Abstract
HISTORY: A 19-year-old men’s college Rugby-15s winger collapsed during match play. The player had no impact with another player, dizziness and no loss of consciousness. A medical history revealed the player had sustained a right clavicular injury in a previous match 25 days prior to this incident. Where he complained of right shoulder pain, after impacting the ground with a multi-player tackle. The player had presented to an Urgent Care facility after that injury and provisionally diagnosed with shoulder sprain -vs- pectoralis strain, placed in arm-sling and sent home on oral analgesics. Right shoulder radiographs at Urgent Care visit were read as normal. PHYSICAL EXAM: Exam in ED revealed slurred speech, and complaints of localized pain and tenderness on right medial clavicle. Right sternoclavicular joint pain on palpation. Limited upper extremity range of motion secondary to pain, no facial droop, decreased left sided upper and lower extremity sensation, reflexes and strength. Symmetrical radial pulses with brisk capillary refills. DIFFERENTIAL DIAGNOSIS: 1. Cervical Neck Injury 2. Stroke 3. Fracture Clavicle 4. Rib Fracture 5. Scapular Fracture 6. Sternal Fracture TEST AND RESULTS: Chest anterior-posterior radiographs: -abnormal right SCJ MRI Brain no contrast: -Large area/acute infarction. Mass effect of right lateral ventricle. No hydrocephalus. Midline shift 1-2mm. CT brain no contrast: -Right MCA infarction with right frontal/parietal lobes, insular cortex, thalamus, caudate nucleus, internal/external capsule, and lentiform nucleus. -Mass-effect on the right lateral and third ventricles. Increased midline shift 8mm. No hydrocephalus. Carotid Duplex: -Arteries bilaterally, normal velocities/waveforms. CT chest: -Right clavicular head dislocated posterior to the sternum, in the superior mediastinum. Subperiosteal hematoma around proximal right clavicle. FINAL/WORKING DIAGNOSIS: Missed posterior sternoclavicular joint dislocation with brachiocephalic artery compromise leading to hemiparesis TREATMENT AND OUTCOMES: 1. Surgical Emergency. Often missed on radiograph. 2. Open repair of brachiocephalic artery, right clavicular reduction/SCJ capsulorraphy with hamstring tendon allograft. 3. Patient recovered with left sided hemiparesis. No return to sport. Sponsor: NOCSAE.org
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