Rockwood Children CH19

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SECTION TWO • Upper Extremity

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Specific radiographic views to evaluate the sternoclavicular joint have been described to overcome these obstacles. Heinig described a tangential view of the sternoclavicular joint which is obtained by laying the patient supine and placing the cassette behind the opposite shoulder. The beam is then angled coro- nally, parallel to the longitudinal axis of the opposite clavicle (Fig. 19-16A). 57 Hobbs 62 proposed taking a 90-degree cephalo- caudal lateral view, by having the patient seated and flexed over a table while the beam is directed through the cervical spine (Fig. 19-16B). Finally, the serendipity view described by Rock- wood is performed by placing the cassette behind the chest and angling the x-ray beam 40 degrees cephalad while it is centered on the sternum, thus providing a view of both sternoclavicu- lar joints (Fig. 19-16C). 158 In cases of anterior dislocation, the Figure 19-15.  A: Apparent normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating asymmetry of the sternoclavicular joint with a posterior dislocation on the right. C: CT scan clearly showing the right poste- rior sternoclavicular dislocation. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

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evaluation occurs to rule out associated life-threatening inju- ries. Signs of venous congestion and arterial insufficiency to the involved extremity or neck region may be present due to com- pression of vessels. IMAGING AND OTHER DIAGNOSTIC STUDIES FOR STERNOCLAVICULAR FRACTURE–DISLOCATIONS As with any injury, plain radiographs are the initial imaging modality performed. The routine AP chest radiograph may demonstrate asymmetry of the sternoclavicular articulations or clavicle lengths. However, these studies can be quite difficult to interpret because of the overlap of the medial clavicle, lungs, ribs, sternum, and spine (Fig. 19-15).

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Figure 19-16.  A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs.