Rosen & Barkin's 5-Minute Emergency Medicine Consult (675 page)

• Infectious disease consultant
  
• Surgeon if source needs excision/drainage
  

• Blyth M, Estela C, Young AE. Severe staphylococcal scalded skin syndrome in children.
  Burns.
  2008;34:98–103.
  
• Freedberg IM, Eisen AZ, Wolff K, et al.
  Fitzpatrick’s Dermatology in General Medicine.
  6th ed. New York, NY: McGraw-Hill; 2003:195.
  
• Ladhani S. Recent developments in staphylococcal scalded skin syndrome.
  Clin Microbiol Infect
  . 2001;7(6):301–307.
  
• Patel GK, Finlay AY. Staphylococcal scalded skin-syndrome: Diagnosis and management.
  Am J Clin Dermatol.
  2003;4:165–175.
  
• Stanley JR, Amagai M. Pemphigus, bullous impetigo, and the staphylococcal scalded-skin syndrome.
  N Engl J Med
  . 2006;355(17):1800–1810.
  

CODES

695.81 Ritter’s disease

BASICS

• Sternoclavicular joint (SCJ) is the only joint that connects the upper limb to the trunk.
  
• Among the least frequently injured joints in the body
  
• Most commonly due to athletic or vehicular injuries
  
• Congenital or spontaneous dislocation and subluxation are rarely seen
  
• SCJ stability depends on ligamentous attachments, primarily anterior and posterior sternoclavicular ligaments, interclavicular ligament, and costoclavicular ligament
  

• Injury to the SCJ can be from sprains, subluxations, or dislocations of the ligamentous structure
  
• In sprains, ligamentous capsule remains intact
  
• Subluxation occurs when sternoclavicular ligament ruptures while costoclavicular ligament remains intact
  
• Complete ligamentous disruption leads to dislocation
  
• The SCJ can dislocate anteriorly or posteriorly. A large force is required. A greater force is required to displace the clavicle posteriorly.
  
• Direction of dislocation depends on the shoulder position:
  
  • Anterior dislocation more likely when the acromion is posterior to the manubrium.
    
  • Posterior dislocation more likely when the acromion is anterior to the manubrium.
    
• Anterior dislocation is more common (more than 90% of dislocations):
  
  • Caused by a posteriorly directed force to the anterolateral aspect of the shoulder
    
  • Reciprocal anterior displacement of the medial clavicle
    
  • May be associated with pneumothorax, hemothorax, pulmonary contusion, and rib fractures
    
  • Subluxation and dislocation may occur spontaneously.
    
• Posterior SCJ dislocation results from:
  
  • Anterior-to-posterior blow to the medial clavicle
    
  • Anteriorly directed force to the lateral aspect of the ipsilateral shoulder
    
  • A blow to the contralateral shoulder when the injured side is braced against an immobile object
    
• Posterior dislocation is a surgical emergency:
  
  • Indications for immediate reduction:
    
    • Compression or tear of trachea, esophagus, or great vessels
      
    • Recurrent laryngeal nerve injury
      

• The medial epiphyseal growth plates of the clavicles are last to ossify, and fuse between ages 22 and 25:
  
  • Until fusion, growth plate is the weakest part of the joint
    
• Fractures through the medial epiphysis mimic SCJ dislocations:
  
  • Most commonly Salter–Harris type I or II fractures
    
  • True dislocations of the SCJ are extremely rare in children because of strong ligamentous attachments.
    

DIAGNOSIS

• Pain and swelling localized to the medial clavicle and SCJ with appropriate mechanism
  
• Affected arm supported across the chest by the contralateral arm
  
• Inability to abduct or externally rotate arm
  
• If subluxed or sprained, the SCJ is tender on direct palpation and with shoulder movement:
  
  • No deformity or significant AP mobility
    
• If the SCJ is dislocated, shoulder appears shortened:
  
  • Head tilts toward injured side due to sternocleidomastoid muscle spasm
    
• In anterior dislocation, medial end of the clavicle is visibly prominent and palpable.
  
• In posterior dislocation, there may be a sulcus of the SCJ area through which the lateral border of the manubrium may be palpated:
  
  • Dislocation may be masked by significant swelling over the SCJ region, and may mimic anterior dislocation.
    
• Posterior dislocation may be accompanied by signs of vascular compromise or damage to mediastinal structures:
  
  • Signs of shock
    
  • Difficulty breathing or speaking
    
  • Upper extremity pain or neurologic symptoms
    

• High-energy direct blow, most often from athletic injuries or motor vehicle collisions
  
• Sprains and subluxations may be associated with other injuries of the shoulder girdle.
  

• Tenderness and swelling in sprains and subluxations
  
• In anterior dislocation, prominence of medial clavicle
  
• For any concern of posterior dislocation, assess for signs of airway or neurovascular compromise:
  
  • Dysphagia or respiratory distress may signify compression or disruption of trachea or esophagus.
    
  • Assess pulses in upper extremities
    
  • Hoarseness may signify injury to the recurrent laryngeal nerve.
    
  • Motor or sensory deficits suggest brachial plexus injury
    
  • Assess venous return in upper extremities:
    
    • Venous compression may lead to engorged upper extremity veins or venous thrombosis
      

• Comprehensive trauma evaluation and resuscitation for other life-threatening injuries
  
• Special attention to respiratory, neurologic, and vascular status
  
• A posterior dislocation implies substantial mechanism of injury; other life-threatening injuries must be ruled out.
  
• Appropriate analgesia for patient comfort
  

• Difficult to assess SCJ injury with routine radiographs:
  
  • May demonstrate asymmetry of the SCJ compared with contralateral side
    
  • More useful to assess coexisting bony, pulmonary, and mediastinal injury
    
  • Chest x-rays may be read as normal and further imaging is warranted if index of suspicion is high
    
• US can reliably demonstrate SCJ dislocations:
  
  • May be useful in the initial ED evaluation of unstable patients with chest trauma
    
  • Use high-frequency linear probe
    
  • In anterior dislocation, medial clavicle seen anterior relative to manubrium compared to contralateral side
    
• CT scan is best to evaluate the SCJ:
  
  • Useful when plain films are inconclusive
    
  • Accurately differentiates fractures from dislocations
    
  • Demonstrates the position of the medial clavicle
    
  • Shows detailed anatomy of the thoracic outlet and mediastinum
    
  • Contrast CT can show related vascular injuries and is the imaging modality of choice.
    
• MRI can be useful in demonstrating ligamentous and soft tissue SCJ injuries:
  
  • The articular disc is the most vulnerable soft tissue structure in SCJ injury.
    
  • Can demonstrate specific ligamentous injuries in the setting of joint subluxation
    
  • Better suited after the initial period of diagnosis and treatment
    
  • Can help distinguish true dislocation from physeal injury in pediatric patients
    

• Sternoclavicular sprain, subluxation, or dislocation
  
• Medial clavicle fracture
  
• Septic arthritis
  
• Osteomyelitis of medial clavicle
  

TREATMENT

• Attention to airway and vital signs, and neurovascular status of affected extremity
  
• Affected arm should be splinted in the position of comfort before transport to the ED.
  

• Endotracheal intubation for signs of airway compromise or as needed in the trauma patient
  
• Emergent SCJ reduction for:
  
  • Unstable or compromised airway
    
  • Signs of shock
    
  • Diminished pulses
    
  • Hoarseness
    
  • Dysphagia
    
  • Neurovascular compromise:
    
    • Upper extremity weakness
      
    • Paresthesia
      

• Sprains and subluxations
  may be treated symptomatically with ice, NSAIDs, sling immobilization, and orthopedic follow-up.
  
• Anterior dislocations
  may be reduced in the ED:
  
  • Procedural sedation for adequate pain control and muscle relaxation
    
  • Rolled towel placed between the shoulder blades in the supine position:
    
    • Longitudinal traction applied to the extended arm with shoulder abducted 90°
      
    • Assistant applies gentle pressure over the displaced end of the clavicle.
      
    • After reduction, immobilize with a well-padded figure-of-8 dressing.
      
  • Many anterior dislocations remain unstable after reduction.
    
  • Surgery rarely indicated, as deformity is mainly cosmetic
    
• Posterior dislocations
  require urgent reduction best achieved in the OR under general anesthesia:
  
  • Orthopedic and thoracic surgery consults
    
  • Closed reduction is preferred (and often successful) but may not be possible in injuries >48 hr.
    
  • If surgeon not immediately available, emergent reduction in the ED may be necessary:
    
    • Relieve serious airway, neurologic, or vascular compromise
      
    • Adequate sedation and analgesia are essential
      
    • Patient placed supine with a roll between shoulder blades
      
    • Affected arm is abducted and extended
      
    • Increased traction as arm is brought into extension
      
    • If unsuccessful, a sterile towel clamp is used to grasp medial clavicular head and apply gentle anterior traction