My Chest HurtsMy Chest HurtsShalini Chandra MDShalini Chandra MD

January 26, 2005January 26, 2005

Case HistoryCase History 12 year-old boy hero was fighting in 12 year-old boy hero was fighting in

his first of three matches at the state his first of three matches at the state wrestling finals when he was wrestling finals when he was ruthlessly thrown to the mat, landing ruthlessly thrown to the mat, landing onto his chest. Fortunately, he did onto his chest. Fortunately, he did not lose consciousness, did not have not lose consciousness, did not have any head injury, did not have any head injury, did not have difficulty breathing or swallowing, but difficulty breathing or swallowing, but had severe chest pain…nonetheless….had severe chest pain…nonetheless….

……our young hero had his pride at stake, so our young hero had his pride at stake, so he decided to be tough and fought not he decided to be tough and fought not one…but two more matches…and despite one…but two more matches…and despite his injury he won a fourth place medal! his injury he won a fourth place medal!

When asked about pain, he said it hurt at When asked about pain, he said it hurt at first but then he didn’t think about it. first but then he didn’t think about it. When asked about sensory loss, he said When asked about sensory loss, he said after the tournament, he noticed a little after the tournament, he noticed a little tingling in his fingers, but as long as he tingling in his fingers, but as long as he keeps his elbow bent it is okay. He had keeps his elbow bent it is okay. He had also noted it to be slightly blue, but this also noted it to be slightly blue, but this too has since resolved.too has since resolved.

Hospital CourseHospital CourseOur patient was taken to an outside Our patient was taken to an outside

hospital first, where an x-ray and a hospital first, where an x-ray and a ct scan were done. The films were ct scan were done. The films were read as a posterior sternoclavicular read as a posterior sternoclavicular joint dislocation. The physicians, joint dislocation. The physicians, promptly put the hero’s right arm in promptly put the hero’s right arm in a figure 8 sling and sent him to the a figure 8 sling and sent him to the one…the only…Penguin Pod at one…the only…Penguin Pod at CHM!CHM!

Hospital CourseHospital CourseHere, at CHM, we promptly Here, at CHM, we promptly

collected the films brought to us by collected the films brought to us by our hero himself. The SC joint did our hero himself. The SC joint did not look quite right.not look quite right.

We examined our patient. We did We examined our patient. We did not remove the sling, however his not remove the sling, however his arm was pink, and his sensation arm was pink, and his sensation perfect…even at the tips of his perfect…even at the tips of his little fingers.little fingers.

We were able to illicit pain on We were able to illicit pain on palpation of the upper right sternal palpation of the upper right sternal border, and mild neck tenderness border, and mild neck tenderness upon turning neck to the left.upon turning neck to the left.

Hospital CourseHospital CourseWe promptly notified the orthopedic surgeon We promptly notified the orthopedic surgeon

on call of the situation who requested us to on call of the situation who requested us to have the films read by our radiologist, and have the films read by our radiologist, and if indeed the dislocation was greater than if indeed the dislocation was greater than one centimeter, he would reduce it.one centimeter, he would reduce it.

Although he initially denied pain, since he Although he initially denied pain, since he had received motrin at the outside had received motrin at the outside hospital, he did eventually ask for some hospital, he did eventually ask for some more motrin. We granted his wish.more motrin. We granted his wish.

Then we waited for the surgeon and the Then we waited for the surgeon and the radiologist to give their verdict…radiologist to give their verdict…

This is actually a normal film.This is actually a normal film.

This is actually a normal film.This is actually a normal film.

The Story so far…The Story so far…The SC joint was indeed separated and The SC joint was indeed separated and

moderately sprained but not dislocated moderately sprained but not dislocated completely…ie it was less than 1cm completely…ie it was less than 1cm displaced, thus no further intervention was displaced, thus no further intervention was needed and our superhero went home with needed and our superhero went home with the sling and was to follow-up with the sling and was to follow-up with orthopedic surgery in 7-10 days to reassess orthopedic surgery in 7-10 days to reassess and begin increasing range of motion. and begin increasing range of motion.

He will likely return to sports upon regaining He will likely return to sports upon regaining full and pain-free range of motion. full and pain-free range of motion.

Sternoclavicular Sternoclavicular JointJoint

DislocationDislocation

What is it?What is it?

An unusual dislocation at the An unusual dislocation at the sternoclavicular joint that is usually the sternoclavicular joint that is usually the result of compressive forces on the result of compressive forces on the shoulder girdle. The forces of posterior shoulder girdle. The forces of posterior compression transmit through the compression transmit through the fulcrum of the costoclavicular ligament fulcrum of the costoclavicular ligament and result in posterior dislocation. and result in posterior dislocation. Alternatively, a direct blow to the Alternatively, a direct blow to the anteromedial clavicle can result in anteromedial clavicle can result in posterior dislocation.posterior dislocation.

Who Gets it?Who Gets it?1.1. Ice Hockey PlayersIce Hockey Players2.2. Lacrosse PlayersLacrosse Players3.3. WrestlersWrestlers4.4. Male GymnastsMale Gymnasts5.5. Football PlayersFootball Players6.6. Soccer PlayersSoccer Players

Know thy enemy…Know thy enemy… Direct trauma to the great vessel origins, Direct trauma to the great vessel origins,

or brachiocephalic vein. Mediastinal or brachiocephalic vein. Mediastinal hematoma is usually presenthematoma is usually present

Respiratory distress from compression on Respiratory distress from compression on the tracheathe trachea

Voice change from compression of the Voice change from compression of the recurrent laryngeal nerverecurrent laryngeal nerve

PneumothoraxPneumothorax

How do we see it?How do we see it? Special plane film views are an option, Special plane film views are an option,

but few people know the technical but few people know the technical aspects of shooting these films, and aspects of shooting these films, and even fewer can read them, so…even fewer can read them, so…

CT is the modality of choice because it CT is the modality of choice because it delineates the anatomy of the joint so delineates the anatomy of the joint so well, shows the degree of separation, well, shows the degree of separation, and can also show vascular or other and can also show vascular or other organ injuries organ injuries

If clinical suspicion is high... go directly If clinical suspicion is high... go directly to CTto CT

Posterior Joint Posterior Joint DislocationDislocation

How do we treat it?How do we treat it? Mild and moderate sprain, Mild and moderate sprain,

treatment is symptomatic and conservative. A treatment is symptomatic and conservative. A sling or figure-of-eight harness can reduce sling or figure-of-eight harness can reduce stresses on the SC joint and prevent stresses on the SC joint and prevent subluxation. subluxation.

After 7 to 10 days, range-of-motion exercise is After 7 to 10 days, range-of-motion exercise is initiated. Return to sports is allowed when the initiated. Return to sports is allowed when the athlete has no pain and full range of motion athlete has no pain and full range of motion and can perform sport-specific movements and can perform sport-specific movements without limitation. without limitation.

How do we treat it? How do we treat it? Anterior dislocations can be easily reduced Anterior dislocations can be easily reduced

with the patient supine and a rolled towel with the patient supine and a rolled towel placed between the scapulae. Traction and placed between the scapulae. Traction and abduction on the arm with direct pressure abduction on the arm with direct pressure on the clavicle will generally reduce the on the clavicle will generally reduce the dislocation. The reduction is often dislocation. The reduction is often unstable, but an anterior dislocation can unstable, but an anterior dislocation can be left unreduced after an initial attempt be left unreduced after an initial attempt with little functional deficit.with little functional deficit.

How do we treat it? How do we treat it? Posterior dislocations require reduction due to Posterior dislocations require reduction due to

high risk of complications. high risk of complications. If the patient is skeletally mature, closed If the patient is skeletally mature, closed

reduction should be attempted in the OR reduction should be attempted in the OR under anesthesia. under anesthesia. Occasionally, conversion to an anterior dislocation is Occasionally, conversion to an anterior dislocation is

the treatment of choice. If that fails, open reduction the treatment of choice. If that fails, open reduction may be indicated.may be indicated.

Younger patients (<22yo) with an open Younger patients (<22yo) with an open proximal physis may not need open reduction proximal physis may not need open reduction because of bony remodeling potentialbecause of bony remodeling potential

Following reduction, follow anterior dislocation Following reduction, follow anterior dislocation instructions.instructions.

Closed ReductionClosed Reduction

The EndThe End