Migration of pins used in operations on the shoulder. F Lyons;C Rockwood; The Journal of Bone & Joint Surgery

Current concepts review: Migration of pins used in operations on the shoulder

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Upper Extremity Injuries in the Paediatric Athlete

Background A variety of reconstructive methods have been described for the treatment of sternoclavicular joint instability, yet none have been analyzed in the laboratory, to our knowledge. The purpose of the present study was to evaluate three different reconstruction techniques with use of a cadaveric model: (1) intramedullary ligament reconstruction, (2) subclavius tendon reconstruction, and (3) reconstruction with use of a semitendinosus graft placed in a figure-of-eight fashion through drill-holes in the clavicle and manubrium. Methods Thirty-six fresh cadaveric specimens were mounted supine on a materials testing machine in a custom testing fixture and were subjected to anterior and posterior subfailure translation to determine stiffness in the intact state after preloading. One of the three reconstruction methods was performed, and the specimens were subjected to anterior or posterior translation to failure. Changes in stiffness compared with the intact state were analyzed statistically. Results In the anterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than that of the intramedullary ligament reconstruction but was not significantly different from that of the subclavius tendon reconstruction. The peak load to failure (as defined by translation equal to the anteroposterior diameter of the medial head of the clavicle) was 230.3 +/- 146.1 N for the semitendinosus figure-of-eight reconstruction, 84.6 +/- 45.7 N for the intramedullary ligament reconstruction, and 75.6 +/- 19.0 N for the subclavius tendon reconstruction. In the posterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than those of both of the other reconstructions. The peak load to failure was 241.4 +/- 49.7 N for the semitendinosus figure-of-eight reconstruction, 85.0 +/- 22.8 N for the intramedullary ligament reconstruction, and 51.5 +/- 28.9 N for the subclavius tendon reconstruction. Conclusions The figure-of-eight semitendinosus reconstruction for sternoclavicular joint instability has initial biomechanical properties that are superior to those of the intramedullary ligament reconstruction and subclavius tendon reconstruction techniques. Clinical relevance While it is difficult to extrapolate in vitro data to the clinical situation, the figure-of-eight semitendinosus technique has superior initial biomechanical properties and may produce improved clinical outcomes in the surgical treatment of sternoclavicular joint instability.

Biomechanical analysis of reconstructions for sternoclavicular joint instability.

Traumatic sternoclavicular joint injuries account for <3% of all traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. MRI is useful in differentiating physeal injury from sternoclavicular dislocation in patients aged<23 years.

Clark Rl

Papers

Fatal aortic perforation and cardiac tamponade due to a Kirschner wire migrating from the right sternoclavicular joint.