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Traumatic Sternomanubrial Dislocation with Associated Bilateral Internal Mammary Artery Occlusion

¹ Department of Radiology, University of Washington, 1959 N.E. Pacific, Box 357115, Seattle, WA 98195.
² Department of Radiology, Harborview Medical Center, University of Washington, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
³ Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA 98104-2499.

Received July 23, 2002; accepted after revision July 23, 2002.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee B. Talner.

Address correspondence to F. A. Mann.

A 23-year-old man sustained extensive polytrauma in a high-speed motor vehicle crash. Initial chest radiography showed a widened mediastinum, and thoracic aortography showed an isolated occlusion of the internal mammary arteries bilaterally and posterior dislocation of the manubriosternal joint (Fig. 1A,1B,1C).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —23-year-old man who sustained type 2 sternomanubrial dislocation in high-speed motor vehicle crash. Resuscitation chest radiograph shows widening of superior mediastinum with no bone abnormalities.

View larger version (59K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —23-year-old man who sustained type 2 sternomanubrial dislocation in high-speed motor vehicle crash. Lateral fluoroscopic image of sternum shows type 2 sternomanubrial dislocation (arrows).

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —23-year-old man who sustained type 2 sternomanubrial dislocation in high-speed motor vehicle crash. Left anterior oblique aortic angiogram shows occlusion of internal mammary arteries bilaterally (arrows) without aortic or great vessel injury.

Sternomanubrial dislocation is a rare injury, typically resulting from a high-energy trauma. However, among patients with preexisting sternomanubrial arthropathy (most commonly, rheumatoid arthritis), dislocation can be caused by a minor trauma [1]. The sternomanubrial joint may be synovial, synchondral, or synosteal. 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 [2]. Two types of sternomanubrial dislocations have been described: 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. Type 1 injuries are caused by a direct impact to the body of the sternum. Type 2 injuries, which are more common, are due to hyperflexion of the upper thoracic spine that transmits a downward and posterior force to the manubrium via the first ribs [3].

Sternomanubrial dislocation is usually diagnosed or at least suspected at physical examination. Detecting sternomanubrial dislocation on frontal chest radiography is difficult. An abnormal horizontal interface projecting over the superior mediastinum has been described as a clue to diagnosis, but it is by no means a definitive sign [1]. Lateral chest radiographs or CT scans can confirm the diagnosis. CT readily depicts the injury and shows any associated mediastinal injury [4], which can include potentially life-threatening injuries to the aorta, great vessels, trachea, and esophagus. Identification of an internal mammary artery injury without a known sternomanubrial dislocation or sternal fracture warrants further evaluation of these structures. Upper thoracic spine and rib fractures share the hyperflexion mechanism of type 2 sternomanubrial injuries [2, 5].

Treatment of a sternomanubrial dislocation depends on the stability of the injury and the presence of associated injuries. Stable, uncomplicated injuries are treated with closed reduction. Unstable injuries and those with an associated mediastinal injury may require open reduction [2]. Investigations with catheter angiography, esophageal contrast studies, or bronchoscopy should be pursued if there is any suspicion of injury to the corresponding mediastinal structure.

References

Top References

 

1. Nicholson AA, Holt ME, Jessop JD. Dislocation of the manubriosternal joint: detection on frontal chest radiographs. Br J Radiol 1988;61:643 -645[Medline]
2. Schwagten V, Beaucourt L, Van Schil PV. Traumatic manubriosternal joint disruption: case report. J Trauma 1994;36:747 -748[Medline]
3. Fowler AW. Flexion-compression injury to the sternum. J Bone Joint Surg Br 1957;39:487 -497
4. Van Hise ML, Primack SL, Israel RS, Muller NL. CT in blunt chest trauma: indications and limitations. RadioGraphics 1998;18:1071 -1084[Abstract]
5. Jones HK, McBride GG, Mumby RC. Sternal fractures associated with spinal injury. J Trauma 1989;29:360 -364[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cheng, S. G. Articles by Borsa, J. J. Search for Related Content PubMed PubMed Citation Articles by Cheng, S. G. Articles by Borsa, J. J. Social Bookmarking                      What's this?