posterior sternoclavicular dislocations.

[hherrn]

Hey all-
First post, though I have perused this site quite a bit.

My background:
ER RN
EMT
Outdoor Emergency Care instructor (ski patrol)

Also have some experience with SOLO and WMA.

NSP has come out with a new curriculuum. Disclaimer: I have not read the text yet. I do know that part of the new protocols includes reduction of posterior sternoclavicular dislocations.

I have personally only seen one sternoclavicular dislocation, and it was anterior, and could not be definitively dx'ed with plain films in the ski hill clinic, went to the hospial emergently for ct.

I have read quite a bit on this injury, and as far as I can tell, it is a really bad idea for people with a 90 hour course to do this procedure outside of a hospital.

Anybody out there know of such a protocol in existence? Anybody familiar with this injury think this protocol is a good idea?

Any input appreciated.
Thanks.

 

[usafmedic45]

I wouldn't do it in the field unless absolutely necessary. There are a lot of neurovascular structures in that area that are at risk if you botch it.

 

[abckidsmom]

I opened this thread wondering how we were going to definitively diagnose it without superpowers.

I wouldn't do it either.

 

[usafmedic45]

I opened this thread wondering how we were going to definitively diagnose it without superpowers.

The handful of cases I have seen of it were pretty obvious with a major depression of the AC joint. Once swelling kicks in though, that gets pretty much obscured rather quickly.

 

[Akulahawk]

AC dislocations are relatively trouble-free from an emergent care standpoint. Normally they just pop up like a piano key. They will have some shoulder instability, but that's nothing that can't wait for the injury to calm down before visiting the surgeon, if necessary. Sternoclavicular dislocations are a different story. An anterior dislocation of the SC joint shouldn't be too troublesome, as long as it doesn't impinge upon anything else (anatomically, there's not much that can be impinged with an anterior SC dislocation). Posterior SC dislocations scare me. There's much vasculature and nerves that run through the area that can be impinged by a posterior dislocation. I'd refer that to an ED for proper evaluation and reduction ASAP. An anterior? As long as they're not having any other issues, I'd refer to a physician of choice...

Of course,this isn't coming from my EMT-P background.

 

[dschmit]

I'm an OEC instructor and was looking for more information on this injury when I stumbled upon your post and felt compelled to reply.

The reasoning behind performing this in the field is because the PSCD is a life threatening injury. The neurovascular structures are exactly why fixing this injury should be done in the field. The posterior dislocation can pierce or put pressure on a number of very important structures that can quickly become fatal. One that the OEC book specifically mentions is compression of the superior vena cava which can become fatal by reducing the amount of blood that reaches the heart.

There are signs and symptoms that the OEC book specifically talks about to help you diagnose this injury. From the OEC instructor side of things I think that you should attempt to fix it if you believe that the injury has occurred. Since leaving it can quickly become fatal then leaving it is a bad idea all around.

This is just my two cents but I personally would fix the PSCD if I found it. You also have to look at the statistics though and most of us will probably never see one.

 

[usafmedic45]

One that the OEC book specifically mentions is compression of the superior vena cava which can become fatal by reducing the amount of blood that reaches the heart.

As an injury researcher, I'd like to point out that it's a low frequency event and the likelihood of it happening to compress the SVC is remote due to the tendency of the clavicle to not move under the sternum without extreme amounts of force. The type of force necessary would be akin to falling a great distance (say 10 feet) and landing on one's shoulder or being struck by a car while crossing the street. Persons exposed to such forces that are able to inflict the injury you are concerned with are not likely to survive anyhow even with optimal care. This likely explains why it's not a commonly described injury in the literature.

The risk of some random person trying to pop a D/C (and likely fractured) clavicle back into place because of ill-placed fear of SVC syndrome (which is not frequently fatal in the short term) is far greater due to the chances of lacerating a blood vessel than anything directly associated with leaving it as it is.

Also, the one described case with full text available describes a first rib fracture (which itself denotes an increased risk of great vessel trauma), a dislocated and fractured clavicle and fractured sternum. If the sternum is fractured (which it commonly is in significant thoracic trauma), how is one supposed to reduce that DC/Fx easily? You'll also note that they case I am talking about they had to resect the clavicle to get it back off the SVC.

http://asianannals.ctsnetjournals.org/cgi/content/full/14/1/85

You also have to look at the statistics though and most of us will probably never see one.

As in there are a whopping two cases of it on Pubmed. How about focusing on skills that are actually going to be helpful and based on

This is just my two cents but I personally would fix the PSCD if I found it.

And why is that?

 

[Akulahawk]

I'm not an injury researcher... but usafmedic45 outlined pretty much why PSCD events scare me. When you apply a medial force to the clavicle and it actually dislocates at the SC joint, it's going to want to go anterior or superior. Basically, any direction other than posterior. The forces that would have to be applied to do a posterior dislocation would almost certainly result in rib and sternal fracture. That kind of force would also almost certainly result in damage to the neuro and vascular structures underlying the clavicle and the affected ribs. That's not even mentioning the SVC and/or Aorta and probable further injury to the cervical spine... I'd also consider it highly likely that lung contusion has also occurred at the minimum.

In otherwords, someone that managed to survive the forces required to produce a posterior sternoclavicular dislocation will be a trainwreck.

It's little wonder why I said posterior SCD events scare me...

 

[Handsome Robb]

No offense to you OEC guys, but if any of the vollys where I patrol professionally tried to preform this procedure I would not be happy about it if I was on scene. Now the guy who is an MD and the girl who is a PT I'd just shut up sit down and watch.

Like Akula said, the pt is going to have a lot more to worry about than a PSCD.

 

[flhtci01]

No offense to you OEC guys, but if any of the vollys where I patrol professionally tried to preform this procedure I would not be happy about it if I was on scene.

Like Akula said, the pt is going to have a lot more to worry about than a PSCD.

I agree.
There seem to be a lot of patrollers getting worked up about this issue.
I think most ski areas have fairly quick access to higher level care and the person should be transferred. It takes 25 minutes for a Basic level truck to arrive at our area, 30-40 for a flight. I really think they included this for a back country scenario where you are possibly hours from higher level help AND the patient is circling the drain.

 

[Handsome Robb]

I agree.
There seem to be a lot of patrollers getting worked up about this issue.
I think most ski areas have fairly quick access to higher level care and the person should be transferred. It takes 25 minutes for a Basic level truck to arrive at our area, 30-40 for a flight. I really think they included this for a back country scenario where you are possibly hours from higher level help AND the patient is circling the drain.

I'll agree with that assessment about the backcountry scenario. I'm spoiled and can get an ALS unit at the bottom of the mountain waiting to meet me as long as something wild isn't going on in the area. Flight to a Level II is about the same give or take a couple due to wind/weather/availability.

If all goes well, and I say this very, very, very painfully, I won't be patrolling this year, but rather working on an ALS truck.

 

[Luno]

Blasphemy!!!

I'll agree with that assessment about the backcountry scenario. I'm spoiled and can get an ALS unit at the bottom of the mountain waiting to meet me as long as something wild isn't going on in the area. Flight to a Level II is about the same give or take a couple due to wind/weather/availability.

If all goes well, and I say this very, very, very painfully, I won't be patrolling this year, but rather working on an ALS truck.

The weather must be different down south, because we've still got snow at about the 5.5k level that hasn't melted from last year, and the possibility of an early season la nina.... I'll get some turns in for ya...

About the OEC training standard, here's the one thing that this does not discuss, OEC is a training standard, not protocol. The issue that has not been raised yet, is that local area management sets protocol, and is responsible for the actions of their patrollers. While OEC is the minimum standard of training for our patrollers, all patrollers treat patients in accordance with our treatment guidelines which encompass several levels of provider, and is signed by county ems, management, and our medical advisor.

As an injury researcher, I'd like to point out that it's a low frequency event and the likelihood of it happening to compress the SVC is remote due to the tendency of the clavicle to not move under the sternum without extreme amounts of force. The type of force necessary would be akin to falling a great distance (say 10 feet) and landing on one's shoulder or being struck by a car while crossing the street. Persons exposed to such forces that are able to inflict the injury you are concerned with are not likely to survive anyhow even with optimal care. This likely explains why it's not a commonly described injury in the literature

While I can't disagree with the frequency of the event, I can disagree with the perception of low impact injury, the force of falling 10' is encountered regularly, and often by people who walk away, however there might be more to this, especially as you look at the angles that the forces are applied to the body, and a person's attempt to self-arrest their fall.

Being that the instructor refreshers are in two weeks, and we start the patrol refreshers in October, I will be interested to see how this affects the line patroller, but I do think that there might be other injuries that patrollers lack proficiency on, and happen more frequently. However, I always appreciate the opportunity to raise the collective medical IQ so to speak among the people that I work with...

 

[usafmedic45]

While I can't disagree with the frequency of the event, I can disagree with the perception of low impact injury, the force of falling 10' is encountered regularly, and often by people who walk away, however there might be more to this, especially as you look at the angles that the forces are applied to the body, and a person's attempt to self-arrest their fall.

Well, for this to happen, it's going to be almost either a direct impact to the clavicle anteriorly (which is going to more than likely break it in at least one, probably two, places) or a loading of the clavicle longitudinally (along the long axis) due to an impact on the point of the shoulder. Someone trying to arrest their fall by outstretching their arm- such as a falling skier- is going to be at a much lower risk of this injury. Even landing directly on the point of the shoulder is more then likely going to shove the dislocated clavicle anterior of the sternum due to the presence of the much stronger pectoral muscles inferiorly compared to the muscles attached to the clavicle superiorly.

Let's just say that as an expert witness for malpractice attorneys, I would LOVE to have a case where someone followed OEC's advice dropped in my lap. They would get eaten alive in court. If the risk of worsening your patient's condition- if not flat out signing their death warrant- does not deter you, the prospect of spending several years and a lot of money while having your clinical abilities and judgment questioned and your reputation ground into the mud should be sufficient to give you pause about doing something this questionable in the field should the situation present itself.

 

[mycrofft]

Hi.

1. If it isn't fatally damaging the structures in place, why not immobilize then transport? Doesn't (attempted) field reduction carry an increased likelihood of failure, or reversion to the dislocated state? If reduced in hospital, after radiography, I'm betting the pt's sternoclav area is going to be wired like a bonsai.
2. If it is fatally damaging structures, then the pt is dead anyway.
3. I see it being of use in the following circumstance: the pt has to be ground transported a significant distance, or over very rough terrain, before smooth and definitive transport can be had, and the pt is in danger of dying due to environmental hazards or concurrent medical threats/insults.

What would the best immobilization probably be? (Remember, the most-likely responder will be a friend or someone with less than the training and/or experience needed to correctly diagnose and address this, and it has to be immobilized even if it is reduced).

 

[usafmedic45]

If it isn't fatally damaging the structures in place, why not immobilize then transport?

Because a few people are focused on the fact that it can (and it can) cause what's called superior vena cava syndrome. They are having a knee jerk reaction and not fully thinking their suggestion through before making it. I don't known about you but given the force necessary to put a posterior dislocated clavicle in that place to begin with, coupled with it's proximity to vital vascular structures (which is why some ski patrollers are apparently so freaked out by it) and the tendency of the clavicle to fracture under either longitudinal or lateral loading, I wouldn't want to be trying to jerk a potentially fractured clavicle (and its associated sharp fragments) out of there.

the pt is in danger of dying due to environmental hazards or concurrent medical threats/insults.

Honestly, if that's the case, trying to reduce the clavicle isn't going to help matters. This isn't an injury that is normally associated with a simple "Hey, reduce it and the guy can help us walk out". It's associated with a lot of other serious injuries because of the amount of force it takes. Chances are there is a very low survival rate associated with it because it would tend to do catastrophic damage to the vascular structures not amenable simply to "pulling it out" even in urban areas which may explain why so few cases have been described in the literature. I've seen two cases that I can think of posteriorly displaced sternoclavicular disarticulations (I've seen several posteriorly displace acromioclavicular separations). Both of them were at autopsy.

 

[usafmedic45]

What would the best immobilization probably be? (Remember, the most-likely responder will be a friend or someone with less than the training and/or experience needed to correctly diagnose and address this, and it has to be immobilized even if it is reduced).

Secure the arm to the chest, avoid pressure over the clavicle and haul ***.

 

[mycrofft]

Agreed to all


Maybe some sort of "figure eight" to tend to keep the clav from mediating?

All of this is in ignorance (as in "ignoring") of the possible associated injuries such as neck injury, closed head injury, torn chest and shoulder ligaments, high-rib or penetrating pneumothorax, etc etc. I do not think this is a low-energy injury like a "trick knee"...unless someone in the field relocated it earlier.h34r:

 

[Akulahawk]

Bind the arm to chest, keep pressure off the clavicle and protect it from any jostling... if the patient has managed to somehow survive the initial insult.

There's another reason why you do not want to try to reduce this kind of dislocation. You only have a few minutes (about 5) from the moment of injury to attempt and complete a reduction. After that, the musculature that is attached to the clavicle will begin to to into a kind of tetany in order to create a natural splint. This will make it difficult-to-impossible to reduce the dislocated clavicle without fracturing it. There is a good reason why (for instance) people with dislocated shoulders are put under a goodly amount of sedation, if not short-term paralysis, for reduction.

I do know how to reduce shoulders... but I know that my best chance to do so is very early on and I'd better be darned certain that it's just a dislocation. Same thing with a SC dislocation. If I were to attempt a reduction, it'd have to be almost immediately post-injury because of the splinting problem. I can almost guarantee that unless I'm literally right there when it happens, there's no way that I'd be able to get to the scene, complete my assessment, deal with other major life-threats, and get to reducing a posterior SC dislocation before the splinting occurs. Thus, even if I found it, I'm going to do nothing more than secure the arm and minimize jostling to prevent further lateral impact on that shoulder, and therefore, increase pressure on that SC joint.

That's reality as I see it, assuming the patient does survive.

 

[usafmedic45]

if not short-term paralysis, for reduction.

LOL I've never seen a paralytic used for that purpose unless they had to fully anesthetize someone to do it (posterior dislocation with a concomitant fracture of the humeral surgical neck). LOL

 

[Akulahawk]

LOL I've never seen a paralytic used for that purpose unless they had to fully anesthetize someone to do it (posterior dislocation with a concomitant fracture of the humeral surgical neck). LOL

Normally, all that's needed is for the patient to be well snowed... but I've heard of even that not working. I would expect that such an event would be normally fairly rare. The last time I looked specifically at the need to medicate for reduction of shoulder dislocations was quite a number of years ago, but I do distinctly recall mention of having to have a paralytic on hand in the event that the patient's musculature isn't relaxed sufficiently by the sedation, and if paralytic use doesn't work... the patient would be off to the OR for open reduction, most likely. Of course, by the time the patient was undergoing the reduction, I'd expect that there'd be a goodly amount of imaging done to confirm the dislocation and give the physician a good idea of what it may take to reduce the dislocation.

I'll leave it at that as further discussion of such things border on getting away from the intent of this thread though, and may therefore constitute a thread-jack.