kuhn J. Clavicle fractures: individualising treat-ment for fracture type. Physician Sportsmed 2003;31(12).

4. Kanosikarin S,WearneW. Fracture and retrosternal dislocationof the clavicle. Aust NZ J Surg 1978;48:95—6.

5. Pearsall IV AW, Russell Jr GV. Ipsilateral clavicle fracture,sternoclavicular joint subluxation and long thoracic nerveinjury: an unusual constellation of injuries sustained duringwrestling. Am J Sports Med 2000;28(6):904—8.

6. Tanlin Y. Ipsilateral sternoclavicular joint dislocation and cla-vicle fracture. J Orthop Trauma 1996;10(7):506—7.

7. Thomas Jr C, Friedman R. Ipsilateral sternoclavicular disloca-tion and clavicle fracture. J Orthop Trauma 1989;3(4):355—7.

8. Toretti J, Lynch S. Sternoclavicular joint injuries. Curr OpinOrthop 2004;15:242—7.