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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 56-58

Traumatic manubriosternal dislocation with associated spinal injury


1 Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Cardiovascular and Thoracic Surgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication16-Dec-2016

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayana Medical College and Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-7391.195934

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  Abstract 

Traumatic manubriosternal dislocation is a rare sequel of blunt thoracic trauma. We report a case of 22-year-old man who presented with the history of road traffic accident and sustained manubriosternal dislocation. Initial chest X-ray did not show the lesion; however, a follow-up lateral view revealed the dislocation. In addition, the patient had fracture of the lamina of the C7 vertebra. In view of uncomplicated manubriosternal dislocation and the absence of any major associated injury, the patient was managed conservatively. In the presented case, we discuss the mechanism of injury, type of dislocation.

Keywords: Chest injury, manubriosternal joint dislocation, spinal injury, sternum


How to cite this article:
Agrawal A, Ramanujdaasudu CK, Subbarao K, Sandeep Y, Shrikhande NN. Traumatic manubriosternal dislocation with associated spinal injury. Niger J Cardiovasc Thorac Surg 2016;1:56-8

How to cite this URL:
Agrawal A, Ramanujdaasudu CK, Subbarao K, Sandeep Y, Shrikhande NN. Traumatic manubriosternal dislocation with associated spinal injury. Niger J Cardiovasc Thorac Surg [serial online] 2016 [cited 2020 Dec 5];1:56-8. Available from: http://www.nigjourcvtsurg.org/text.asp?2016/1/2/56/195934


  Introduction Top


A manubriosternal dislocation is rare following blunt thoracic trauma, and when the dislocation is associated with other injuries (to ribs, lungs, or myocardium), it can be potentially life-threatening. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] In the present article, we discuss a case of young male who sustained manubriosternal dislocation following fall on his back and discuss the pathophysiology and management of this rare condition.


  Case Report Top


A 22-year-old man presented with the history of road traffic accident hit by an auto rickshaw while he was going on a two wheeler. He had a history of fall on his back. There was a history of loss of consciousness for 15 min. There was no history of vomiting, seizures, or ear, nasal, and oral bleed. At the time of examination in the emergency room, the patient was conscious, alert, and oriented. He had mild tenderness over the chest region. His general and systemic examinations were normal. On chest examination, the air entry was equal bilaterally. Heart sounds were normally heard. His X-ray chest postereoanterior view was apparently normal. Blood investigations and electrocardiograph were normal. Computed tomography (CT) scan brain was normal. In view of history of loss of consciousness, the patient was admitted for conservative management and observation. The patient continued to complain pain over the chest. A repeat chest X-ray lateral view showed manubriosternal dislocation [Figure 1]. The patient was further investigated with a thin slice contrast CT scan of the chest which showed manubriosternal dislocation and fracture of the lamina of the C7 vertebra [Figure 2] and [Figure 3]. There was no evidence of other associated injuries. In view of uncomplicated manubriosternal dislocation, the patient was managed conservatively.
Figure 1: Apparently normal initial X-ray chest posteroanterior view.

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Figure 2: Left image: Chest X-ray lateral view shown type II manubriosternal dislocation, Right image: Three-dimensional computed tomography reconstruction of the sternum to show the manubriosternal dislocation.

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Figure 3: Computed tomography scan chest bone window showing fracture of the lamina of C7 vertebra on the right side.

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  Discussion Top


Manubriosternal dislocations are usually reported after in high-energy trauma sustained to thoracic region in motor vehicular accidents. [1],[6],[11] Whether the trauma shall result in a fracture or dislocation depends on the unique anatomical characteristics of the manubriosternal joint (hyaline more prone for dislocation and synchondrosis or synostosis more prone for fracture). [2],[3],[6] Anatomically, the manubrium is attached to the first rib with a massive costal cartilage which allows the first rib to control its movements, and additionally, the first ribs articulate posteriorly articulate with the first thoracic vertebrae through costovertebral and costotransverse joints (thus, transmitting force sustained by spine to the manubrium). [8] Depending on the relative position and displacement of the manubrium to the sternum, it can be dorsal dislocation of the sternum over manubrium (Type I, usually occurs due to the direct trauma to the chest wall) and ventral dislocation of the sternum over manubrium (Type II, usually occurs due to the hyperflexion and compression injury to the upper thoracic region). [1],[8],[12],[13] It has been reported that flexion of cervical and upper thoracic spine following a fall on the back generates a downward and backward force to the manubrium through the first ribs resulting in disruption of the joint and type II dislocation. [3],[12],[14],[15],[16]

In a patient who sustained chest trauma complains of chest pain, and on physical examination, he has associated local swelling over the sternum; clinically, one should suspect sternomanubrial dislocation and perform appropriate investigations (a lateral radiograph as a screwing tool). [6],[7],[17],[18],[19] A lateral radiograph may show an abnormal horizontally projecting interface (ventral or dorsal depending on the mechanism of the injury) located at the level of the superior mediastinum. [7] A thin slice CT scan (preferably with contrast) shall be the investigation of choice not only to confirm the diagnosis but also to rule out the other associated visceral injuries (injuries to the great vessels, trachea, esophagus, myocardium, and diaphragms), bony injuries (rib fractures, spinal fractures) or injuries to the neural elements. [6],[17],[18],[19] In adults, manubriosternal dislocation has been shown to be associated severe spinal column injury, [20] fortunately our patient had small lamina fracture without any neurological deficit.

The management of manubriosternal dislocation depends on the extent of dislocation and the severity of associated injuries. [3],[4],[19] A conservative approach in the form of close reduction can be adopted for stable and uncomplicated manubriosternal dislocation. [2],[3],[11] Surgical reduction and internal fixation are recommended for significant dislocation, and also to manage any associated mediastinal injury and to prevent delayed sequel (e.g., chronic pain). [2],[3],[4],[9],[21] Management of associated depends on the type and severity of injury. [6],[22] Arrhythmias associated with myocardial injury can be troublesome and shall need appropriate treatment. [23]


  Conclusion Top


Traumatic manubriosternal dislocation is a rare manifestation of blunt chest trauma. The clinical suspicion is the key for early diagnosis. Lateral chest radiograph can help confirm the diagnosis and a thin slice contrast CT is recommended for greater details of any associated injury and to plan the management. In a noncomplicated case without any major associated injury, conservative management shall result in good outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lyons I, Saha S, Arulampalam T. Manubriosternal joint dislocation: An unusual risk of trampolining. J Emerg Med 2010;39:596-8.  Back to cited text no. 1
    
2.
El Ibrahimi A, Smahi M, Shimi M, Lakranbi M, Sbai H, Daoudi A, et al. Traumatic manubriosternal dislocation: A new method of stabilization postreduction. J Emerg Trauma Shock 2011;4:317-9.  Back to cited text no. 2
    
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Schwagten V, Beaucourt L, Van Schil P. Traumatic manubriosternal joint disruption: Case report. J Trauma 1994;36:747-8.  Back to cited text no. 3
    
4.
Lemaitre J, Koriche C, Massard G, Wihlm JM. Manubriosternal disjunction a new approach for surgical repair. Acta Chir Belg 2004;104:593-5.  Back to cited text no. 4
    
5.
Cameron HU. Traumatic disruption of the manubriosternal joint in the absence of rib fractures. J Trauma Acute Care Surg 1980;20:892-4.  Back to cited text no. 5
    
6.
Kothari M, Saini P, Shethna S, Dalvie S. Manubriosternal dislocation with spinal fracture: A rare cause for delayed haemothorax. Chin J Traumatol 2015;18:245-8.  Back to cited text no. 6
    
7.
Nicholson AA, Holt ME, Jessop JD. Dislocation of the manubriosternal joint: Detection on frontal chest radiographs. Br J Radiol 1988;61:643-5.  Back to cited text no. 7
    
8.
Kelly MC, Hopkinson ND, Zaphiropoulos GC. Manubriosternal joint dislocation in rheumatoid arthritis: The role of thoracic kyphosis. Ann Rheum Dis 1986;45:345-8.  Back to cited text no. 8
    
9.
Diarra O, Ba M, Ndiaye A, Ciss G, Dieng PA, Sy MH, et al. Traumatic manubriosternal joint dislocation in adult: About two surgical cases. Dakar Med 2007;52:231-5.  Back to cited text no. 9
    
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Kälicke T, Feil E, Steuer K, Hansis M. Manubriosternal dislocation caused by indirect flexion-compression trauma. A case report and review of the literature. Unfallchirurg 2001;104:257-60.  Back to cited text no. 10
    
11.
Kälicke T, Frangen TM, Müller EJ, Muhr G, Hopf F. Traumatic manubriosternal dislocation. Arch Orthop Trauma Surg 2006;126:411-6.  Back to cited text no. 11
    
12.
Fowler AW. Flexion-compression injury of the sternum. J Bone Joint Surg Br 1957;39-B:487-97.  Back to cited text no. 12
    
13.
Thirupathi R, Husted C. Traumatic disruption of the manubriosternal joint. A case report. Bull Hosp Jt Dis Orthop Inst 1982;42:242-7.  Back to cited text no. 13
    
14.
Park WM, McCall IW, McSweeney T, Jones BF. Cervicodorsal injury presenting as sternal fracture. Clin Radiol 1980;31:49-53.  Back to cited text no. 14
    
15.
Sevitt S. Fatal road accidents. Injuries, complications, and causes of death in 250 subjects. Br J Surg 1968;55:481-505.  Back to cited text no. 15
    
16.
Nikas DJ, Freeman JE, Newsome RE Jr., Fletcher JR. Late repair of chest deformity secondary to traumatic manubriosternal disruption: Case report. J Trauma 1995;39:781-3.  Back to cited text no. 16
    
17.
Stanley D. Isolated traumatic anterior dislocation of the radial head - A mechanism of injury in children. Injury 1986;17:182-3.  Back to cited text no. 17
    
18.
Van Hise ML, Primack SL, Israel RS, Müller NL. CT in blunt chest trauma: Indications and limitations. Radiographics 1998;18:1071-84.  Back to cited text no. 18
    
19.
Smith M, Lenehan B, O′Keefe D, Martin A. Manubriosternal joint dislocation in contact sport. Emerg Med J 2001;18:488-9.  Back to cited text no. 19
    
20.
Gopalakrishnan KC, el Masri WS. Fractures of the sternum associated with spinal injury. J Bone Joint Surg Br 1986;68:178-81.  Back to cited text no. 20
    
21.
Nijs S, Broos PL. Sterno-manubrial dislocation in a 9-year-old gymnast. Acta Chir Belg 2005;105:422-4.  Back to cited text no. 21
    
22.
Ferguson LP, Wilkinson AG, Beattie TF. Fracture of the sternum in children. Emerg Med J 2003;20:518-20.  Back to cited text no. 22
    
23.
Gouldman JW, Miller RS. Sternal fracture: A benign entity? Am Surg 1997;63:17-9.  Back to cited text no. 23
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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