Traumatic manubriosternal dislocation: A new method of stabilization postreduction.

Traumatic manubriosternal dislocation is a rare lesion. In the literature, only a few case reports of patients treated surgically are published. In this case, we report an unstable posterior dislocation of the manubriosternal joint in a 50-year-old women caused by direct trauma. An open reduction was performed, and the manubriosternal joint was fixed by two staples. We are the first to use this alternative technique. At the last follow-up, the result was very good without complication.

INTRODUCTION

Manubriosternal dislocation is rare and occurs readily during a violent traumatism of the chest. Only 10 cases without predisposing factors such as arthropathy or infectious joint alterations have been described until now.[1-7] It is potentially serious injury that can be associated with concurrent injuries to ribs, lungs, spine, great vessels, or myocardium.

Only a few case of patients treated surgically are reported in the literature. In this study, we report a single case treated with an alternative method of stabilization.

CASE REPORT

A 49-year-old woman was referred to our department after a frontal car crash. She was complaining from anterior chest and left knee pains. At physical examination, the patient was conscious with stable vital signs. She had a blood pressure of 120/80mmHg, a pulse rate of 80 beats/min, a respiratory rate of 20 breaths/min, and O2 saturation at 100%.

Careful palpation revealed a painful and important deformity which is projected to the manubriosternal joint. Examination of the cardiovascular system was normal as was the electrocardiogram. Creatinine phosphokinase, myoglobin, and troponin were normal.

Lateral chest radiograph showed a type I manubriosternal joint dislocation: posterior displacement of the sternal body in relation to the manubrium [Figure 1], the mechanism of which was a direct impact to the sternum at the scoreboard (front passenger without seat belt, no airbag). Radiological examination found a fracture of the patella bone. No other thoracic lesion had been objectified.

Figure 1

Chest x-ray: Posterior manubriosternal dislocation

After 24 h of observation, the treatment was performed under general anesthesia in a supine position. After failure of closed reduction, the indication of surgical treatment had been raised. The manubriosternal joint had been identified using a midsternal approach of 5 cm. After removal of hematoma, we found the sternal body dislocated posterior to the manubrium [Figure 2]. The manubriosternal dislocation was unstable. After debridement of the joint and liberation of the intact, but stripped anterior periost, the sternum was reduced to the manubrium using a reduction clamp. The body was stabilized to the manubrium using two Blount staples [Figures 3 and 4]. The wound was closed in layers with small suction drainage tubes. A surgical treatment was carried out for the lesions of the left patella.

Figure 2

Operative view showing a posterior manubriosternal dislocation

Figure 3

Reduction and stabilization with staples

Figure 4

Postoperative x-ray showing the double staples stabilization

Postoperative recovery was uneventful, and the patient was discharged on the third postoperative day. Four months after the initial treatment, the outcome was satisfactory, the patient is asymptomatic and the manubriosternal joint is well aligned and stable.

DISCUSSION

The manubriosternal joint may be synovial, synchondrotic, or synostotic junction and because of the powerful ligamentous attachments in this region, dislocation of the manubriosternal joint is very much a rarity. Dislocation is most common with the synovial type of joint, whereas synchondral and synosteal types typically fracture through the manubrium rather than dislocate at the joint.[7]

Manubriosternal dislocation is an uncommon chest injury, typically resulting from a high-energy trauma. However, dislocation can be caused by a minor trauma among patients with preexisting manubriosternal arthropathy (most commonly, rheumatoid arthritis and extreme forms of kyphosis).[8] Only 10 cases without predisposing factors such as arthropathy or infectious joint alterations have been described until now, we represent the 11th case in the literature.

Thirupathi and Husted divided manubriosternal dislocations into two types: type 1, in which the sternum is dislocated posteriorly with respect to the manubrium, and type 2, in which the manubrium is dislocated posteriorly with respect to the sternum. Direct or indirect trauma may cause manubriosternal dislocation. Generally, type 1 injuries are caused by a direct impact to the body of the sternum.[9] It is possible to have a type 1 dislocation in the absence of any direct sternal trauma.[1] Type 2 injuries are due to hyperflexion of the upper thoracic spine that transmits a downward and posterior force to the manubrium via the first ribs.[7]

On physical examination, manubriosternal dislocation is usually diagnosed or suspected. Detecting this dislocation on frontal chest radiography is difficult,[9] but lateral chest radiographs can confirm the diagnosis. CT scan or MRI readily demonstrated the lesion and shows any associated mediastinal injury,[10] which can include potentially life-threatening injuries to the aorta, internal mammary artery, trachea, and esophagus. There are a few cases of manubriosternal dislocation in the literature, making it difficult to establish the incidence and the type of associated mediastinal injuries.

Treatment of a manubriosternal dislocation depends on the stability of the injury and the presence of associated injuries. Stable, uncomplicated injuries are treated with closed reduction and immobilization. Unstable injuries and those with an associated mediastinal injury may require open reduction and fixation.[7] If untreated correctly, these disorders can lead to chronic pain, periarticular calcification with ankylosis, and progressive deformity.

Published literature on surgical repair of manubriosternal dislocation is sparse and unfamiliar to most surgeons. It has not been possible to establish an optimal, standardized operative procedure so far because of the small number of reported cases. However, different methods were used for the fixation of the manubriosternal joint: Kirchner wires,[2] plates,[6] suture with PDS ropes[4] or braided polyester thread,[2] all of which have been reported to be successful.

We report an alternative technique which consists in simple stabilization with staples. In our opinion, this material is advantageous because it is more stable than sternal wires, and does not break as easily while being tied. Finally, ulceration of the skin with this method does not occur, as it may be observed with sternal wires.

We are the first to use a stapling technique; it allows us to make quick and efficient surgical gesture with excellent stability of the manubriosternal joint. We strongly believe that this method is safe and reliable, and favors immediate physiotherapy. In our case, the result without further complication is very good.

CONCLUSION

The manubriosternal dislocation is a rare and serious injury. Operative treatment can result in an early relief of complaints and return to a functional level. We describe a stapling technique not mentioned before in the literature. This method is efficient and safe resulting in stable fixation and good functional outcome.