Bipolar dislocation of the clavicle
The patient was informed that the case would be presented for publication and she agreed.\nA 41-year-old lady met with a car accident in June 2009 and was admitted to the hospital with the chief complaint of chest and back pain and restrictions of movements of right shoulder. During the accident, the patient was knocked down by a car when she was riding a motorcycle and trying to cross a street. She hit the ground with her right shoulder which suffered internal rotation and abduction. There was no history of coma, nausea, vomiting, respiratory distress, and shortness of breath.\nPhysical examination showed slight swelling and tenderness on the right shoulder. Sternoclavicular joint deformity [] was also spotted. Piano key sign and thoracic squeeze sign were both positive. Active abduction and flexion were limited to 60°, while there was limitation of extension and adduction. Passive abduction was restricted to 90°. There was bruising at the back.\nRadiographic examination showed dislocation of right acromioclavicular joint and sternoclavicular joint, multiple rib fractures, and minor right pleural effusion []. 3D CT reconstruction [] of the injured clavicle demonstrated posterior dislocation of the lateral end of the clavicle and anterosuperior dislocation of the sternoclavicular joint.\nOpen reduction and internal fixation was performed under general anesthesia through a 10-cm curved incision from acromian and a 5-cm horizontal incision on the right sternoclavicular joint. After exposure, superioposterior dislocation was at the acromio claviculer joint, while the medial end of the clavicle was found subluxed anteriorly and upward. Moreover, coracoclavicular ligament avulsion was also spotted. The sternoclavicular joint was fixed first. To relocate the clavicle, we firstly removed the adherent dense fibrous connective tissue in the joint space. Next, with a satisfied reduction of the clavicle, in the sternoclavicular joint, an oblique T-type steel plate was transfixed by four screws, while at the same time another lag screw was inserted from the superior surface of clavicle toward sternum []. The acromioclavicular joint was fixed with two Kirschner wires (3.0mm). The wires were inserted from the lateral end of acromion, parallel to the articulation []. Repair of the articular capsule and surrounding ligaments was then done.\nAfter wound closure, the patient was asked to wear an abduction device for a month. Passive motion exercises began after 1 week while the active ones began 2 weeks later. Removal of both Kirschner wires and plate was performed under general anesthesia 6 months after surgery. X-ray conducted 1 week [], 6 months [], 1 year [] and 2 years [] after the operation showed stable fixation and good relationship of both acromioclavicular and sternoclavicular joints. At 2 year followup, the patient had an abduction of approximately 150°, forward flexion of 160°, backward extension of 60°, and normal rotation [Figure –]. Besides, the power of the shoulder girdle muscles recovered and no instability of the dislocated joints was noted.