Orthopedics

Case Reports 

Bipolar Clavicular Dislocation

Evan Argintar, MD; Michael Holzman, MD; Stephen Gunther, MD

Abstract

Bipolar clavicular dislocation rarely occurs. Although referred to by several different names (panclavicular dislocation, bifocal clavicle dislocation, traumatic floating clavicle, and periarticular clavicle dislocation), knowledge regarding appropriate treatment of this condition is limited. Conservative therapy remains the gold standard in asymptomatic individuals. In younger individuals with higher functional demands, or individuals with persistent pain or instability, open reduction with internal fixation of the acromioclavicular joint has also proven successful. In situations with continued medial instability, internal fixation can be used at both the acromioclavicular joint and sternoclavicular joint.

Chronic bipolar dislocation may require total claviculectomy, especially when chronic dislocation has led to nonviable acromioclavicular and sternoclavicular joint viability. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

Drs Argintar and Holzman are from Georgetown University Hospital, and Dr Gunther is from Washington Hospital Center, Washington, DC.

Drs Argintar, Holzman, and Gunther have no relevant financial relationships to disclose.

Since Beckman’s review of 16 complete dislocations of the clavicle in 1924, 1 few recorded cases of this injury exist. Bipolar clavicular dislocation has also been referred to as panclavicular dislocation, 2 bifocal clavicle dislocation, traumatic floating clavicle, 3 and periarticular clavicle dislocation. Knowledge regarding appropriate treatment of this condition is limited. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

A 55-year-old man sustained a fall from a 12-foot ladder while working for a window installation company. He reported the focus of his impact was centered on the anterolateral aspect of his shoulder. The patient was treated acutely for facial lacerations and a broken rib. Two years later, the patient presented with nonradiating right shoulder pain and dysphagia with vocal disturbance.

On examination, a deformity was visible to his right shoulder girdle (Figure ). The medial end of his clavicle appeared anterior/superior to his sternum. Laterally, a prominent acromion was visible. The clavicle was rigidly fixed in this position. The patient demonstrated diffuse tenderness to his shoulder, including at both poles of the clavicle. The patient was able to abduct his effected extremity to 75° (90° with his noninjured shoulder). He had forward flexion to 150° (165° noninjured shoulder) and symmetric external and internal rotation. He was able to raise both arms overhead and demonstrated no hand impairment. Bilateral shoulder strength was symmetric, peripheral pulses were strong, and the patient demonstrated normal sensation to light touch along all dermatomes. Radiographs revealed dislocation of both clavicular articulations with synostosis to the first and second rib (Figure ). The medial clavicular end was displaced superior/anterior, and the lateral clavicular end was in an inferior/posterior location.

Figure 1:. Clinical photographs demonstrating bipolar clavicular dislocation.

Figure 2:. Preoperative radiographs demonstrating bipolar clavicular dislocation.

Initially, we felt conservative therapy in the form of physical therapy would provide relief. Clinically, the patient demonstrated scapular dyskinesia, and he was subsequently prescribed rehabilitation for optimization of his shoulder girdle function. This intervention offered no symptomatic relief. With conservation treatment in excess of 2 years failing, we opted for surgical intervention.

With a surgical plan for bipolar clavicle osteotomy and acromioclavicular and sternoclavicular joint evaluation, at 2-year follow-up, the patient underwent operative intervention. A 6-cm skin incision was made along the length of the prominent clavicle and carried down to the bone. The clavicle was immobile, and we encountered medial synostosis to the first and second rib. This connection was osteotomized. Next, the clavicle was explored laterally, where its end was found encased in scars posterior to the acromioclavicular joint. At this point, both clavicle ends demonstrated no viable cartilage. With no hope of reconstituting either the normal acromioclavicular or sternoclavicular joints,…

Abstract

Bipolar clavicular dislocation rarely occurs. Although referred to by several different names (panclavicular dislocation, bifocal clavicle dislocation, traumatic floating clavicle, and periarticular clavicle dislocation), knowledge regarding appropriate treatment of this condition is limited. Conservative therapy remains the gold standard in asymptomatic individuals. In younger individuals with higher functional demands, or individuals with persistent pain or instability, open reduction with internal fixation of the acromioclavicular joint has also proven successful. In situations with continued medial instability, internal fixation can be used at both the acromioclavicular joint and sternoclavicular joint.

Chronic bipolar dislocation may require total claviculectomy, especially when chronic dislocation has led to nonviable acromioclavicular and sternoclavicular joint viability. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

Drs Argintar and Holzman are from Georgetown University Hospital, and Dr Gunther is from Washington Hospital Center, Washington, DC.

Drs Argintar, Holzman, and Gunther have no relevant financial relationships to disclose.

Correspondence should be addressed to: Evan Argintar, MD, 11000 Sugarbush Terrace, Rockville, MD 20852 (evanargintar@hotmail.com).
Posted Online: July 07, 2011

Since Beckman’s review of 16 complete dislocations of the clavicle in 1924, 1 few recorded cases of this injury exist. Bipolar clavicular dislocation has also been referred to as panclavicular dislocation, 2 bifocal clavicle dislocation, traumatic floating clavicle, 3 and periarticular clavicle dislocation. Knowledge regarding appropriate treatment of this condition is limited. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

Case Report

A 55-year-old man sustained a fall from a 12-foot ladder while working for a window installation company. He reported the focus of his impact was centered on the anterolateral aspect of his shoulder. The patient was treated acutely for facial lacerations and a broken rib. Two years later, the patient presented with nonradiating right shoulder pain and dysphagia with vocal disturbance.

On examination, a deformity was visible to his right shoulder girdle (Figure ). The medial end of his clavicle appeared anterior/superior to his sternum. Laterally, a prominent acromion was visible. The clavicle was rigidly fixed in this position. The patient demonstrated diffuse tenderness to his shoulder, including at both poles of the clavicle. The patient was able to abduct his effected extremity to 75° (90° with his noninjured shoulder). He had forward flexion to 150° (165° noninjured shoulder) and symmetric external and internal rotation. He was able to raise both arms overhead and demonstrated no hand impairment. Bilateral shoulder strength was symmetric, peripheral pulses were strong, and the patient demonstrated normal sensation to light touch along all dermatomes. Radiographs revealed dislocation of both clavicular articulations with synostosis to the first and second rib (Figure ). The medial clavicular end was displaced superior/anterior, and the lateral clavicular end was in an inferior/posterior location.

Clinical photographs demonstrating bipolar clavicular dislocation.

Figure 1:. Clinical photographs demonstrating bipolar clavicular dislocation.

Preoperative radiographs demonstrating bipolar clavicular dislocation.

Figure 2:. Preoperative radiographs demonstrating bipolar clavicular dislocation.

Initially, we felt conservative therapy in the form of physical therapy would provide relief. Clinically, the patient demonstrated scapular dyskinesia, and he was subsequently prescribed rehabilitation for optimization of his shoulder girdle function. This intervention offered no symptomatic relief. With conservation treatment in excess of 2 years failing, we opted for surgical intervention.

With a surgical plan for bipolar clavicle osteotomy and acromioclavicular and sternoclavicular joint evaluation, at 2-year follow-up, the patient underwent operative intervention. A 6-cm skin incision was made along the length of the prominent clavicle and carried down to the bone. The clavicle was immobile, and we encountered medial synostosis to the first and second rib. This connection was osteotomized. Next, the clavicle was explored laterally, where its end was found encased in scars posterior to the acromioclavicular joint. At this point, both clavicle ends demonstrated no viable cartilage. With no hope of reconstituting either the normal acromioclavicular or sternoclavicular joints, we decided complete clavicle resection offered the most predictable clinical outcome.

Meticulous dissection was conducted in a subperiosoteal fashion, as to avoid disturbing the neighboring brachial plexus and pleural cavity. Once the clavicle was removed in bloc, the remaining sharp edges of the rib were contoured to minimize prominence (Figure ). The sternocleidomastoid and other muscles were reattached to the anterior soft tissue sleeve, and were sutured along the line of the former clavicle location. The incision was closed with intradermal absorbable sutures, and the wound was covered with a sterile dressing.

Postoperative radiographs demonstrating shoulder girdle after claviculectomy.

Figure 3:. Postoperative radiographs demonstrating shoulder girdle after claviculectomy.

Early motion began 10 days postoperatively. At 1 month postoperatively, the patient was satisfied with the results of his surgery. Range of motion was symmetric, and the previous pain along his clavicle was relieved. Furthermore, the patient noted a decrease of the pressure in his throat that previously was exacerbated with deep inhalation and prolonged speech. Both the respiratory and musculoskeletal improvements that were clinically apparent early in the recovery period were maintained at the patients’ final office examination 1 year following his claviculectomy.

Discussion

The articular anatomy of the clavicle, both at the acromioclavicular and sternoclavicular joints, is well described. Functionally, the clavicle acts to protect the inferior brachial plexus and vessels, provides a frame for muscular attachment, and acts as a mechanical strut for the shoulder resulting in enhanced motion and strength in the upper extremity. Although isolated subluxations and dislocations of the acromioclavicular and sternoclavicular joints are well described, simultaneous injury resulting in bipolar dislocation is rare.

Based on these few reports, bipolar clavicle dislocation tends to be recognized and managed acutely. One case report documents sequential joint injury (delayed acromioclavicular joint dislocation) with completion during physical therapy 3 days after the initial injury. 4 Nearly all reported bipolar clavicle dislocations occurred as a consequence of high-energy traumatic injury, while only 1 patient sustained bipolar clavicular dislocation following several shoulder surgeries. 5 Sternoclavicular joint dislocations tend to occur in the anterior/superior direction, while all reported acromioclavicular joint dislocations were recorded as being displaced in the posterior/inferior direction.

Controversy exists for treatment of bipolar clavicular dislocation. The majority of bipolar dislocations have been treated conservatively. This approach, consisting of a combination of observation and physical therapy, has been successful. 2,3,6 Although complaints of poor cosmesis were frequent, patients were satisfied with shoulder girdle function. Only one patient managed conservatively later underwent subsequent operation for continued symptoms of pain and weakness (lateral clavicle excision). 7

Operative treatment has also demonstrated clinical effectiveness for treatment of bipolar clavicular dislocations. Operative interventions have included a combination of lateral clavicle resection with partial coracoacromial ligament transfer with coracoclavicular screw fixation, 8 acromioclavicular joint and sternoclavicular joint articular stabilization with percutaneously placed Kirschner wires, 9 transarticular sternoclavicular joint Kirschner wire fixation with a tension-band wire configuration at the acromioclavicular joint, 10 open reduction with internal fixation (ORIF) of the acromioclavicular joint with Kirschner wires with concurrent CA ligament repair, 11 and ORIF using 2 hook plates. 12 All operations required secondary operations for hardware removal.

Although a rare procedure, claviculectomy has been used for resection of metastatic or primary clavicular neoplasm, subclavian vessel repair, decompression for thoracic outlet syndrome, and debridement of osteomyelitis. Clinical review has demonstrated excellent functional results. 13,14 Calviculectomy is not without risks. Three complications have been reported in 5 patients, including subclavian vein laceration (1 patient) and superficial (2 patients) and deep (2 patients) infection. 15

One claviculectomy has been documented for treatment of bipolar clavicle dislocation. In 1999, Attarian 5 described this procedure for treatment of an atraumatic floating clavicle that developed 8 years following anterior glenohumeral stabilization for recurrent shoulder dislocation, as well ipsilateral lateral clavicle resections. At 1-year postoperatively, the patient reported relief of the majority of her symptoms, with mild weakness and fatigue.

Our patient is the first patient treated with claviculectomy for traumatic bipolar dislocation. With failure of conservative treatment, operative intervention was indicated as a result of the patients continued functional and vocal impairment. Due to the intraoperative findings of degenerative acromioclavicular and sternoclavicular joints, this salvage claviculectomy was performed because it was the most predictable option to accomplish pain control. The delay in injury identification contributed to this unique presentation, and removal of the patient’s clavicle resulted in complete symptomatic respiratory and musculoskeletal resolution.

Bipolar clavicular dislocation is a rare and potentially disabling injury. Conservative therapy remains the gold standard in asymptomatic individuals. In younger individuals with higher functional demands, or individuals with persistent pain and/or instability, ORIF of the acromioclavicular joint has proven successful. In situations with continued medial instability, internal fixation can be performed at both the acromioclavicular joint and sternoclavicular joint. Chronic bipolar dislocation may require total claviculectomy, especially when chronic dislocation has led to nonviable acromioclavicular and sternoclavicular joint viability.

References

  1. 1. Beckman T. A case of simultaneous luxation of both ends of the clavicle. Acta Chir Scandinavica. 1924; (56):156–163.
  2. 2. Gearen PF, Petty W. Panclavicular dislocation. Report of a case. J Bone Joint Surg Am. 1982; 64(3):454–455.
  3. 3. Jain ASTraumatic floating clavicle. A case report. J Bone Joint Surg Br. 1984; 66(4):560–561.
  4. 4. Cook F, Horowitz M. Bipolar clavicular dislocation. Report of a case. J Bone Joint Surg Am. 1987; 69(1):145–147.
  5. 5. Attarian DE. Atraumatic floating clavicle and total claviculectomy. J South Orthop Assoc. 1999; 8(4):293–296.
  6. 6. Pang KP, Yung SW, Lee TS, Pang CE. Bipolar clavicular injury. Med J Malaysia. 2003; 58(4):621–624.
  7. 7. Eni-Olotu DO, Hobbs NJ. Floating clavicle—simultaneous dislocation of both ends of the clavicle. Injury. 1997; 28(4):319–320. doi: 10.1016/S0020-1383(97)00009-0 [CrossRef]
  8. 8. Sanders JO, Lyons FA, Rockwood CAJr. Management of dislocations of both ends of the clavicle. J Bone Joint Surg Am. 1990; 72(3):399–402.
  9. 9. Arenas AJ, Pampliega T, Iglesias J. Surgical management of bipolar clavicular dislocation. Acta Orthop Belg. 1993; 59(2):202–205.
  10. 10. Scapinelli R. Bipolar dislocation of the clavicle: 3D CT imaging and delayed surgical correction of a case [published online ahead of print April 22, 2004]. Arch Orthop Trauma Surg. 2004; 124(6):421–424. doi: 10.1007/s00402-004-0669-2 [CrossRef]
  11. 11. Echo BS, Donati RB, Powell CE. Bipolar clavicular dislocation treated surgically. A case report. J Bone Joint Surg Am. 1988; 70(8):1251–1253.
  12. 12. Schemitsch LA, Schemitsch EH, McKee MD. Bipolar clavicle injury: posterior dislocation of the acromioclavicular joint with anterior dislocation of the sternoclavicular joint: a report of two cases. J Shoulder Elbow Surg. 2011; 20(1):e18–22. doi: 10.1016/j.jse.2010.08.016 [CrossRef]
  13. 13. Wood VE. The results of total claviculectomy. Clin Orthop Relat Res. 1986; (207):186–190.
  14. 14. Wessel RN, Schaap GR. Outcome of total claviculectomy in six cases [published online ahead of print December 22, 2006]. J Shoulder Elbow Surg. 2007; 16(3):312–315. doi: 10.1016/j.jse.2006.07.007 [CrossRef]
  15. 15. Krishnan SG, Schiffern SC, Pennington SD, Rimlawi M, Burkhead WZJr. Functional outcomes after total claviculectomy as a salvage procedure. A series of six cases. J Bone Joint Surg Am. 2007; 89(6):1215–1219. doi: 10.2106/JBJS.E.01436 [CrossRef]

10.3928/01477447-20110526-23

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