Retrosternal Dislocation of the Clavicle

Dislocation of the clavicle, either at the acromial or sternal end, is much less common than fracture ; and retrosternal dislocation is so unusual that there is little reference to it in the literature. Standard text-books on fractures and dislocations ignore the condition completely, or dismiss it in a few lines. The rarity of the injury, the typical signs and symptoms, and the grave potentialities, have prompted presentation of this case. A youth, seventeen years of age, was admitted to the Toronto General Hospital on March 18, 1948. Four days before admission he was scuffling with a group of boys and 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 pain in the region of the sterno-clavicular joint, a tight feeling in his throat, and difficulty in swallowing. His mother noted that, for the first time in his life, he snored when asleep. Physical examination showed discolouration of skin over the clavicle with generalised swelling. There was difficulty in palpating the sternal end of the bone which is usually so prominent. Attempted abduction of the limb, whether active or 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 day, at operation, a transverse incision was made over the medial end of the clavicle, crossing the sterno-clavicular joint. Part of the clavicular head of the left sternomastoid was divided. There was disruption of the joint, haemorrhage into surrounding tissues, and tearing of the capsule. The articular disc was still attached to the sternal part of the joint. Even under direct vision it was not possible to reduce the dislocation by pulling on the abducted limb. The clavicle was therefore grasped with bone forceps and lifted forcibly from beneath the sternum into its normal position. A Compere wire was introduced into the bone at the junction of the inner and middle thirds, threaded across the sternoclavicular joint into the manubrium sterni, and left protruding at the lateral extremity of the incision. Repair was reinforced by fascial sutures passed through drill-holes in the sternum and clavicle as described by Bankart (1938). The limb was immobilised in a plaster spica for two months, after which time the wire was removed.