Posterior dislocation of the clavicular head…quite close to the blood vessels and the trachea (www.radiographics.rsna.org)

Most NFL fans know that St. Louis Rams wide receiver Danny Amendola left last Thursday night’s game against the Arizona Cardinals (which the Rams won, handing the Cardinals their first loss) with a right clavicular (collarbone) injury. After being evaluated in the locker room, he returned to the sideline in street clothes, right arm in a sling, to support his team for the remainder of the game.  We know that the left arm was working fine, as evidenced by his frustrated helmet toss on the way in to be treated.

In a surprising twist, Jay Glazer reported during Fox’s pregame show that Amendola’s injury was potentially life-threatening.  On his twitter timeline, Glazer commended that Rams medical staff for correcting the problem immediately.

So what really happened to the wide receiver?  He sustained a clavicular head dislocation, where the part of the collarbone closest to the sternum (breastbone) becomes detached and slips out of position.  Normally, the bone pops out and is displaced forward.  It hurts like a son-of-a-gun, but it’s not too dangerous.  Pop it back in place (otherwise known as a closed reduction, as opposed to surgical fixation, which is an open reduction), let it heal, and you’re ready to rumble.

In Amendola’s case, however, his clavicle popped IN behind the sternum, otherwise known as a posterior dislocation.  This is a surprisingly rare phenomenon, with only 120 or so cases documented.  There are some fairly important structures behind the clavicle, including some large blood vessels and the trachea (windpipe).  If the dislocated bone injures those structures when it gets forced in, the patient can have massive bleeding or problems breathing, which is clearly life-threatening.  The most common cause of this is traumatic injury, typically a motor vehicle accident or contact sports like football or rugby, which are characterized by high-energy impacts.  The diagnosis is made by chest Xray or CT scan.

So what’s the treatment?  A nice summary is provided by the Canadian Journal of Emergency Medicine:

Management options for posterior SCJ dislocations include closed reduction in the ED, using procedural sedation, or orthopedic reduction in the operating room under general anesthesia.  Immediate ED reduction should be performed in cases involving airway compression or major vascular compromise.  The classically described approach for reduction involves placing the patient supine with a rolled towel between the scapulae.  After appropriate procedural sedation, traction is applied to the abducted arm while it is gradually extended.  If reduction cannot be achieved, a towel clip can be used to grasp the clavicle and provide additional anterior traction.

If the reduction is unsuccessful or the dislocation recurs, surgical fixation is an option.

Most of the medical literature I reviewed recommended that the reduction of the dislocation should be performed in an Emergency Department (where the operating room is close by) or even in an OR by an orthopaedic surgeon.  One discussion even suggested that a thoracic (chest) surgeon be on standby in the event that the chest needs to be opened immediately to control any bleeding.  According to Glazer, Amedola’s dislocation was performed in the locker room at the stadium.  There was no mention of what type of medical personnel was present for the procedure.

Amendola will likely miss 6-8 weeks while recovering from this injury.  Overall, he was extremely lucky that the damage wasn’t worse, and he was able to walk out of the locker room in a sling.

Melanie Friedlander, MD, is a board-certified general surgeon.  You can ask her questions about your favorite NFL athlete’s injury or follow her on Twitter at www.twitter.com/girlsurgeon.