Rockwood Children CH19

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

INJURIES ASSOCIATED WITH STERNOCLAVICULAR FRACTURE–DISLOCATIONS Because of the high-energy mechanisms that cause posterior sternoclavicular injuries, associated chest wall injuries do occur such as rib fractures. In addition, the trachea, esophagus, lungs, or great vessels may be compressed. Dysphagia or dyspnea is present in up to 30% of patients. 144 Patients may also experience a brachial plexopathy. Life-threatening injuries, including ves- sel laceration, stroke, pneumomediastinum, or even death can occur but are rare. Very rarely, the entire clavicle may dislocate from both the sternoclavicular joint and AC joint, thus constitut- ing a floating shoulder. It is imperative to carefully evaluate the entire shoulder girdle for concomitant fractures or dislocations. SIGNS AND SYMPTOMS OF STERNOCLAVICULAR FRACTURE–DISLOCATIONS Patients who sustain sternoclavicular joint injuries present with complaints of pain localized to the sternoclavicular joint. Addi- tional subjective complaints may include shortness of breath, dyspnea, dysphagia, odynophagia, or hoarseness. 155 If an asso- ciated brachial plexopathy is present, patients may report the presence of paresthesias and/or weakness in the ipsilateral arm. Objective evaluation will demonstrate a significant amount of swelling and ecchymosis present, so much so, that it may be dif- ficult to determine the direction of the dislocation. 55 Anterior dis- locations may exhibit prominence of the medial clavicle, which is more easily appreciated with the patient supine (Fig. 19-14). 55 In contrast, the corner of the sternum may be palpable in cases of posterior dislocation, as the medial clavicle is displaced poste- riorly. 111 However, at times, the posterior fracture dislocation can be more subtle than expected as the swelling can mimic normal sternoclavicular alignment on cursory examination. Passive range of motion of the ipsilateral shoulder will cause pain and may elicit the sensation of instability. It is impera- tive that a formal trauma team or emergency room physician

Treatment can be immobilization alone for injuries that are not widely displaced, but operative intervention should be performed for significantly displaced injuries. Restoration of normal anatomy by reduction of the AC joint, suture repair of the periosteum, and ligamentous repair as needed can yield excellent outcomes in the pediatric population while avoiding utilization of metal implants. Future studies are necessary to assess outcomes of these injuries in the pediatric and adoles- cent populations.

Sternoclavicular Fracture–Dislocations

INTRODUCTION TO STERNOCLAVICULAR FRACTURE–DISLOCATIONS

Injuries to the sternoclavicular joint are rare, representing less than 5% of shoulder girdle injuries. 27,66 These injuries occur sec- ondary to high-energy mechanisms and therefore can be associ- ated with life-threatening complications. Historically, treatment by observation has occurred in the pediatric and adolescent populations. More recent trends are to operatively reduce and stabilize acute posterior fracture–dislocations to restore anat- omy and improve functional outcomes.

ASSESSMENT OF STERNOCLAVICULAR FRACTURE–DISLOCATIONS

MECHANISMS OF INJURY FOR STERNOCLAVICULAR FRACTURE–DISLOCATIONS A significant amount of force is required to disrupt the ster- noclavicular joint because of the numerous surrounding ligaments as well as the stability provided by the rib cage. Therefore, high-energy mechanisms, such as motor vehi- cle accidents and sports participation, result in greater than 80% of injuries. 21,111,154 Sports injuries are the most common mechanism of injury (71%), with football, rugby, and wres- tling being the most commonly involved sports. 144 Motor vehicle collisions may result in either an anterior or posterior force across the joint with a resultant anterior or posterior dislocation or fracture/dislocation. 57,103 A direct lateral blow to the shoulder with the shoulder extended will result in the more common anterior dislocation. Posterior dislocations can result from indirect force transferred to the shoulder gir- dle when the shoulder is adducted and flexed. Alternatively, a direct anterior-to-posterior blow to the medial clavicle is another mechanism for posterior sternoclavicular dislocation during sports participation. 55 Of note, most cases of anterior sternoclavicular instability are atraumatic and associated with ligamentous laxity.

Figure 19-14.  Clinical photograph demonstrating an anterior sterno- clavicular dislocation. This was more easily identified once the patient was lying supine. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)