Posterior dislocation of the sternoclavicular joint.

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HIPPOKRATIA 2011, 15, 3
284
Posterior dislocation of the sternoclavicular joint
Dear Editor,
Sternoclavicular joint (SCJ) dislocations are not common; representing less than 1% of all dislocations in the body and counts
for approximately 3% of all shoulder injuries1,2. In most cases, medial end of the clavicle dislocates anteriorly. Posterior disloca-
tions are extremely rare and may have life threatening complications because of close proximity to superior mediastinum.
A 27-years-old man presented with a history of falling on his right shoulder. Pain and swelling at the medial clavicu-
lar region, venous congestion at the neck, and difficulty in swallowing were noted. Posterior dislocation of the right SCJ
was diagnosed at computerized tomography (CT) scans and the serendipity view radiograph. Pressure on the trachea
from the right side and compression at the right innominate vein were also determined at the CT scans.
Closed reduction was performed under general anesthesia at the operation room. Longitudinal traction applied to the
90 degrees abducted arm. While extending the shoulder, medial clavicular head has been levered anteriorly from under
the manubrium by pushing the shoulder posteriorly. The SCJ has been reduced with a popping. Reduction has been
confirmed with CT examination. Patient discharged at the next day and kept in a figure-of-eight bandage for 6 weeks.
Pain-free full range of motion was present at the third month.
In patients with pain, swelling and tenderness at the medial clavicle with a history of shoulder injury, traumatic SCJ
lesions should be considered. Anterior dislocations are the most common traumatic SCJ lesions. Posterior dislocations
present with much pain and some symptoms like dyspnea, dysphagia and dysphonia which are related to more serious
injuries. There are some life threatening complications associated with posterior SCJ dislocations including compression
and lacerations of great vessels, trachea and esophagus in the mediastinum. These complications may be observed at the
time of injury; also late appearing complications including tracheoesophageal fistulas, mediastinitis, brachial plexus le-
sions, thoracic outlet syndrome and vascular compromise may occur with old unreduced posterior SCJ dislocations3.
Asymmetry between the medial ends of the clavicle seen at the chest radiogram should be considered as a sign for fur-
ther radiological intervention in the patients with shoulder injury. Serendipity (Rockwood) view, Hobbs view and Heinig’s
projection are the specific plain radiograms for evaluating the SCJ. Serendipity view is the best known and most useful tech-
nique to determine any traumatic SCJ pathology4. CT examination is also useful and sensitive way to evaluate the joint.
Preferred treatment is closed reduction in acute posterior SCJ dislocations without any mediastinal injury. Open re-
duction may be necessary in the presence of a mediastinal injury and when the closed reduction fails. The surgical team
must be alert for any complication requires emergency thoracic surgery during manipulation for closed reduction.
Life threatening traumatic lesions to the mediastinal structures may be seen with posterior SCJ dislocations. Posterior
SCJ dislocations should be kept in mind in the patients with a trauma to the posterior aspect of the shoulder.
References
1. Jougon JB, Lepront DJ, Dromer CEH. Posterior dislocation of the sternoclavicular joint leading to mediastinal compression. Ann Thorac
Surg. 1996; 61: 711-713.
2. Mitani M, Nabeshima Y, Ozaki A, Mori H, Fujii H. Unexpected reduction of a posterior sternoclavicular dislocation: A case report. J Shoul-
der Elbow Surg. 2008; 17: e25-e27.
3. Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma. 1967; 7: 416-423.
4. Laffosse JM, Espié A, Bonnevialle N, Mansat P, Tricoire JL, Bonnevialle P, 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. 2010; 92: 103-109.
Ciftdemir M, Copuroglu C, Ozcan M
Trakya University Faculty of Medicine, Department of Orthopaedics and Traumatology, Edirne, Turkey
Key words: sternoclavicular joint, dislocations, mediastinum
Corresponding author: Mert Ciftdemir, e-mail:dr.mert@gmail.com
Renal artery pseudoaneurysm after partial nephrectomy
Dear Editor,
Nephron-sparing surgery has emerged as an excellent option for the management of small renal cortical tumors.
Renal artery pseudoaneurysm is a rare complication of partial nephrectomy and a limited number of reports describ-
ing the presentation and management of this situation have been published so far1. We report two cases of renal artery
pseudoaneurysm occurred after elective nephron-sparing surgery.
The first one is refered to a 35-year-old woman who underwent an open left partial nephrectomy. Complete intraop-
erative hemostasis was achieved using interrupted figure-of-eight 4-0 chromic sutures at sites of parenchymal bleeding.
Twelve days postoperatively, the patient reported gross hematuria and intermittent left flank pain. Renal arteriography
was performed and revealed a left renal artery pseudoaneurysm with active extravasation. Coil embolization was per-
formed with complete resolution of her hematuria.
The second case to a 59-year-old man underwent retroperitoneal laparoscopic partial nephrectomy. The defect was closed