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RETROSTERNAL
DISLOCATION
C.
JOHN
From
Dislocation
of the
than
fracture
the literature.
completely,
symptoms,
the
Division
KENNEDY,
TORONTO,
of Orthopaedic
clavicle,
either
Surgery,
at the
; and retrosternal
dislocation
Standard
text-books
on
or dismiss
it in a few lines.
and
the
grave
A youth,
seventeen
March
18, 1948.
Four
OF
potentialities,
THE
CLAVICLE
CANADA
Toronto
acromial
General
or
Hospital
sternal
end,
is much
less
common
is so unusual
that there
is little
reference
to it in
fractures
and
dislocations
ignore
the condition
The rarity
of the injury,
the typical
signs
and
have
prompted
years
of age, was
days before
admission
presentation
admitted
he was
to the
scuffling
of this
case.
Toronto
General
Hospital
with a group
of boys and
on
fell
to the ground.
As he lay on his left side, supporting
his weight
on the left shoulder,
another
boy fell on his right
shoulder.
He felt a painful
buckling
sensation
at the inner
end of the
left clavicle.
The limb was immobilised
in a figure-of-eight
bandage.
During
the next three
days
he complained
of severe
in his throat,
life, he snored
and difficulty
when
asleep.
clavicle
generalised
with
pain
in the
region
of the
in swallowing.
His
Physical
examination
swelling.
There
was
sterno-clavicular
joint,
mother
noted
that,
for
showed
discolouration
the
difficulty
in palpating
the
a tight
feeling
first time in his
of skin over the
sternal
end
of the
bone which
is usually
so prominent.
Attempted
abduction
of the limb, whether
active
passive,
gave rise to severe
pain in the region
of the sterno-clavicular
joint.
Radiographic
examination
confirmed
the clinical
diagnosis
of retrosternal
dislocation
(Fig. 1).
The
next
clavicle,
mastoid
tissues,
of the
and
tearing
joint.
Even
on the
forcibly
into
day,
at operation,
crossing
the
was divided.
a transverse
sterno-clavicular
There
was
bone
at
clavicle
for two
as
the
junction
described
months,
after
Discussion-The
sternum
relatively
invites
clavicle
made
over
the
medial
end
of the
by
which
inner
end
inner
of
and
sterni,
by fascial
Bankart
time
therefore
grasped
its normal
position.
the
wire
thirds,
middle
threaded
The
was
clavicle
limb
was
immobilised
and lifted
introduced
across
and left protruding
at the lateral
sutures
passed
through
drill-holes
(1938).
the
with
bone
forceps
A Compere
wire was
was
the
sterno-
extremity
in the
in
of
sternum
a plaster
spica
removed.
is
attached
firmly
by
strong
ligaments
to
the
and first
rib.
The capsule,
strong
in its anterior
and
posterior
distribution,
is
thin
in the superior
and inferior
areas.
The oblique
plane
of the joint
almost
dislocation,
and it is the strength
of the costo-clavicular
ligament,
anchoring
the
to the
first
rib,
which
protects
it.
This
ligament
must
necessarily
be torn
in
dislocation
of the
Retrosternal
joint.
dislocation
may
occur
from
direct
or indirect
violence.
Examples
types
of injury
have been recorded.
In one case the patient
was kicked
by a mule.
the injury
was a blow on the lateral
aspect
of the shoulder
(Greenlee
1944).
now
of the
Part
of the clavicular
head
of the left sternoof the joint,
haemorrhage
into
surrounding
of the capsule.
The
articular
disc was still attached
to the sternal
part
under
direct
vision
it was not possible
to reduce
the dislocation
by pulling
clavicular
joint
into the manubrium
the incision.
Repair
was reinforced
and
was
joint.
disruption
abducted
limb.
The clavicle
from beneath
the sternum
into
the
incision
or
reported
the
injury
In establishing
the
was
due
diagnosis
to indirect
the
of both
In another
In
the
case
violence.
history
is often
of assistance,
particularly
when,
after
direct
or indirect
injury
to the sterno-clavicular
limitation
of abduction
of the limb, dysphagia,
joint,
there
is local pain
and tenderness,
snoring
due to tracheal
pressure,
and evidence
on physical
prominence
examination
of loss
The
diagnosis
is confirmed
projections,
stereograms,
and
The
fortunate.
74
potentialities
Death
has
of the
normal
by radiographic
laminograms.
of this dislocation
been recorded
from
of the
examination
are so great
that
tracheal
laceration.
THE
medial
which
the
JOURNAL
should
rarity
There
OF
end
of the
include
of the injury
is also danger
BONE
AND
JOINT
clavicle.
oblique
is indeed
of injury
SURGERY
RETROSTERNAL
to
the
great
caused
personal
case
were
vessels
the
death
of the
of
superior
Manipulative
reduction
now
it was
exposed
successful,
has
dispatch
oesophagus
by
been
I
admission
THE
with
haemothorax-a
at
in the
few
in which
The
1944
also
degree
which
(Dewar,
F.
P.,
In
the
be involved.
is seldom
by
cases
complication
in
might
limbs
dislocation
redisplacement.
I,)
Njimegan
duct
abducted
the
CLAVICLE
rider
thoracic
on the
to reduce
Moreover,
usually
and
traction
impossible
at operation.
there
Army
The
OF
mediastinum
a Canadian
communication).
reported
DISLOCATION
successful.
traction
even
closed
when
reduction
of damage
to
the
parts
has
joint
been
capsule
FIG.
Radiograph
appear
taken
show
to
scrutiny
Ofl
no
reveals
might
ahnormalit,
that
tile
at
l)Ilt
left
clavicle
higher
and
more
medial
position
The
inset
shows
diagrammatically
operation,
and
emphasizes
the
Iirst
sight
more
close
1S ridIng
at
the
right.
thall
the hudings
joint
disruption.
at
and
extra-articular
ligaments
is such
that
Sometimes
the sternal
end of the clavicle
has
to the sternum.
In this case,
fascial
repair
Summary-Retrosternal
a
dislocation
of
reconstructive
been removed.
with
internal
the
clavicle
complications
may arise from damage
to the trachea,
the oesophagus,
and
the thoracic
duct.
Operative
ligaments
is the most reliable
treatment.
Acknowledgment
and
Chief
is made
of the
to
Division
Dr
R.
I. Harris,
of Orthopaedic
Associate
Surgery
Professor
of the
Toronto
surgery
In other
fixation
is
an
the great
reduction
is usually
indicated.
cases it has been fused
was successful.
unusual
injury.
of Surgery
General
in the
Hospital,
University
for
his
helpful
REFERENCES
A.
BANKART,
R.
BROWN,
VOL.
31 B,
NO.
H. M.
1,
(1927):
D.
GREENLEE,
LEE,
S. BLUNDELL
P.
(1937):
FEBRUARY
(1938):
Surgical
(1944):
Journal
Minnesota
1949
British
Clinics of
Journal
North
of the
America,
American
1\Iedicine, 20, 480.
of Surgery,
26,
320.
7, 1263.
Medical
Serious
vessels
of the mediastinum,
and
reconstruction
of
Association,
125, 426.
of Toronto,
criticism.
the