ALiEM AIR Series | Procedures Module

ALiEM AIR Series: Procedures 2023

Welcome to the AIR Procedures Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to procedures in the Emergency Department. 6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 2 AIR and 4 Honorable Mentions. We recommend programs give 3 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Procedures Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Procedures

SiteArticleAuthorDateLabel
Rebel EMIntra Articular Lidocaine vs Sedation in Shoulder ReductionsNordia Matthews, MD30 Jan 2023AIR
EM DocsVideo Laryngoscopy in the EDCameron Jones, MD8 Aug 2022AIR
First 10 EMLacerations: Does closure technique matter?Justin Morgenstern, MD28 Nov 2022HM
DFTBRegional nerve blocks moduleNicola Mulrooney, MD7 Dec 2022HM
EM DocsUltrasound Guided Regional Anesthesia for Hip FracturesOlivia Victoriano, MD and Jacob Avila, MD5 Dec 2022HM
Core EMUltrasound Guided Lumbar PuncturesAaron Bola, MD31 Mar 2022HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

Trick of the Trade: Gel-free ultrasound-guided peripheral IV technique

Ever finally step away from a busy resuscitation and someone stops you for peripheral IV access? You set up everything, have the patient positioned, and then notice there is no sterile ultrasound gel. No gel? No problem. The trick is to eliminate anything of poor acoustic impedance between the ultrasound probe and the patient’s skin.

Trick of the Trade

1. Apply a transparent adhesive dressing with a thin alcohol layer on the probe

Instead of using gel, we squeeze alcohol pads to create a thin alcohol layer and place a transparent adhesive cover, such as Tegaderm ©. The thin alcohol layer serves to eliminate any air bubbles under the adhesive cover as well as minimizes residual adhesive material sticking to the probe when removing the cover. The adhesive cover itself serves as a sterile barrier and a slick surface to improve probe maneuverability. Note that some ultrasound manufacturers do not recommend the use of isopropyl alcohol on their transducers. Therefore check your specific ultrasound’s recommendations before trying [1, 2].

2. Use sterile saline instead of gel on the patient’s skin

Squirt normal saline flush on the patient’s skin to create a coupling medium between the probe and the patient.

Why it works:

Ultrasound procedures use a range of frequencies (1.5-20 MHz) to visualize internal structures and require a medium to replace air, which has a poor acoustic impedance for the ultrasound waves [3]. Acoustic impedance is defined as the resistance of the propagation of ultrasound waves through tissues and is the product of the density and speed of sound in the tissue [4]. Ultrasound gel has an acoustic impedance that is similar to soft tissue and is therefore considered the ideal medium [3]. Because most soft tissue is comprised of water, the acoustic impedance of water, and therefore 0.9% saline, is actually pretty similar [5], as demonstrated by water bath techniques for ultrasounding distal extremity injuries [6].

We find great visual clarity for performing ultrasound-guided peripheral IVs using this trick, as shown in Figure 1.

Peripheral IV ultrasound screen without gel

Figure 1: Peripheral IV ultrasound using alcohol under transparent film dressing and topical saline flush – all without ultrasound gel

Read other Tricks of the Trade articles.

References

  1. Cleaning and Disinfecting FUJIFILM SonoSite Products User Guide [PDF]. Sonosite. 2015. Accessed April 5, 2023.
  2. Disinfectants and Cleaning Solutions for Ultrasound Systems and Transducers [PDF]. Philips. 2021. Accessed April 5, 2023
  3. Afzal S, Zahid M, Rehan ZA, et al. Preparation and Evaluation of Polymer-Based Ultrasound Gel and Its Application in Ultrasonography. Gels. 2022 Jan 6;8(1):42. doi: 10.3390/gels8010042. PMID: 35049577; PMCID: PMC8774352
  4. Suzuko S, Peter G, Philipp L. 20 – Local Anesthetics, Ed(s): Hugh C. Hemmings, Talmage D. Egan, Pharmacology and Physiology for Anesthesia (Second Edition), Elsevier, 2019, Pages 390-411, ISBN 9780323481106. DOI: 10.1016/B978-0-323-48110-6.00020-X
  5. R. Alkins, K. Hynynen, 10.08 – Ultrasound Therapy, Editor(s): Anders Brahme, Comprehensive Biomedical Physics, Elsevier, 2014, Pages 153-168, ISBN 9780444536334. DOI 10.1016/B978-0-444-53632-7.01010-8
  6. LeDonne S, Sengupta D. US Probe: Ultrasound Water Bath for Distal Extremity Evaluation. Alerhand S, Singh M, editors. emDOCs.net – Emergency Medicine Education. 2017.

By |2023-04-06T20:53:38-07:00Apr 12, 2023|Radiology, Tricks of the Trade, Ultrasound|

SAEM Clinical Images Series: A Rare Pediatric Scalp Rash

rash

The patient is a 3-month-old, full-term male who presents with a rash on his head. The rash started one day prior to presentation on his forehead and spread to the rest of his head. Today, it developed a central clearing with surrounding redness. He has a history of sensitive skin since birth with patches of eczema and cradle cap. He treats these with Aquaphor and Honest Co. Cream; he has never been prescribed topical steroids for his rashes. Denies fever, cough, rhinorrhea, congestion, decreased appetite, diarrhea, and decreased urination. He had an uncomplicated birth history.

General: Well appearing, no distress.

Skin: Large, serpiginous rash on the left forehead and scalp with central clearing and peripheral erythema as well as areas of erythematous plaques. He has some erythema of the left medial epicanthus. He also has a large erythematous patch at the base of his skull. The remainder of his skin is clear.

CV: Normal rate and rhythm, no murmur.

White blood cell (WBC) count: 8.4

Hemoglobin: 12.4

Hematocrit: 37.1

Platelet Count: 468

Complete metabolic panel (CMP): ALT 30, AST 60, Alk phos 266, Tbili 0.7, Total Protein 6.4

The image is of the cutaneous manifestation of neonatal lupus erythematosus. Neonatal lupus erythematosus is an autoimmune disease caused by transplacental passage of maternal autoantibodies to Sjögren’s syndrome A or B autoantigens (SS-A/SS-B). It can present with reversible changes including cutaneous lesions (most common, in up to 40% of patients), hepatobiliary disease, and cytopenias, which resolve once maternal autoantibodies have been cleared.

All infants that present with concern for neonatal lupus erythematosus should have screening labs performed to evaluate for hematologic, cardiac, and hepatobiliary involvement including a CBC with differential, liver enzymes, and antibody testing. In addition, an EKG is essential given that neonates can present with irreversible total atrioventricular heart block, which can present in utero or after birth.

The rash typically presents in the first few weeks of life but can present as late as 2-3 months of life (usually within 1-2 days of first sun exposure). Eighty percent of cases are not clear at birth and present in the first month of life. The rash appears as a coalescing rash with raised margins, with annular and discoid erythema involving the head in 95% of cases. It is often misdiagnosed as skin infections or eczema if the mom is asymptomatic. Fifty percent resolve by four months of life and 100% by one year.

Any neonate with a slow fetal heart rate or the postnatal diagnosis of atrioventricular heart block warrants immediate maternal testing for these autoantibodies. Most cardiac changes from neonatal lupus are diagnosed before 26 weeks gestation, with <20% later in pregnancy and 2% detected postnatally.

Take-Home Points

  • While cutaneous findings of neonatal lupus most commonly present in the first month of life, they can present as late as 2-3 months.
  • The cutaneous findings associated with neonatal lupus most of the time resolve in 4-6 months (when maternal antibodies are cleared from the infant’s circulation).
  • Any baby with findings concerning for neonatal lupus should have an EKG performed. Around 2% of infants present with heart block postnatally within the first month.

  • Diaz-Frias J, Badri T. Neonatal Lupus Erythematosus. [Updated 2021 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526061/
  • Lee LA. Neonatal lupus erythematosus: clinical findings and pathogenesis. J Investig Dermatol Symp Proc. 2004 Jan;9(1):52-6. doi: 10.1111/j.1087-0024.2004.00827.x. PMID: 14870986.

By |2023-04-05T14:00:29-07:00Apr 10, 2023|Dermatology, Pediatrics, SAEM Clinical Images|

Trick of the Trade: Chest tube rewarming with Foley tubing connector

You have a pulseless hypothermic patient requiring aggressive internal rewarming. ECMO is not available, and you’ve made the decision to initiate thoracic lavage. After placing your chest tubes, you step back triumphantly, but in short order, the nurse hands you large diameter IV tubing with warmed fluids so that you can connect it to the chest tube. You are left with the IV tubing in one hand and a chest tube in the other with no time to waste, but no elegant or straightforward solution to interface the two.

Trick of the Trade

Using Foley bag tubing

The tube from a standard Foley bag, available in all emergency departments, contains a Luer lock near the tapered nozzle. This unique connector setup allows you to instill warm fluids into the thoracic space with minimal spillage.

rewarming hypothermia IV tubing chest tube foley tubing

Technique for Rewarming

  1. Attach the warmed IV fluids to the Luer lock port on the Foley bag tubing.
  2. Insert the tapered nozzle on the Foley bag tubing (typically interfaces with the urine drainage port of the Foley catheter) into the chest tube.
  3. Clamp the remainder of the Foley bag tubing just proximal to the Luer lock to minimize backflow of IV fluids into the bag.
  4. Optional: Cut the tubing proximal to the clamp to declutter the space around the interface.
  5. Instill warm fluid through one chest tube and drain it from the adjacent chest tube.
  6. Continue rewarming resuscitation protocols.
Chest tube connected to IV tubing via Foley bag tubing

IV tubing connected to chest tube via Foley bag tube (left photo is a closeup view with arrow designating IV fluid flow)

Read other Tricks of the Trade posts.

The Febrile Infant: Incorporating the 2021 American Academy of Pediatrics guidelines

Can you trust a febrile infant?

“No” has been, and continues to be, the resounding answer over the last 40 years as researchers and clinicians work to determine the optimal evaluation and management of the well-appearing young febrile infant [1].

The goal remains to identify infants with bacterial infections in this at-risk cohort of patients while also considering the balance of cost-effectiveness on a population scale and the potential for iatrogenic harm with evaluation such as unnecessary lumbar punctures, unnecessary antibiotics, and unnecessary hospitalization. Fortunately, bacteremia and bacterial meningitis in this age group are uncommon [2]. Unfortunately, delayed or missed diagnosis can be devastating [1-3].

In the most recent 2021 Clinical Practice Guideline, the American Academy of Pediatrics (AAP) aims to provide guidance with 3 separate age-based algorithms for the evaluation and management of the well-appearing febrile infant [4]. These guidelines were made possible by the recent PECARN, Step by Step, and other studies and the invaluable information they have provided [5-7].

Who’s included?

  • Well-appearing febrile infants
    • The AAP acknowledges that clinician experience is likely the best determinate of what is “well-appearing”, further admitting that there is no measure or definition of either “experience” or “well-appearing”
  •  Febrile
    • Rectal temperatures of  38.0C or 100.4F at home in the past 24 hours or determined in a clinical setting
    • Subjective fevers at home are excluded
  •  Gestation
    • Between 37-42 weeks
    • Premature infants excluded
  • Age
    • Days 8 to 60 and have been discharged home following birth

Who is not included?

  • Preterm or infants with congenital/chromosomal abnormalities
  • Infants with focal bacterial infections
  • Cellulitis, omphalitis, septic arthritis, osteomyelitis
  •  Bronchiolitis
    • With or without a positive RSV test
  •  Immunocompromised
    • Either suspected or known deficiency
  • Immunizations in the previous 48 hours

It should also be noted that the AAP has named the following as high-risk inflammatory markers that will be referenced in the soon-to-be-discussed guidelines [4,5].

  • Temperature >101.3F (38.5C)
  • C-reactive protein (CRP) > 20 mg/L
  • Procalcitonin >0.5 ng/mL
  • Absolute neutrophil count (ANC) >4000 mm3  (or 5200 mm3 if your facility does not have procalcitonin available)

The Groups

While the AAP makes the distinction of an age 0-7 days group from the age 8-21 days, they provide no specific recommendations about emergency department (ED) management in the youngest group [4]. Despite this, these infant groups are likely best evaluated and managed similarly in the ED:

  • Urinalysis (UA) +/- urine culture if indicated by UA
  • Blood culture
  • Lumbar puncture (LP)
    • Cell count, Gram stain, glucose, protein, bacterial culture, and enterovirus PCR (if available)
  • Admission

Inflammatory markers are not required to determine ED management in this age group but may guide inpatient clinicians.

Treatment

  • Ampicillin IV or IM
  • Ceftazidime IV or IM or gentamicin IV or IM

The addition of acyclovir to IV antibiotics depends on the following risk factors which increase the likelihood of HSV:

  • Maternal genital HSV lesions or fever 48 hours before or after delivery
  • Infants with vesicles, seizures, hypothermia, mucous membrane ulcers
  • CSF pleocytosis with a negative Gram stain result
  • Leukopenia, thrombocytopenia, or elevated AST/ALT levels

Although many febrile infants in this group will still require a full evaluation for sepsis, there are some new alternatives in patients meeting certain criteria. At the minimum, all 22-28 day old infants will need:

  • UA +/- culture
  • Blood culture
  • Inflammatory markers (ANC, CRP, procalcitonin)

Further management of a well-appearing infant in this group can be based on the following pathways:

    1. If UA positive with negative inflammatory markers
      • LP may be performed but is not required
      • IV antibiotics and admission are required regardless
    2. If UA negative with negative inflammatory markers, then there are 2 options
      • Perform LP
        • If LP negative, then the patient can be given a dose of parenteral antibiotics and discharged home with close follow-up in 24 hours.
        • If LP is traumatic or pleocytosis is present, administer antibiotics and admit.
      • Defer LP
        • Antibiotics may be administered, but the patient should be admitted.
    3. If UA negative and ANY positive inflammatory marker (procalcitonin > 0.5 mg/mL, CRP >20 mg/L, ANC >4000, or temperature >101.3F), LP is required
      1. If LP positive
        • Admit with IV antibiotics
      2. If LP negative
        • Admit +/- antibiotics, OR
        • Discharge home after one dose of parenteral antibiotic with 24-hour follow-up

Treatment

  • Same antibiotic options as the day 0-21 infants

The nuances of this group’s decision tree revolve around the inflammatory markers.

Each infant in this group should have the following completed:

  • Urinalysis
  • Blood Cultures
  • Inflammatory markers (CRP, ANC, and procalcitonin)

If everything is negative (UA & inflammatory markers):

  • Infants may be discharged home without antibiotics and with close follow-up within 36 hours.

If inflammatory markers are negative:

  • Infants with a positive urinalysis and negative inflammatory markers may be treated with oral antibiotics.
    • They may be either admitted to the hospital for observation or discharged with 24-hour follow-up.
    • No LP needed.

If inflammatory markers are positive:

  • A LP may be performed if the clinician feels it necessary but is not required.
    • If performed and CSF is negative the infant may be discharged with close follow-up.
    • Given high risk of bacteremia with elevated inflammatory markers in this age group, a dose of parenteral antibiotics prior to discharge is appropriate.
  • If LP deferred:
    • Administer parenteral antibiotics, and likely admit to hospital.
    • The caveat to this is if they have viral testing completed that is positive and are well appearing.
      • Example: A 48-day-old infant presents with a fever of 100.6F, CRP of 22 mg/L, and otherwise normal procalcitonin, ANC, and UA. The mother reports that an older brother has had a runny nose. Viral PCR testing is positive for rhinovirus. Seeing as the UA is negative, the infant appears well with a positive viral test, they may go home with shared decision-making and close outpatient follow-up, despite a positive inflammatory marker (CRP 22 mg/L) [3].

Treatment

Urinary Tract Infection:

  • Ceftriaxone (IV/IM) or cephalexin/cefixime as oral options.

Concern for Bacteremia/Meningitis:

  • Ceftriaxone + vancomycin
  • May add acyclovir for the above-mentioned antiviral treatment indications.

What should be done if the viral panel is positive?

  • Children 29 days or older with fever from a documented viral source can be managed according to their clinical presentation and can go outside the algorithm.
  • This requires a documented positive viral swab and not just a presentation consistent with a viral syndrome.
  • UTI is common in this age group, and a UA should be obtained [8].

Conclusion

Over the course of nearly the last half century there has been a lack of clear evidence-based guidelines in evaluating the young febrile infant [1]. Although serious bacterial infections in these young, febrile infants are uncommon, studies show that in the first month of life, bacteremia can be present in nearly 3% of febrile infants, with bacterial meningitis occurring in about 1% [2]. The absence of consensus regarding management has led to significant costs due to hospitalizations and their associated iatrogenic complications [9]. In the movement to create new recommendations, shifting epidemiology pushed changes in previous guidelines with a new focus on the use of the now widely available inflammatory markers [10].  With the advent of multiple large-scale studies and the recent improvements in lab testing, the newly updated AAP guidelines provide recommendations on how to manage this challenging population [4-7].

Take Home Points

  • These management strategies can only be used in WELL-APPEARING infants – if they’re ill-appearing, do a complete workup.
  • Evaluation of febrile infants 0-21 days remains the same – do everything (blood culture, UA +/- culture, LP with CSF studies), give antibiotics, and admit.
  • For those infants 22-28 days, get the UA, blood culture, and inflammatory markers to guide management.
    • Not all febrile infants in the 22-28 day subset need an LP, though it should still be obtained in certain clinical circumstances, and discussed between  provider and parents in other situations
  • In infants ≤28 days, a complete workup is still needed even if a viral source is present.
  • Febrile infants 29-60 days old may be sent home after a negative workup with close follow-up.

References:

    1. Roberts KB. Young, febrile infants: a 30-year odyssey ends where it started. JAMA. 2004 Mar 10;291(10):1261-2. PMID: 15010450.
    2. Biondi EA, Lee B, Ralston SL, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis.JAMA Network Open. 2019 Mar; 2(3). PMID: 30901044.
    3. Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week old infants. Pediatrics. 1990;85(6):1040–1043. PMID: 2339027
    4. Pantell RH, Roberts KB, Adams WG, et al. Clinical Practice Guideline: Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. PMID: 34281996
    5. Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. PMID: 30776077
    6. Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” approach in the management of young febrile infants. The Journal of Pediatrics. 2016 Aug; 138(2):e20154381. PMID: 27382134
    7. Nguyen THP, Young BR, Poggel LE, et al. Roseville Protocol for the Management of Febrile Infants 7-60 Days. Hosp Pediatr. 2020 Dec 17:hpeds.2020-0187. PMID: 33334815
    8. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302-308. PMID: 18316994
    9. Coyle C, Brock G, Wallihan R, Leonard JC. Cost Analysis of Emergency Department Criteria for Evaluation of Febrile Infants Ages 29 to 90 Days. J Pediatr. 2021 Apr;231:94-101.e2. doi: 10.1016/j.jpeds.2020.10.033. Epub 2020 Oct 31. PMID:33130155.

    Milcent K, Faesch S, Gras-Le Guen C, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants [published correction appears in JAMA Pediatr. 2016 Jun 1;170(6):624].JAMA Pediatr. 2016;170(1):62-69. doi:10.1001/jamapediatrics.2015.3210 PMID: 26595253

SAEM Clinical Images Series: An 8-year-old Male with Dysuria

dysuria

An 8-year-old Caucasian male with no significant past medical history presented to the pediatric emergency department (ED) with complaints of three days of abdominal pain and dysuria, accompanied by nausea, vomiting, and poor oral intake. The patient had previously presented to his pediatrician, where he was found to have microscopic hematuria and subsequently sent to the ED. Microscopic hematuria and increased abdominal pain in the ED prompted a point of care ultrasound (POCUS).

GI: Soft on palpation, normal bowel sounds, tender to palpation at midline below the umbilicus.

GU: No trauma or erythema of the penis.

Remaining exam wnl.

Urinalysis (UA): Yellow; Cloudy; Ketones: 15; Protein >=300; Leukocyte esterase: large; Nitrite: positive; WBC/HPF: Packed; RBC/HPF:51-100

Urine Culture: >100,000 staphylococcus CFU/mL

The most likely site of abnormality in this patient is the urethra. Image 1 shows massive bilateral hydronephrosis while image 2 shows hydroureter and bladder wall thickening. This presentation in a male, together with the lab findings suggestive of a UTI, should raise concerns for posterior urethral valves (PUV). PUV, a congenital obstruction of the urethra, is one of the most common causes of lower urinary tract obstruction in males. [1]

The next step in management for patients with probable PUV is a referral to a urologist for a voiding cystourethrogram (VCUG) and cystoscopy to assess for vesicoureteral reflux and valvular obstruction. Patients who are found to have PUV can then undergo incision and correction of the urethral valve. PUV typically presents in the newborn period in males with a poor urinary stream, urinary tract infections, and other voiding complaints and can be corrected with bladder catheterization or valvular ablation [1,2].

Take-Home Points

  • While rare, PUV should be considered in the differential for any pediatric patient presenting with urinary tract-related complaints, abdominal pain, and unexplained nausea or vomiting, particularly in school-aged males.
  • A school-aged male without an underlying diagnosis presenting to the hospital with a UTI should prompt clinicians to look for underlying predisposing conditions, such as PUV – an undertaking in which bedside ultrasound can be extremely useful.
  • Point of care ultrasound (POCUS) is a tool used in real time by emergency physicians to provide evidence for hydronephrosis, which can lead to the diagnosis of PUV.

  • Hodges SJ, Patel B, McLorie G, Atala A. Posterior urethral valves. ScientificWorldJournal. 2009 Oct 14;9:1119-26. doi: 10.1100/tsw.2009.127. PMID: 19838598; PMCID: PMC5823193.
  • Shields LBE, White JT, Mohamed AZ, Peppas DS, Rosenberg E. Delayed Presentation of Urethral Valves: A Diagnosis That Should Be Suspected Despite a Normal Prenatal Ultrasound. Glob Pediatr Health. 2020 Oct 15;7:2333794X20958918. doi: 10.1177/2333794X20958918. PMID: 33117862; PMCID: PMC7570289.

SAEM Clinical Images Series: My Shoulder Hurts

An 18-year-old male presents to the Emergency Department (ED) with right shoulder pain after wrestling with his brother. He heard a “pop,” and has been having pain along his right clavicle and shoulder since. He is unable to move his right shoulder. No numbness, tingling, or weakness in his arm or hand. No dysphagia, stridor, or shortness of breath. No medical or surgical history. He has no history of shoulder dislocation or fractures.

Vitals: HR 71; BP 139/77; RR 18; O2 sat 98% on RA

General: Uncomfortable appearing young man with his right arm held in adduction and internal rotation.

Respiratory: Clear breath sounds without stridor or shortness of breath.

CV: Heart is regular rate and rhythm without murmur, rub or gallop. Radial pulses are 2+ bilaterally, with brisk capillary refill.

MSK: Right shoulder without gross deformity. Right sternoclavicular joint is boggy, tender to palpation, and asymmetric when compared to the left. Limited active range of motion due to pain.

Neuro: Grip strength is 5/5 bilaterally, with intact motor and sensation demonstrated in the radial, median and ulnar distributions.

Shoulder and clavicular x-ray: No fracture or dislocation.

Point-of-care ultrasound: Clavicle (blue circle) posterior to the sternum (red square) at the sternoclavicular joint.

This is a posterior sternoclavicular dislocation. These dislocations are rare and are often the result of indirect lateral shoulder compression. It takes a high level of suspicion to diagnose as the physical exam and initial x-ray may be unrevealing. These patients require admission with emergent orthopedic consultation as there is a 30% chance of developing life-threatening complications due to damage of underlying structures including the trachea, esophagus, innominate artery and vein, and thoracic duct. Closed reduction in the operating room (OR) is typically the first line of treatment, with open reduction and internal fixation with cardiothoracic surgery consult available as the secondary treatment option.

CT with contrast is the imaging modality of choice, showing the sternoclavicular relationship in detail and allowing for evaluation of the underlying vascular and mediastinal structures. If unavailable, an oblique “serendipity view” x-ray may allow for better evaluation of the sternoclavicular joint than a standard shoulder or clavicle series. Additionally, point-of-care ultrasound can be an imaging modality that allows for quick and reliable bedside evaluation and diagnosis of sternoclavicular dislocation.

Take-Home Points

  •  Consider posterior sternoclavicular dislocation for those with traumatic shoulder or clavicular pain, particularly when the initial x-ray is unrevealing.
  • Posterior sternoclavicular dislocation can have subtle exam findings that are easily missed if a high level of suspicion is not maintained.
  • Posterior sternoclavicular dislocations can result in damage to underlying structures and require emergent orthopedic consultation for reduction in the OR with cardiothoracic backup available.

  • Bengtzen RR, Petering RC.Point-of-Care Ultrasound Diagnosis of Posterior Sternoclavicular Joint Dislocation. The Journal of Emergency Medicine. (2017) Volume 52,(4) 513-515. https://https://doi.org/10.1016/j.jemermed.2016.11.001.
  • Deren ME, Behrens SB, Vopat BG, Blaine TA. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthop Rev (Pavia). 2014 Mar 12;6(1):5245. doi: 10.4081/or.2014.5245. PMID: 24744842; PMCID: PMC3980158.
  • Grantier III RL, Craddock P. Recanting Impressions: Posterior Sternoclavicular Joint Dislocation. EMResident, Published 2018 June 6.
  • Roepke C, Kleiner M, Jhun P, Bright A, Herbert M. Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation. Ann Emerg Med. 2015 Nov;66(5):559-61. doi: 10.1016/j.annemergmed.2015.09.015. PMID: 26497437.

By |2023-03-18T23:11:47-07:00Mar 20, 2023|Orthopedic, SAEM Clinical Images|
Go to Top