aka Pulmonary Puzzle 015

Post coauthor: Chris Nickson

A 40 year old man had been in ICU for nearly 2 weeks and was slow to wean off the ventilator due to ARDS (acute respiratory distress syndrome). A percutaneous dilational tracheostomy (PDT) was performed. Following the procedure he developed a requirement for increased respiratory support.

He was sufficiently stable for a CT chest to be performed. Representative images are shown below:

Click to enlarge

Click to enlarge

Questions

Q1. Describe the CT findings

Answer and interpretation

Q2. What are the important possible causes of the key finding on the CT Chest?

Answer and interpretation

Q3. What clinical findings may be present?

Answer and interpretation

Q4. What are the management priorities?

Answer and interpretation

Q5. How would you treat a tension pneumomediastinum?

Answer and interpretation

Q6. Should chest x-rays be performed after performing percutaneous dilational tracheostomy (PDT)?

Answer and interpretation

References and links

Lifeinthefastlane.com

• Pulmonary Puzzle 003 — Roast duck and juniper beer

Textbooks and journal articles

• Frova G, Sorbello M. Iatrogenic tracheobronchial ruptures: the debate continues. Minerva Anestesiol. 2011 Dec;77(12):1130-3. Epub 2011 Jun 13. PubMed PMID: 21666570. [Fulltext]
• Kumar VM, Grant CA, Hughes MW, Clarke E, Hill E, Jones TM, Dempsey GA. Role of routine chest radiography after percutaneous dilatational tracheostomy. Br J Anaesth. 2008 May;100(5):663-6. Epub 2008 Mar 27. PubMed PMID: 18369239. [Fulltext]

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Neurological Mind-boggler 009

A middle-aged man presents having been shot in the head and arm:

Remarkably he is alive despite his traumatic brain injury (TBI)….

Questions

Q1. What are the initial principles of management?

Answer and interpretation

The principles of EMST/ ATLS apply; taking part in these courses is highly recommended if you are involved in this area at all.

Initial management is focused on preventing secondary brain injury by preventing hypoxia and hypotension, which have been shown in the context of TBI to be the most important variables affecting outcome.

Hypotension alone increases mortality in severe TBI from 27% to 60%.

Hypoxia, in addition to hypotension, is associated with a mortality of 75%.

In the context of trauma, the principles of ATLS are followed, with a primary survey focusing on airway patency and C-Spine protection, adequate ventilation with oxygenation and addressing life threatening haemorrhage. In this case, preventing haemorrhage from the arm injury is crucial to prevent hypovolaemic shock and reduced cerebral perfusion pressure.

This is followed by the appropriate adjuncts and a complete secondary survey. Associated injuries that might result in hypotension or hypoxia must be identified early.

Evaluation for occult injuries is routine, e.g. CT of the abdomen, FAST, DPL, and chest x-ray.

Urgent CT scan, frequent neurologic revaluations, and repeat CT scans are used to identify progressive injuries.

Q2. What are the specific considerations for airway management in this case?

Answer and interpretation

Endotracheal intubation with rapid sequence induction is required for airway protection if the GCS is </=8 or if it falls by >/=2 points.

Intubation may also be required for other reasons, e.g. coexistent respiratory problem or prior to operative intervention.

During intubation it is critical to avoid further elevations in ICP (EICP). This may be exacerbated by hypoxia, hypotension and drugs or various manoeuvres. To avoid this, consider the following measures:

• Experienced airway doctor
• Full preparation for difficult intubation available
• Adequate preoxygenation
• Judicious use of sedative agents (being mindful of blood pressure and ICP)
• Fluids and vasopressors e.g. metaraminol available
• With good clinical or radiological evidence of EICP, a MAP of >/=80mmHg should be targeted assuming ICP is >/= 20mmHg
• Hypercapnoea should be avoided as it produces cerebral vasodilatation, thereby further increasing ICP. Hypocapnoea produces cerebral vasoconstriction, decreases cerebral blood volume (and flow) and therefore temporarily reduces ICP but risks inducing ischaemia itself. Therefore normocapnoea (35-40mmHg) should be targeted initially.

After initial resuscitation the patient is taken to the operating theatre; he returns to the neuro-intensive care after a decompresive craniectomy and insertion of several monitoring devices.

Q3. What is this device?

Answer and interpretation

A Codman ICP monitor, used intraparenchymally in this instance.

Q4. What are the pros and cons of different intra-cranial pressure (ICP) monitors?

Answer and interpretation

ICP monitor	Advantages	Disadvantages
1. External Ventricular Drain (EVD) (Fluid coupled catheter with external strain gauge)	Most accurate Allows drainage of CSF as treatment or for culture Inexpensive Can give intrathecal antibiotics Can re-zero in situ	Higher infection rate (less so with antibiotic impregnated) Can block with air, blood and debris Fail with ventricular collapse
2. Parenchymal pressure transducer devices	Can use with collapsed ventricles Not dependent on fluid coupling Low infection rate	Cannot recalibrate in vivo (issue after 5 days) Cannot drain CSF Local not global pressure measure
3. Subdural devices	No parenchymal damage	Inaccurate, unreliable
4. Subarachnoid fluid coupled devices	No parenchymal damage	Inaccurate, unreliable
5. Epidural devices	No parenchymal damage	Inaccurate, unreliable

Q5. What does this monitor show? What is it used for in the ICU setting?

Answer and interpretation

Trans-cranial doppler

Trans-cranial doppler is a big topic in its own right (see references) and was only used as a component of research in this case.

Trans-cranial doppler is used in the ICU to:

Detect vasospasm post SAH in unconscious patients

Predict onset of delayed ischaemic neurological defecit

Non-invasively estimate ICP after traumatic brain injury (TBI)

Detect vasospasm post TBI

Assess cerebrovascular autoregualtion

Test for brain death (not on its own however)

Q6. What is this bit of kit? How useful is it?

Answer and interpretation

NIRS: Near-infrared spectroscopy.

NIRS is a non-invasive monitor of cerebral oxygenation. It is attracting a lot of interest currently but remains to be validated for use in guiding therapy or inferring prognosis in TBI (see references).

Q7. And what is this? It is inserted through the same bolt as the ICP monitor and the blue box shown below. What are the components shown? What does the device tell you?

With permission from CMA (http://www.microdialysis.se/)

Show answer

It is a cerebral microdialysis catheter

The components of the cerebral microdialysis (MD) catheter are:

1. pump connector
2. inlet tube
3. MD catheter
4. MD membrane
5. outlet tube
6. microvial holder
7. microvial for collection of microdialysate

Cerebral microdialysis is a well-established laboratory tool that is increasingly used as a bedside monitor to provide on-line analysis of brain tissue biochemistry during neurointensive care. Microdialysis has the potential to become an established part of mainstream multi-modalitymonitoring during the management of acute brain injury but at present is a research tool for use in specialist centres.

A recent review by Tisdall and Smith (2006) describes the principles of cerebral microdialysis and the rationale for its use in the clinical setting, including discussion of the most commonly used microdialysis biomarkers of acute braininjury, with potential clinical applications and future potential research applications (see references).

Q8. Here is even more multi-modal monitoring. What is it? Is it more or less useful than the rest of the devices we’ve seen?

Answer and interpretation

PbO2 monitor (it measures brain tissue oxygenation)

The prevention and aggressive treatment of cerebral hypo-oxygenation and control of ICP with a PbtO(2)-directed protocol has been shown to reduced the mortality rate after TBI in major trauma, and result in improved clinical outcomes over the standard ICP/CPP-directed therapy. This was shown in two  single centre studies with historically matched controls, which have inherent limitations (see references: Narotam et al 2009; Spiotta et al 2010).

However, as there have been no randomized controlled trials carried out to determine whether PbtO2 monitoring results in improved outcome after severe TBI, use of this technology has not so far been widely adopted in neurosurgical intensive care units.

A  study is about to commence (see the details here at www.clinicaltrials.gov — it will be the first randomized, controlled clinical trial of PbtO2 monitoring, and is designed to obtain the data required for a definitive phase III study, such as efficacy of physiologic maneuvers aimed at treating PbtO2, and feasibility of standardizing a complex intensive care unit management protocol across multiple clinical sites:

Patients with severe TBI will be monitored with ICP monitoring and PbtO2 monitoring, and will be randomized to therapy based on ICP along (control group) or therapy based on ICP in addition to PbtO2 values (treatment group). 182 participants will be enrolled at four clinical sites in the United States.  Functional outcome will be assessed at 6-months after injury.

Q9. What other complications might you expect following this event?

Answer and interpretation

Complications include:

Poor neurological recovery

Head wound infection (from shardes of bone/debris suckied in by the bullet)

Arm wound infection

Meningitis

Line sepsis

Ventialtor associated pneumonia

Neurogenic cardiomyopathy

All the other complications of a prolonged ICU admission!

References

Good reviews of different aspects of penetrating brain injury were compiled in a supplement of The Journal of Trauma in 2001, here are the references:

• Antibiotic prophylaxis for penetrating brain injury. J Trauma. 2001 Aug;51(2 Suppl):S34-40. Review. PMID: 11505198
• Surgical management of penetrating brain injury. J Trauma. 2001 Aug;51(2 Suppl):S16-25. Review. PMID: 11505195.
• Antiseizure prophylaxis for penetrating brain injury. J Trauma. 2001 Aug;51(2  Suppl):S41-3. Review. PMID: 11505199.
• Vascular complications of penetrating brain injury. J Trauma. 2001 Aug;51(2 Suppl):S26-8. Review. PMID: 11505196.
• Management of cerebrospinal fluid leaks. J Trauma. 2001 Aug;51(2 Suppl):S29-33. Review. PubMed PMID: 11505197.

Transcranial doppler:

• White H, Venkatesh B. Applications of transcranial Doppler in the ICU: a review. Intensive Care Med 2006 Jul;32(7):981-94. Epub 2006 May 10. Review. PMID: 16791661.

Near-infrared spectroscopy:

• Highton D, Elwell C, Smith M. Noninvasive cerebral oximetry: is there light at the end of the tunnel? Curr Opin Anaesthesiol. 2010 Oct;23(5):576-81. PMID: 20830845

Cerebral microdialysis:

• Tisdall MM, Smith M. Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006 Jul;97(1):18-25. PMID: 16698861

Brain tissue oxygen monitoring:

• Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg. 2009 Oct;111(4):672-82. PMID: 19463048
• Spiotta AM, Stiefel MF, Gracias VH, Garuffe AM, Kofke WA, Maloney-Wilensky E, Troxel AB, Levine JM, Le Roux PD. Brain tissue oxygen-directed management and outcome in patients with severe traumatic brain injury. J Neurosurg. 2010 Sep;113(3):571-80. PMID: 20415526

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Case Study:

A 55 year old male is brought into your trauma bay c/o of severe central chest pain thats reproducible on palpation and movement , post being involved in a rear ended MVA at 60kph. The patient was a restrained driver, of an old model car with-out airbags. Paramedics report patient was haemodynamically stable en-route, ECG shows sinus tachycardia, and pain has been relieved by intranasal fentanyl.

You begin your primary and secondary trauma survey, and arrange for a chest x-ray, 12 lead ECG, IV access and bloods including cardiac markers, and ask the friendly ED ultrasound consultant to FAST scan the patient.

Seat belt sign with sternal fracture

Sternal Fractures:

• Sternal fractures result from severe mediastinal trauma, and occur in approximately 3% of blunt chest trauma.
• Sternal fractures are caused by blunt anterior chest trauma, with 60-90% of cases occurring in motor vehicle accidents by seat belts or by direct impact with the steering wheel. (Incidents are now decreasing with more cars fitted with airbags.)
• Other causes of sternal fracture are assaults, contact sports, and bone insufficiency
• Patients over 50 have a higher prevalence and risk of sustaining sternal fractures, with a higher incident in the elderly and women
• Fractures of the sternum are considering among the most painful thoracic wall injuries
• 6-12% of patients with sternal fractures will develop an associated myocardial contusion

Image from: www.kidport.com

Emergency Department Assessment:

• Assess: Airway, breathing, circulation,C-spine, disability and exposure
• Secondary survey; looking for associated injuries
• Sternal fractures can result from hyperflexion injuries, also causing spinal column injuries
• Patients will generally complain of localised pain to the sternum, worse on movement, inspiration and expiration, and is easily reproduced on palpation and coughing
• Crepitation or displacement is generally not able to be elicited on exam unless the fracture involves significant instability of the sternal bone
• Around half of patients with sternal fractures will have localised soft tissue swelling and bruising
• Obtain 12 lead ECG and cardiac monitoring to assess for cardiac contusion, dysrhythmia, conduction disturbances, or ST-segment changes consistent with myocardial injury
• Cardiac markers (Troponin, Creatine kinase, myoglobin) are required initially to assess for blunt cardiac injury
• Diagnosis is able to be made clinically however imaging is recommended to assess for associated injuries

Assess for associated injuries:

• Rib fractures
• Flail chest
• Pneumothorax
• Haemothorax
• Pulmonary Contusion
• Blunt cardiac injuries
• Pericardial tamponade
• Sternoclavicular joint dislocation
• Vascular injury
• Spinal Injuires
• Trauma to head, neck, abdomen and extremities

Radiological Investigations:

X:Ray:

• Currently remains diagnostic tool of choice, although ultrasound is catching up with promising result being published
• Standard anteroposterior chest and lateral chest X-ray can reveal fracture, however sternal views are more definitive for detecting injury

Click image to see full sized version

Ultrasound:

• A recent study has shown ultrasound to  have a 100% sensitivity and specificity compared to 70.8% for plain radiographs for detecting sternal fractures in blunt chest trauma (abstract)
• Sonography of sternal fractures may reveal discontinuity of hyperechoic line representing the bony cortex

Transverse Sternal Fracture with displacement

• Is useful for assessing for associated injuries
• Newer CT scanners with 3D capabilities have superior sensitivity and specificity however should be used as a last resort after X-ray and ultrasound related to cost and radiation exposure

Emergency Department Management:

• Initial management involves, supplemental oxygen, cardiac monitoring, analgesia, and imaging.
• Opiates generally required initially for adequate pain control, then a regular and frequent analgesia regime needs to be provided on discharge to assist in patients managing their pain at home
• Patients (generally elderly) with isolated sternal fractures generally require short admissions to hospital for pain control
• Most patients recover completely over a period of 9-12 weeks (average 10.4weeks), with two-thirds only requiring analgesia, most predominant symptom is chest pain during this period.
• ECG changes and positive cardiac markers require admission for further monitoring
• Patients with difficulty managing pain and unstable fractures respond better to surgical intervention and fixation over conservative management, with follow up studies demonstrating no significant complication’s in the surgical group when compared to the conservative management group.

Reference:

• Day, C. & Wastson, N. (2006). Emergent chest radiology: chest wall, pleura, lungs and diaphragm. Imaging. 18, 111-121. (abstract)
• Felton, S. Slabinski, M. & Sigler, M. (2010). Fracture, Sternal. emedicine.medscape.com (full text)
• Fisher, D. Gazzaniga, D. & Lastig, S. (2008). Imaging in Sternal Fractures. emedicine.medscape.com (full text)
• Garrel, T. et.al. (2004). The sternal fracture: Radiographic analysis of 200 fractures with special reference to concomitant injuries. The Journal of Trauma, Injury, Infection, and Critical Care. 57(4), 837-844. PMID: 15514539
• Jones, A. & Dollery, W. (2009). Admission not needed for uncomplicated sternal fractures. bestbets.org (full text)
• Lee, W. & Lin H. (2010). Severe chest pain after blunt chest trauma. Emergency Medicine Journal. PMID: 20360484
• Potaris, K. et.al. (2002). Management of Sternal Fractures: 239 Cases. Asian Cardiovascular & Thoracic Annals. 10(2), 145-149. PMID: 12079939
• Rippey, J. Accessed 04/10/2010. www.ultrasoundvillage.com (full text)
• Roy-Shapira, A. Levi, I. & Khoda, J. (1994). Sternal fractures: a red flag or a red herring? Journal of Trauma. 37(1), 59-61. PMID: 8028060
• Summers, A. (2006). The Sternum. Emergency Nurse. 14(4), 19-23. PMID: 16878847
• Ursic, C. & Curtis, K. (2010). Thoracic and neck trauma. Part Two. International Emergency Nursing. 18,99-108. PMID: 20382371
• Velissaris, T. Tang, A. Khallifa, K. & Weeden, D. (2003). Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury. 924-927, PMID: 1436736
• You, JS. et.al. (2010). Role of sonography in the emergency room to diagnose sternal fracture. Journal of Clinical Ultrasound. 38(3), 135-137. PMID:20127877

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Scenario

An 11 year old boy has an isolated head injury after falling from a skateboard 10 hours ago.

He has a GCS of 4 with decerebrate posturing.

Question

a.	Describe and interpret his CT scan	(30%)
b.	Outline your pre-operative treatment in the emergency department	(70%)

Answer

Answer and Interpretation

ACEM Fellowship Visual Aid Questions

• FACEM VAQ Overview
• FACEM VAQ by YEAR
• FACEM VAQ by SUBJECT

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Gastrointestinal Gutwrencher 002

A 29 year old man presents to the ED with 4 hours of colicky left lower quadrant pain.

The pain came on rapidly, not long after breakfast, and is associated with nausea. It is aggravated by lying back, and eased by leaning forward and lying on his left side. He has passed flatus this morning but not opened his bowels. He has no urinary or bowel changes, and no past medical history of note.

On further questioning, he reports two similar episodes in the past ten days, both causing him to present to hospital, however the pain improved both times within 8h following treatment with analgesia and buscopan. He has been well in the intervening period.

On examination his vital signs are unremarkable, but there is marked guarding over the left umbilical area, with a palpable boggy and tender mass, roughly the size of a fist. Bowel sounds were not detected. His FBP, UEC and CRP are all within normal limits.

While awaiting a surgical consult a CT is performed. The CT findings are very similar to this image from RadioGraphics.rsna.org:

Click image to go to RadioGraphics.rsna.org

Questions

Q1. What is the diagnosis?

Clue: What is between P and D?

Answer and interpretation

Q2. How common is this condition?

Answer and interpretation

Q3. What is the cause of this condition?

Answer and interpretation

Q4. What other types of this condition exist and what is their relative incidence?

Answer and interpretation

Q4. What are the clinical features of this condition?

Answer and interpretation

Q5. How is this condition diagnosed?

Answer and interpretation

References

• Blachar A, Federle MP, Dodson SF. Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001; 218: 68–74. PMID: 11152781
• Kohli A, Choudhury HS, Rajput D. Internal hernia : A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2010 Jul 22];16:563-6. Available from: http://www.ijri.org/text.asp?2006/16/4/563/32269
• Takeyama, N et al. CT of Internal Hernias, RadioGraphics 2005, 25, 997-1015. Available from: http://radiographics.rsna.org/content/25/4/997.full#sec-10

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Is it possible that looming just beyond the horizon is a future epidemic of radiation-induced cancers? Is it possible that it will be traced back to the rise of computed tomography and it’s growing universality as the investigation of choice for just about any medical condition you can think of?

Order your CTs wisely.

Many of the issues regarding the safety of CTs are explored in a recent must-read perspective article in the New England Journal of Medicine. Find it fulltext and free here. You might also want to use this handy online radiation risk calculator (hat tip to @PeterPietch) and explore this great blog review from Peter McCartney.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Cardiovascular Curveball 008

Reviewed and revised 18 March 2012

A previously well 50 year old presents with sharp severe chest pain after a long haul flight from North America.  A chest X-ray and ECG are performed and reveal no abnormalities.  The examination is unremarkable.

The patient proceeds to a CTA chest.

Q1. What is the diagnosis?

show answer

Q2. Outline the classification systems for this condition

show answer

There are two systems in common usage.

The DeBakey Classification

• type 1 originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally
• type 2 originates in and is confined to the ascending aorta
• type 3 originates in descending aorta, rarely extends proximally but will extend distally

The Stanford Classification

• type A is any dissection that involves the ascending aorta (proximal)
  type B is any dissection does not involve the ascending aorta (distal)

 

Source: Wikipedia

Michael DeBakey (1908-2008)

At the age of 97, Michael DeBakey – who we met briefly in SurgeXperiences 318 – suffered an aortic dissection. He declined surgery (the procedure that he had developed); however, after he lapsed into unconsciousness, the surgery was performed anyway with the approval of the local hospital ethics committee. He was hospitalised for 8 months after his operation but eventually recovered and was able to return to work. He subsequently thanked the surgical team for prolonging his life and worked until the day he died at the age of 99.

A car mechanic said argumentatively to his client, a cardiac surgeon: “So Doc, look at this work. I also take valves out, grind ’em, put in new parts, and when I finish this baby will purr like a kitten. So how come you get the big bucks, when you and me are doing basically the same work?”
The surgeon replied: “Try doing your work with the engine running.”
— legend has it the surgeon was Michael DeBakey (1908–2008)

—

Q3. Outline the management of this condition

show answer

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Sternoclavicular joint dislocation is a relatively uncommon injury that can be easily missed or misdiagnosed. Bilateral posterior sternoclavicular joint dislocation is even rarer still…

The importance in determining the direction of dislocation is emphasised by the dichotomy of management. Hence, a thorough history and examination, especially looking for evidence of compression of retrosternal structures, is paramount. Specialised sternoclavicular X-ray views should be supplemented by CT/MRI if clinical suspicion is high. Posterior dislocations necessitate prompt orthopedic referral.

Case Report

A 30 year old man presented to ED with bilateral “shoulder pain” after a quad bike accident. Having taken a corner at high speed, he feel from the bike landing on his right shoulder and was crushed by the bike landing on his left shoulder.

On presentation, ABCs were intact. No dysphonia, dysphagia or dyspnoea.

Both right and left shoulders were dislocated anteriorly and were relocated at triage.

There was swelling and tenderness over both sternoclavicular joints and the patient was unable to abduct either shoulder actively despite glenohumeral enlocation. Passive movement of the shoulders was limited by pain “over the collarbone”, although the clavicles themselves were only tender near their junction with the sternum. Specifically, the AC joints and humerus were non-tender and arm neurovascular status was normal.

Initial Chest X-ray was performed and reported as normal

However in light of the high clinical suspicion for sternoclavicular joint injury; continued anterior chest pain and failure in shoulder abduction special plain film tomography views of both SC joints was performed:

There is widening of the right sternoclavicular joint when compared to the left side.  This appearance is suspicious for subluxation/dislocation. There is probable subtle widening of the left sternoclavicular joint as well. Several well-corticated bone ossicles are noted in the vicinity of the sternoclavicular joints bilaterally.

This was confirmed on CT scan:

Watch the 3D Video of the CT here

Superior dislocation of bilateral sternoclavicular joints. Associated fracture of the left 1st rib anteriorly noted.

Anatomy of the sternoclavicular joint

• The sternoclavicular joint is a diarthodial saddle-type joint which provides a pivot for the shoulder girdle on the trunk.
• The joint capsule is reinforced anterioposteriorly by the anterior and posterior sternoclavicular ligaments.  Superomedially the joint is reinforced by the interclavicular ligament which joins both the upper boarder of both clavicles to the suprasternal notch.
• The clavicle is also bound to the first costal cartilage and the first rib by the costoclavicular ligament.

Original Description

Sir Astley Paston Cooper

Sir Astley Paston Cooper (23 Aug 1768 – 12 Feb 1841)

An English surgeon and pioneer in experimental surgery. He was the first to tie the abdominal aorta in treating an aneurysm (1817), among various other operations he performed successfully at a time before antiseptic procedures. He was devoted to the study and teaching of anatomy, and is said to have dissected daily throughout his career.

In 1820 he excised and infected sebaceous cyst from the scalp of King George IV. He was appointed sergeant surgeon to George IV, William IV and Queen Victoria. He was elected President of the Royal College of Surgeons on two occasions (1827 &1836).

Sir Astley Cooper is credited with the first report of thisentity in ‘A treatise on dislocations and on fractures of the joints‘ in 1824. Approximately 120 cases of posterior sternoclavicular joint (SCJ) dislocation have been documented in the medical literature since it was first described, a statistic which underlies its relative rarity.  Despite this statistic, emergency physicians should be familiarwith the condition the mechanismof injury and physical findings and the potentially life-threatening injuries.

Clinical Presentation

Incidence

• Sternoclavicular dislocations account for 3% of all shoulder girdle injuries.
• 95% of SCJ dislocations are unilateral and anterior dislocations are far more common than posterior dislocations due to the weaker anterior sternoclavicular ligament (ratio 9:1). Bilateral superior dislocations, as in the case above, are rarely described.

Mechanism of Injury

• Dislocations of the SCJ generally occur following a fall on the outstretched hand or a direct blow to the shoulder. Sporting injuries and motor vehicle accidents account for the most causes of SCJ dysfunction. However, they can also occur without any history of injury.
• Patients commonly present with pain and swelling in the proximal sternum and sternoclavicular region. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing or coughing.
• Patients often laterally flex their neck towards the affected side to relieving pressure on the SCJ. Asymmetry is best appreciated when viewed from above the patient’s head.
• Additional symptoms include dysphonia, dysphagia or dyspnoea.

Diagnostic Imaging

• Plain X-ray: standard views may not provide a definitive diagnosis. Alternate views such as ‘serendipity view’ (40-degree cephalic tilt) may provide more information.
• CTA or MRA to determine direction of dislocation and potential for vascular compromise. A contrast study is required for definitive evaluation of surrounding structures.

Complications

Many complications have been reported in the literature related to retrosternal (posterior) dislocation of the medial end of the clavicle including:

• Subclavian compression and laceration
• Mediastinal compression
• Pneumothorax
• Oesophageal rupture
• Myocardial conduction abnormalities
• Brachial plexopathy
• Tracheal tear
• Thoracic outlet syndrome

Management

Simple sprain of the SCJ

• Patients will complain of mild to moderate pain and there will be no joint instability on clinical examination.
• Conservative treatment with ice, analgesia, shoulder sling for immobility will lead to complete recovery in 1 week.
• Subluxation of the SCJ will require the application of a clavicular splint or sling for 3 to 6 weeks

Anterior SCJ Dislocations

• Anterior sternoclavicular dislocations are usually managed nonoperatively.
• The clavicle often stabilises in its subluxed position, with asymmetrical ventral protrusion of the affected side. The arm should be rested in a sling which will assist in the reduction of pain. Patients generally experience a good pain-free functional outcome at 2-3 weeks. Very rare complications include chronic pain, periarticular calcifications with ankylosis and progressive deformity.
• Closed reduction may be indicated in rare circumstances where the patient is engaged in strenuous upper limb activities causing a painful SCJ. It is however, often unsuccessful. The application of direct pressure over the medial end of the clavicle may also reduce the joint.

Posterior SCJ Dislocations

• Posterior sternoclavicular dislocations should always be reduced in theatre because of the associated risk to intrathoracic and superior mediastinal structures.

Example of a Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation CT

Methods of reduction

The initial treatment of choice is a closed reduction. Various methods have been described:

• Classical:  Patient positioned supine with a towel/sandbag between scapulae. Sedation is administered and traction is applied to the abducted arm with simultaneous extension. This has an 80% success rate.
• Buckerfield and Castle: While shoulders are pushed posteriorly by an assistant, the ipsilateral arm is adducted against the torso and caudal traction is applied.
• Towel Clip: Anterior traction force can be applied to clavicle by percutaneously applied towel clip, often used with one of the above methods.
• A figure of eight sling is applied after the reduction for 4-6 weeks to allow for ligamentous healing.

If the SCJ becomes chronically unstable or if closed reduction is unsuccessful, then open reduction is indicated.

Discussion

Traumatic sternoclavicular joint dislocation is an uncommon condition whose diagnosis is often missed. The importance in determining the direction of dislocation is emphasised by the dichotomy of management. The posterior version of this dislocation has been associated with multiple complications and owing to the rarity of this injury, there is a relative lack of familiarity with the diagnosis, surgical anatomy and treatment options. [Reference]

A thorough history and examination, especially looking for evidence of compression of retrosternal structures, is paramount. Specialised sternoclavicular X-ray views should be supplemented by CT/MRI if clinical suspicion is high. Posterior dislocations necessitate prompt orthopedic referral.

References

Saltzman, M., Mercer, D., Bertelsen, A., Warme, W., & Matsen, III, F. (2009). Bilateral posterior sternoclavicular dislocations Radiology Case Reports, 4 (1) DOI: 10.2484/rcr.v4i1.256

• Jacques B. Jougon, MD, Denis J. Lepront, MD, Claire E. H. Dromer, M. Posterior Dislocation of the Sternoclavicular Joint Leading to Mediastinal Compression. [Reference]
• Hoekzema N. Torchia M. Adkins M Cassivi SD. Posterior sternoclavicular joint dislocation [Reference]
• Mirza AH, Alam K, Ali A Posterior sternoclavicular dislocation in a rugby player as a cause of silent vascular compromise: a case report. Br J Sports Med. 2005 May;39(5):e28. [Reference]
• Asplund C, Pollard ME. Posterior sternoclavicular joint dislocation in a wrestler. Mil Med. 2004 Feb;169(2):134-6. [Reference]
• Wirth MA, Rockwood CA Jr. Acute and Chronic Traumatic Injuries of the Sternoclavicular Joint.J Am Acad Orthop Surg. 1996 Oct;4(5):268-278. [Reference]
• Brinker MR, Bartz RL, Reardon PR, Reardon MJ. A method for open reduction and internal fixation of the unstable posterior sternoclavicular joint dislocation. J Orthop Trauma. 1997 Jul;11(5):378-81. [Reference]
• Saltzman, M., Mercer, D., Bertelsen, A., Warme, W., & Matsen, III, F. (2009). Bilateral posterior sternoclavicular dislocations Radiology Case Reports, 4 (1) DOI: 10.2484/rcr.v4i1.256
• O’Connor PA. Nölke L. O’Donnell A. Maha Lingham A. Retrosternal dislocation of the clavicle associated with a traumatic pneumothorax [Reference]
• Cooper A. A treatise on dislocations and on fractures of the joints. In: Longman, Hurst, Orme, Brown, Green, eds. London, 1824:359

An old Scotch physician, for whom I had a great respect, and whom I frequently met professionally in the city, used to say, as we were entering the patient’s room together, ‘Weel, Mister Cooper, we ha’ only twa things to keep in meend, and they’ll searve us for here and herea’ter; one is always to have the fear of the Laird before our ees; that ‘ill do for herea’ter; and t’other is to keep your booels open, and that will do for here.’ – Sir Astley Cooper

Research Credit – Dr Andrew Toffoli

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

A 50 year-old man presented to the ED with sharp abdominal pain localised to his left lower quadrant.

The pain came on rapidly the day before, when he took his dog for a walk after dinner. The pain is non-radiating and worse on movement, but he has no other symptoms. Past medical history is unremarkable. His vitals were within normal limits, his abdomen was soft with no herniae or scrotal abnormalities, but he was distinctly tender in the left lower quadrant.

FBC, UEC and urinalysis were within normal limits. Following a surgical review, a CRP was ordered and the following CT abdomen was obtained:

From Sand et al. (2007) - click to enlarge

Q1. What is the diagnosis?

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Q2. How common is this condition?

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Q3. What causes this condition?

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Q4. What are the clinical features of this condition?

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Q5. What is the best way to make the diagnosis?

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Q6. How should this patient be managed?

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Reference

Sand, M., Gelos, M., Bechara, F., Sand, D., Wiese, T., Steinstraesser, L., & Mann, B. (2007). Epiploic appendagitis – clinical characteristics of an uncommon surgical diagnosis. BMC Surgery, 7:11 DOI: 10.1186/1471-2482-7-11

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Life in the Fast Lane Medical Blog - Emergency Medicine education blog