Posterior Sternoclavicular Joint Injury in the Pediatric Patient

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1 Posterior Sternoclavicular Joint Injury in the Pediatric Patient Andrew Schapiro MD, Jie Nguyen MD, MS, Michael Kim MD, Kara Gill MD University of Wisconsin Hospital and Clinics

2 Disclosures The authors have no disclosures

3 Purpose Review the anatomy of the sternoclavicular (SC) joint and mechanisms of injury Review the clinical presentation and possible complications of posterior SC injury Consider the use of various imaging modalities in imaging assessment Describe methods of treatment

4 Posterior Sternoclavicular Injury Two types in children and young adults: Medial clavicle physeal fracture with posteriorly displaced clavicular metaphysis Most common injury until physeal fusion Salter-Harris I or II True posterior/retrosternal SC joint dislocation Epidemiology: Rare Ratio of anterior to posterior SC injury 2.5:1 to 20:1 Only 1 case of posterior injury in a large series of 1603 shoulder girdle injuries <1% of dislocations in the body Significance Often easily overlooked on clinical and imaging assessment Acute and delayed complications can occur if unrecognized and untreated Can be lethal

Anatomy Clavicle 1 st long bone to ossify - 5 weeks GA Last epiphysis to fuse - 21-31 years old Sternoclavicular joint Overlies the upper mediastinum - great vessels, trachea, esophagus Only true

5 Anatomy Clavicle 1 st long bone to ossify - 5 weeks GA Last epiphysis to fuse years old Sternoclavicular joint Overlies the upper mediastinum - great vessels, trachea, esophagus Only true articulation between the upper extremity and axial skeleton Diarthrodial, saddle shaped joint Most unstable major joint in the body - <50% of the medial clavicle articulates with the manubrium Ligaments provide joint stability Figure 1: Axial cadaver section demonstrating the proximity of the SC joints to the upper mediastinal structures. Clavicle (C), sternum (S), right subclavian vein (RSV), right innominate artery (RIA), left carotid artery (LCA), left subclavian vein (LSV), left subclavian artery (LSA), trachea (Tr), esophagus (E) (Levinsohn EM. Clin Orthop Relat Res 1979;140:12-16)

6 Anatomy SC (capsular) ligaments Thickenings of the anterior and posterior joint capsule Major stabilizers of the SC joint Posterior is thicker/stronger may partially account for increased rate of anterior dislocation Coracoclavicular ligament Extends from the medial first rib to the medial clavicle Opposes the pull of the sternocleidomastoid muscle on the clavicle Interclavicular ligament Connects the superomedial aspect of the clavicles with the capsule and upper sternum Helps prevent lateral displacement of the clavicle Intra-articular disk ligament Arises from the synchondral junction of the 1 st rib and sternum and divides the SC joint into two Helps prevent medial displacement of the clavicle Figure 2: Illustration of the basic anatomy of the SC joint. (Nettles JL. J Trauma 1968;8:158-64)

7 Cause of injury Mechanism MVA - most common cause (40%) Sports injury - second most common cause (21%) Falls, industrial accidents, miscellaneous trauma (39%) Rarely can be spontaneous Mechanism of injury Indirect Force to the posterolateral shoulder Clavicle levers on the first rib, transmitting a posterior force to the medial clavicle Most common mechanism of injury Direct Force to the anteromedial aspect of the clavicle Less common mechanism of injury - 1 in 4 to 1 in 9 cases

8 Clinical Presentation Signs and symptoms of injury Pain localized to the SC joint, clavicle, and/or shoulder Tenderness over the SC joint Ipsilateral arm flexed at the elbow and supported across the chest by the other arm Head tilt toward the ipsilateral side Depression of the medial clavicle and/or swelling over the clavicle Decreased range of motion due to pain Signs of secondary effect on the mediastinum Dysphagia Dyspnea Dysphonia Upper extremity weakness and/or paresthesia Neck and upper extremity venous congestion Decreased upper extremity pulse Hypotension/shock Figure 3: Signs of posterior SC injury. (Worman LW. J Trauma1967;7:416-23)

a b c Figure 4: 15 year old male who sustained a direct force to the anterior upper

(a) Photo obtained during physical exam demonstrates depression of the medial right

(b) AP clavicle radiograph showing subtle superior displacement of the right

9 a b c Figure 4: 15 year old male who sustained a direct force to the anterior upper right chest during wrestling. (a) Photo obtained during physical exam demonstrates depression of the medial right clavicle. (b) AP clavicle radiograph showing subtle superior displacement of the right clavicular head relative to the left. (c) CT chest without contrast showing a posteriorly displaced right clavicle Salter-Harris fracture with a tiny fracture fragment (arrow) anterior to the medial right clavicle.

Complications Mediastinal complications in ~25% of patients Acute Great vessels compression, laceration Trachea compression, tracheoesophageal fistula Esophagus compression, rupture Lungs pulmonary

10 Complications Mediastinal complications in ~25% of patients Acute Great vessels compression, laceration Trachea compression, tracheoesophageal fistula Esophagus compression, rupture Lungs pulmonary contusion, pneumothorax, hemothorax Brachial plexus or recurrent laryngeal nerve injury Chronic SC joint instability and/or osteoarthritis Arterial stenosis or pseudoaneurysm Venous congestion Thoracic outlet syndrome

patient supine, tube lateral to the patient tangential to one SC joint and parallel to the other, often images of both sides are obtained for

11 AP view Radiography May show asymmetry of the medial clavicles Posterior SC injury is often occult Additional views Serendipity patient supine, 40 degree cranial tilt of the X-ray tube Hobbs patient seated leaning over table, tube aimed downward toward the C-spine Heinig patient supine, tube lateral to the patient tangential to one SC joint and parallel to the other, often images of both sides are obtained for comparison a b Figure 5: (a) Serendipity view (b) Hobbs view (Cope R. Skeletal Radiol 1993;22:233-8) Figure 6: Heinig view (Lee FA. Radiology 1974;110:631-4)

12 Obtaining an AP view and at least one additional view (typically serendipity at our institution) is recommended to increase sensitivity for detection

(a) AP view of the bilateral clavicles showing minimal inferior

13 a b Figure 7: 14 year old male who fell onto his right shoulder during snowboarding. (a) AP view of the bilateral clavicles showing minimal inferior displacement of the medial right clavicle relative to the left. (b) Serendipity view much better demonstrating this inferior displacement.

(a) AP view of the left clavicle showing superior displacement of the left

14 a b Figure 8: 17 year old male who sustained an impact to the lateral left shoulder during a hockey game. (a) AP view of the left clavicle showing superior displacement of the left clavicle relative to the right. (b) Serendipity view of the left clavicle on which the clavicular displacement is occult.

15 CT CT for SC dislocation first described in 1979 Advantages Widely available and readily accessible in the acute setting Can identify SC dislocation that is occult on radiographs, or confirm a radiographic diagnosis If the epiphysis is at least partially ossified CT may help differentiate a medial clavicle Salter- Harris fracture from true SC dislocation, which may impact management Can be used to assess the vasculature if contrast is administered Can identify evidence of injury to other structures including the esophagus and trachea Intra-operative cone beam CT can be used to confirm the success of reduction Disadvantages Ionizing radiation - limited coverage of just the SC joints minimizes radiation exposure If contrast is administered there is a small risk of reaction and/or nephrotoxicity

16 Even if radiographs appear normal CT should be obtained if high clinical suspicion remains Use of IV contrast is recommended to assess the vasculature prior to reduction

(a) CT without contrast shows posterior displacement of the left medial clavicular

17 a b Figure 9: 17 year old male who sustained a lateral impact to the left shoulder during a hockey game. (a) CT without contrast shows posterior displacement of the left medial clavicular metaphysis with the epiphysis seen anteriorly (arrow), compatible with displaced Salter-Harris fracture. (b) Intra-operative cone beam CT showing successful reduction of the fracture.

18 a Figure 10: 13 year old male thrown onto his right shoulder during wrestling. (a) CT chest with contrast on bone window showing posterior right SC dislocation. (b) Same CT image on soft tissue window showing mass effect from the posteriorly dislocated clavicle on the distal left brachiocephalic vein (arrow). b

MRI Advantages No ionizing radiation Excellent soft tissue contrast resolution Osseous structures and unossified cartilage can be identified Contrast can be administered to assess the vasculature Low

19 MRI Advantages No ionizing radiation Excellent soft tissue contrast resolution Osseous structures and unossified cartilage can be identified Contrast can be administered to assess the vasculature Low rate of contrast reaction Low theoretical risk of nephrotoxicity Newer contrast agents with a longer blood pool half-life (i.e. gadofosveset trisodium) may help optimize vascular assessment by allowing for extended vascular imaging Patients with SC injury are typically teenagers who can remain still for MRI without sedation Disadvantages Not always readily available in the acute setting Difficulty monitoring the unstable patient (i.e. trauma patient with polyinjury) More expensive than routine CT

20 MRI may play a more prominent role in the imaging of sternoclavicular joint injury in the future given its ability to simultaneously evaluate the bones, cartilage, soft tissue structures, and the vasculature without the use of ionizing radiation

(a) MRI/MRA chest showing posterior displacement of the medial right clavicle (solid arrow).

21 a b Figure 11: 16 year old male involved in a motorcycle accident who presented with right clavicle pain. The patient had multiple distracting injuries and posterior SC injury was missed on initial radiographs. (a) MRI/MRA chest showing posterior displacement of the medial right clavicle (solid arrow). Surrounding soft tissue edema and anterior callus formation (open arrow) are present. (b) CT without contrast showing the posterior dislocation and early callus formation.

5 weeks later with persistent medial right clavicle pain.

22 a Figure 12: 17 year old female who fell and landed on her right shoulder during a soccer game. Initial radiographs obtained at an outside hospital were interpreted as negative. The patient presented 3.5 weeks later with persistent medial right clavicle pain. (a) CT without contrast showing posterior dislocation of the right clavicular head with anterior callus formation (arrow). (b) MRI/MRA following repair showing improved alignment and post-surgical change. b

23 Ultrasound (US) Reports of US use for posterior SC injury Intra-operative assessment of closed reduction success Diagnosis of closed reduction failure at clinic follow-up Advantages No ionizing radiation Real-time assessment in any imaging plane Portable, with potential for use in the emergency department, operating room, or clinic. Disadvantages Mediastinal structures cannot be assessed Limited expertise for this indication Limited literature on the use of this modality for this indication

(b) Extended field of view US image demonstrating the relative positions of the right and left

24 Figure 13: (a) Side by side US images of the right (arrowhead) and left (solid arrow) medial clavicles in a patient with a posterior dislocation of the left SC joint. (b) Extended field of view US image demonstrating the relative positions of the right and left clavicular heads. The periosteal sleeve is seen anterior to the left clavicle (open arrows). Sternum (S). (Delganelo A. Skeletal Radiol 2012;41:857-60)

25 Controversial Closed reduction Management Many advocate attempt at closed reduction if performed within 48 hours of injury Successful closed reduction up to 10 days after injury has been described Reported success ~40-60% in several adult series Sedation or general anesthesia typically administered Thoracic surgery should be on standby or in the operating room Open reduction performed right away if unsuccessful Open reduction Some advocate open reduction as first line therapy in pediatric patients due to the high rate of physeal fracture in this population and reported poor success of closed reduction in this setting Many different methods Internal fixation with plates, pins, wire no longer recommended due to reports of multiple fatalities related to hardware migration Tendon grafts Suture fixation performed at our institution Medial clavicle resection not recommended in pediatric patients Thoracic surgery should be on standby or in the operating room

26 Figure 14 (left): Illustration of a commonly used closed reduction technique (the technique typically used at our institution). The patient is laid supine with a several centimeter thick sandbag between the scapulae. The ipsilateral arm is abducted and extended and traction is applied. The medial end of the clavicle may be grasped and pulled anteriorly with fingers or a towel clamp. (Salvatore JE. Clin Orthop Relat Res 1968;58:51-5) C Figure 15 (right): Intra-operative photo showing suture fixation of a clavicle Salter-Harris fracture with nonabsorbable suture. Clavicle (C), sternum (S). (Waters PM. J Pediatr Orthop 2003;23:464-9) S

27 Summary Posterior SC injury is rare but associated with many complications It is often missed on initial radiographs Obtain at least 2 views Always assess medial clavicular alignment Obtain CT with contrast or MRI/MRA if there is high clinical suspicion regardless of radiographic findings Can identify or confirm the diagnosis Can evaluate for associated vascular or soft tissue injuries Prompt diagnosis can impact management and reduce morbidity

28 References: Bearn JG. Direct observations on the function of the capsule of the sternoclavicular joint in clavicular support. J Anat Jan;101(Pt 1): Cope R. Dislocations of the sternoclavicular joint. Skeletal Radiol. 1993;22(4): Deganello A, Meacock L, Tavakkolizadeh A, et al. The value of ultrasound in assessing displacement of a medial clavicular physeal separation in an adolescent. Skeletal Radiol Jan;41: Gobet R, Meuli M, Altermatt S, et al. Medial clavicular epiphysiolysis in children: the socalled sterno-clavicular dislocation. Emerg Radiol Apr;10(5): Heinig, CF. Retrosternal dislocation of the clavicle: Early recognition, X-ray diagnosis and management. J Bone Joint Surg (Am). 50:830. Laffosse JM, Espie A, Bonnevialle N, et al. Posterior dislocation of the sternoclavicular joint and epiphyseal disruption of the medial clavicle with posterior displacement in sports participants. J Bone Joint Surg (Br) Jan;92(1): Lee FA, Gwinn JL. Retrosternal dislocation of the clavicle. Radiology Mar;110(3): Leighton D, Oudjhane K, Ben Mohammed H. The sternoclavicular joint in trauma: retrosternal dislocation versus epiphyseal fracture. Pediatr Radiol. 1989;20(1-2): Levinsohn EM, Bunnell WP, Yuan HA. Computed tomography in the diagnosis of dislocations of the sternoclavicular joint. Clin Orthop Relat Res May;(140):12-6.

29 References: Luhmann JD, Bassett GS. Posterior sternoclavicular epiphyseal separation presenting with hoarseness: a case report and discussion. Pediatr Emerg Care Apr;14(2): Mehta JC, Sachdev A, Collins JJ. Retrosternal dislocation of the clavicle. Injury. 1973;5: Nettles JL, Linscheid RL. Sternoclavicular dislocations. J Trauma Mar;8(2): Rudzki JR, Matava MJ, Paletta GA Jr. Complications of treatment of acromioclavicular and sternoclavicular joint injuries. Clin Sports Med Apr;22(2): Salgado RA, Ghysen D. Post-traumatic posterior sternoclavicular dislocation: case report and review of the literature. Emerg Radiol Dec;9(6): Salvatore JE. Sternoclavicular joint dislocation. Clin Orthop Relat Res May- June;58;51-5. Siddiqui AA, Turner SM. Posterior sternoclavicular joint dislocation: the value of intraoperative ultrasound. Injury Jun;34(6): Sykes, JA, Eztendu C, Sivitz A, et al. Posterior dislocation of the sternoclavicular joint encroaching on ipsilateral vessels in 2 pediatric patients. Pediatr Emerg Care Apr;27(4): Tepolt F, Carry PM, Taylor M, Hadley-Miller N. Posterior sternoclavicular joint injuries in skeletally immature patients. Orthopedics Feb;37(2):e

30 References: Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop Jul-Aug;23(4): Webb PA, Suchey JM. Epiphyseal union of the anterior iliac crest and medial clavicle in a modern multiracial sample of American males and females. Am J Phys Anthropol Dec;68(4): Wirth MA, Rockwood CA Jr. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg Oct;4(5): Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma May;7(3):

Disclosure Statement. Acromioclavicular (AC) Joint

Disclosure Statement. Acromioclavicular (AC) Joint Michael D. Loeb. M.D. Texas Orthopedics, Sports Medicine, and Rehabilitation Associates, P.A. Austin, Texas Disclosure Statement NO INTERESTS PERTAINING TO INFORMATION GIVEN IN THIS PRESENTATION Acromioclavicular