Case reports
563
monary bypass and occlusion of the main pulmonary artery with a vascular clamp before manipulation to prevent migration into the pulmonary artery (Ledgerwood, 1975). Transvenous removal of the intracardiac and intravascular bullets using a wire basket is possible; however, caution should be used in attempting this procedure since dislodgement may result in embolization of the bullet (Ledgerwood, 1977; Smith, 1982). Precise localization of the migrating bullet using fluoroscopic facilities is mandatory prior to operative removal as migration of the bullet during operative manipulation is a common problem. The use of balloon catheters (e.g. Swan-Ganz) is recommended to prevent migration of the bullet during any operative manipulation (Ledgerwood, 1977; Michelassi et al., 1990). In conclusion intravascular bullet embolism should be suspected in any patient with a huncal gunshot wound that is unaccompanied by an exit wound and in whom routine radiographs of the thorax and abdomen fail to demonstrate the missile. In such cases whole body fluoroscopy is recommended before surgery for the removal of the migratory bullet.
Acknowledgement Thanks to Mr Muradali Bana, Department preparing the manuscript.
of Surgery,
for
References Banerjee B. and Das R. K. (1991) Sonographic detection of foreign bodies of the extremities. BY.1. Rudiol. 64, 107. Bland E. F. and Beebe G. W. (1966) Missiles in the heart -
A twenty-year follow-up report of World War II cases, N. Engl. J Med. 274,1039. Falkamer L., Eriksson A., Arnerloric et al. (1987) Arterial bullet embolism with radiologic demonstration of vessel entrance. World]. Surg. II. 548. Ledger-wood A. M. (1977) The wandering bullet. Surg. Clin. North Am. 57‘97. Mathox K., Beall A. C., Ennix C. L. et al. (1979) Intravascular migratory bullets. Am. 1. Surg. 13 7, 192. Michelassi F., Pictrabissa A., Ferrari M. et al. (1990) Bullet emboli to the systemic and venous circulation. Srqqery 107,239. Smith L. P. (1982) An improved method for intraarterial foreign body retrieval. Radiology 145, 539. Way C. W. V. (1989) Intrathoracic and intravascular migratory foreign bodies. Surg. Clin. North Am. 69, 125. Paper accepted
27 January
1992.
Requests for reprints should be aaihssd too:Dr S. T. Esufali, Assistant of Surgery, The Aga Khan University Hospital, PO Box 3500, Stadium Road, Karachi-74800, Pakistan.
Professor, Department
Retrosternal dislocation of the clavicle: the ‘stealth’ dislocation D. W. Gale, I. D. Dunn, S. McPherson and 0.0. Department
of Orthopaedic
A. Oni
Surgery, Leicester Royal Infirmary, Leicester, UK
Introduction Retrostemal dislocation of the clavicle is a rare injury, with one case reported in 1600 patients with an injured shoulder girdle (Cave, 1961). Diagnosis is often difficult (Tyer et al., 1963), but can have serious consequences if missed. Pressure from the clavicle may put important thoracic structures at risk. Closed reduction may only be possible within the first 48 h of injury. Thus, for retrostemal dislocation of the clavicle, the term ‘stealth dislocation’ is apt. We report a case illustrating the diagnostic difficulties, and the associated thoracic complications as a reminder of the condition in order that the diagnosis is considered in all cases of a shoulder girdle injury without obvious changes on plain radiography.
movements of the arm. He had also developed dysphagia stridor. On inspection of the shoulder girdle there was remarkably deformity (Figure I). Repeated plain radiographic examination unremarkable. A contrast-enhanced CT scan was obtained in
and little was view
Case report While on a rugby tour, a 17-year-old youth injured his right shoulder in a loose strum during a game. No abnormalities were detected on clinical and radiographic review at the local accident and emergency department. On return home, 24 h later, he
attended the Leicester Royal Infirmary complaining of continued pain in the region of the medial end of the clavicle made worse by 0 1992 Butterworth-Heineman 002&1383/92~080563-02
Ltd
Figure 1. Clinical photograph of the patient, change in shoulder girdle contour (arrowed).
showing
subtle
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 8
564
of the dysphagia (&red). This revealed a complete retrostemal displacement of the medial end of the clavicle. An arch aortogram demonstrated compression of the right innominate artery (Figure3). Following an unsuccessful closed reduction using the technique described in Rockwood and Green (197.5), the dislocation was reduced under direct vision. The stemoclavicular joint was stabilized with interosseous sutures. Stabilization with Kirschner wires has been shown to be dangerous with two fatal cases reported following pin migration. Recovery after 6 weeks of immobilization was uneventful.
Discussion Diagnosing
retrostemal
dislocation
of the clavicle is difficult.
The injury is rare, local swelling obliterates the contour of the clavicle, and plain anteroposterior radiographs may appear normal (Eking, 1972). Patients should be examined in a good light with a clear view of both shoulders. Special radiographic projections, the Hobbs or Serendipity views may be required (Rockwood and Green, 1975). The investigation of choice is computerized axial tomography (Levinsohn et al., 1979). This injury complex occurs as a result of a force applied to the point of the shoulder, compressing the anterior arch of the shoulder girdle and rupturing the ligamentous stability of the stemoclavicular joint, resulting in the clavicle displacing posteriorly. In 30 per cent of cases it is a result of a direct blow on the anterior aspect of the medial end of the clavicle. The close proximity of the great vessels, and their susceptibility to compression is well illustrated in this case. The presence of a cervical bruit, dysphagia or voice hoarseness should be ascertained as these may provide a clue to the diagnosis.
References Figure 2. Computerized axial tomographic the dislocation (arrowed).
scan demonstrating
Cave A. J. E. (1961) The nature and morphology of the costoclavicular ligament. J Amf. 95, 170. Elting J. J. (1972) Retrostemal dislocations of the clavicle. Arch surg 104,35. Levinsohn E. M., Bunnell W. P. and Yuan H. A. (1979) Computed tomography in the diagnosis in dislocation of the stemoclavicular joint. C/in. O&p. 140, 12. Rockwood C. A. and Green D. P. (1975) Fracfur~, Vol. 1. Philadelphia: J. 8. Lippincott, 924. Tyer H. D. D., Sturrock W. D. S. and Callow F. McC. (1963) Retrostemal dislocation of the clavicle. J. Bone Joid .%g MB, 132.
Paper accepted 24 February
Figure 3. Arch aortogram. (arrowed).
1992.
fiquesfs for reprints shouki be addressed fo: D. W. Gale FRCSEd,
with
the
vascular
impingement
Department of Orthopaedic Surgery, Caird BLock, Dundee Royal Infirmary, Dundee, DDI 9ND, UK.
563
monary bypass and occlusion of the main pulmonary artery with a vascular clamp before manipulation to prevent migration into the pulmonary artery (Ledgerwood, 1975). Transvenous removal of the intracardiac and intravascular bullets using a wire basket is possible; however, caution should be used in attempting this procedure since dislodgement may result in embolization of the bullet (Ledgerwood, 1977; Smith, 1982). Precise localization of the migrating bullet using fluoroscopic facilities is mandatory prior to operative removal as migration of the bullet during operative manipulation is a common problem. The use of balloon catheters (e.g. Swan-Ganz) is recommended to prevent migration of the bullet during any operative manipulation (Ledgerwood, 1977; Michelassi et al., 1990). In conclusion intravascular bullet embolism should be suspected in any patient with a huncal gunshot wound that is unaccompanied by an exit wound and in whom routine radiographs of the thorax and abdomen fail to demonstrate the missile. In such cases whole body fluoroscopy is recommended before surgery for the removal of the migratory bullet.
Acknowledgement Thanks to Mr Muradali Bana, Department preparing the manuscript.
of Surgery,
for
References Banerjee B. and Das R. K. (1991) Sonographic detection of foreign bodies of the extremities. BY.1. Rudiol. 64, 107. Bland E. F. and Beebe G. W. (1966) Missiles in the heart -
A twenty-year follow-up report of World War II cases, N. Engl. J Med. 274,1039. Falkamer L., Eriksson A., Arnerloric et al. (1987) Arterial bullet embolism with radiologic demonstration of vessel entrance. World]. Surg. II. 548. Ledger-wood A. M. (1977) The wandering bullet. Surg. Clin. North Am. 57‘97. Mathox K., Beall A. C., Ennix C. L. et al. (1979) Intravascular migratory bullets. Am. 1. Surg. 13 7, 192. Michelassi F., Pictrabissa A., Ferrari M. et al. (1990) Bullet emboli to the systemic and venous circulation. Srqqery 107,239. Smith L. P. (1982) An improved method for intraarterial foreign body retrieval. Radiology 145, 539. Way C. W. V. (1989) Intrathoracic and intravascular migratory foreign bodies. Surg. Clin. North Am. 69, 125. Paper accepted
27 January
1992.
Requests for reprints should be aaihssd too:Dr S. T. Esufali, Assistant of Surgery, The Aga Khan University Hospital, PO Box 3500, Stadium Road, Karachi-74800, Pakistan.
Professor, Department
Retrosternal dislocation of the clavicle: the ‘stealth’ dislocation D. W. Gale, I. D. Dunn, S. McPherson and 0.0. Department
of Orthopaedic
A. Oni
Surgery, Leicester Royal Infirmary, Leicester, UK
Introduction Retrostemal dislocation of the clavicle is a rare injury, with one case reported in 1600 patients with an injured shoulder girdle (Cave, 1961). Diagnosis is often difficult (Tyer et al., 1963), but can have serious consequences if missed. Pressure from the clavicle may put important thoracic structures at risk. Closed reduction may only be possible within the first 48 h of injury. Thus, for retrostemal dislocation of the clavicle, the term ‘stealth dislocation’ is apt. We report a case illustrating the diagnostic difficulties, and the associated thoracic complications as a reminder of the condition in order that the diagnosis is considered in all cases of a shoulder girdle injury without obvious changes on plain radiography.
movements of the arm. He had also developed dysphagia stridor. On inspection of the shoulder girdle there was remarkably deformity (Figure I). Repeated plain radiographic examination unremarkable. A contrast-enhanced CT scan was obtained in
and little was view
Case report While on a rugby tour, a 17-year-old youth injured his right shoulder in a loose strum during a game. No abnormalities were detected on clinical and radiographic review at the local accident and emergency department. On return home, 24 h later, he
attended the Leicester Royal Infirmary complaining of continued pain in the region of the medial end of the clavicle made worse by 0 1992 Butterworth-Heineman 002&1383/92~080563-02
Ltd
Figure 1. Clinical photograph of the patient, change in shoulder girdle contour (arrowed).
showing
subtle
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 8
564
of the dysphagia (&red). This revealed a complete retrostemal displacement of the medial end of the clavicle. An arch aortogram demonstrated compression of the right innominate artery (Figure3). Following an unsuccessful closed reduction using the technique described in Rockwood and Green (197.5), the dislocation was reduced under direct vision. The stemoclavicular joint was stabilized with interosseous sutures. Stabilization with Kirschner wires has been shown to be dangerous with two fatal cases reported following pin migration. Recovery after 6 weeks of immobilization was uneventful.
Discussion Diagnosing
retrostemal
dislocation
of the clavicle is difficult.
The injury is rare, local swelling obliterates the contour of the clavicle, and plain anteroposterior radiographs may appear normal (Eking, 1972). Patients should be examined in a good light with a clear view of both shoulders. Special radiographic projections, the Hobbs or Serendipity views may be required (Rockwood and Green, 1975). The investigation of choice is computerized axial tomography (Levinsohn et al., 1979). This injury complex occurs as a result of a force applied to the point of the shoulder, compressing the anterior arch of the shoulder girdle and rupturing the ligamentous stability of the stemoclavicular joint, resulting in the clavicle displacing posteriorly. In 30 per cent of cases it is a result of a direct blow on the anterior aspect of the medial end of the clavicle. The close proximity of the great vessels, and their susceptibility to compression is well illustrated in this case. The presence of a cervical bruit, dysphagia or voice hoarseness should be ascertained as these may provide a clue to the diagnosis.
References Figure 2. Computerized axial tomographic the dislocation (arrowed).
scan demonstrating
Cave A. J. E. (1961) The nature and morphology of the costoclavicular ligament. J Amf. 95, 170. Elting J. J. (1972) Retrostemal dislocations of the clavicle. Arch surg 104,35. Levinsohn E. M., Bunnell W. P. and Yuan H. A. (1979) Computed tomography in the diagnosis in dislocation of the stemoclavicular joint. C/in. O&p. 140, 12. Rockwood C. A. and Green D. P. (1975) Fracfur~, Vol. 1. Philadelphia: J. 8. Lippincott, 924. Tyer H. D. D., Sturrock W. D. S. and Callow F. McC. (1963) Retrostemal dislocation of the clavicle. J. Bone Joid .%g MB, 132.
Paper accepted 24 February
Figure 3. Arch aortogram. (arrowed).
1992.
fiquesfs for reprints shouki be addressed fo: D. W. Gale FRCSEd,
with
the
vascular
impingement
Department of Orthopaedic Surgery, Caird BLock, Dundee Royal Infirmary, Dundee, DDI 9ND, UK.
