ISOLATED MANUBRIOSTERNAL DISLOCATION SECONDARY TO CRUSH INJURY

Objectives: Manubriosternal Joint (MSJ) Dislocation remains an elusive injury, infrequently seen in trauma. This unique injury pattern is sustained in less than 3% of trauma patients, yet carries significant clinical importance. Typically associated with deceleration or high energy trauma, these injuries, although nonfatal, can herald potentially lethal concomitant injuries. Additionally, these injuries can severely impair respiratory function. Despite the associated morbidity, a dearth of reports exist in the literature currently regarding this pathology. The optimal management of these injuries remains debated due to lack of randomized controlled trials and sparse occurrence. Many studies, coinciding with the advancement of sternal fixation devices, suggest that open reduction and internal fixation (ORIF) can reduce length of stay, cost, and improve quality of life. A 31 year-old female presented after sustaining a direct compressive blow from a car door which rolled over her central chest. Upon arrival, the patient was hemodynamically stable, but complained of central sternal pain with readily apparent deformity over her manubrium. Upon further work-up, she was found to have evidence of MSJ dislocation with posterior displacement of the manubrium relative to the sternal body as seen in Images 1 &2. Following admission, the patient had persistent pain and associated respiratory difficulty, which prompted consideration for open reduction and internal fixation. We achieved open reduction through direct sternal cut-down, debridement of the joint along the anterior periosteum, and reduction of the manubrium with bone reposition forceps. Fixation was performed with titanium sternal ladder (Image 3). Post-operative recovery was uneventful and she was discharged home. At follow-up the patient was healing well without crepitus, respiratory difficulty, or malalignment. Referred to as the eponymous “Angle of Louis”, the MSJ remains an integral component of chest wall stability, plasticity, and respiratory function - specifically inspiration. As previously mentioned, subluxation is infrequent, however can result from high-energy trauma or even minor trauma in those with pre-existing arthropathy. As the incidence is rare, the treatment remains unfamiliar to many trauma and thoracic surgeons. To compound, no preeminent guidelines have been established. Although treatment typically depends upon the stability of the injury, most cases reported in the literature required open reduction with internal fixation. Although more studies are needed, some studies suggest that operative fixation portends favor over conservative measures including decreased pain, length of stay, and healthcare costs. Here we present successful and efficient management of MSJ dislocation with open reduction and internal fixation with sternal plate.

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