Sternoclavicular dislocation

Background

• Very stable joint making a dislocation rare; majority of injuries are simple sprains
• Dislocations usually require severe force (MVC, sports injuries)
  • Mechanism either direct blow to the chest, or lateral compression
• Anterior dislocations are much more common than posterior
• Due to both force and anatomic location, damage to the brachial plexus, subclavian, trachea, and esophagus may occur
• Trivia - SC joint is only true articulation between the upper extremity and the axial skeleton

Clinical Features

Sternoclavicular dislocation

Sprain

• Pain and swelling are localized to the joint

Dislocation

• Severe pain that is exacerbated by arm motion and lying supine
• Shoulder appears shortened and rolled forward
• Anterior dislocation: prominent medial clavicle end is visible/palpable ant to sternum
• Posterior dislocation: Medial end is less visible and often not palpable
  • If there is delay in presentation, edema may have developed making depression of the medial head less obvious

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Traumatic asphyxia

Evaluation

• CT
  • Study of choice (plain films may not be diagnostic)
  • Consider IV contrast if concern for injury to mediastinal structures
• Serendipity view Xray
  • Xray taken at a 40 degree cephalic tilt may be useful if CT unavailable.
• MRI is a consideration, though less likely to be practical

Management

• Symptoms of stridor, shortness of breath, or dysphagia, indicate aerodigestive tract injury and require immediate reduction. Also immediately reduce if evidence of vascular occlusion.

Sprain

• Rice, sling, analgesics

Anterior Dislocation

• May discharged without attempted reduction (no impact on function)
• Clavicular splinting, ice, analgesics
• Ortho referral within several days

Posterior Dislocation

• May be associated with life-threatening injuries:
  • Pneumothorax, compression/laceration of surrounding great vessels, trachea, or esophagus
• Consult ortho for closed reduction (ideally performed in the OR or under Procedural Sedation)
  • Reduction must be performed with Cardiothoracic Surgery on-call or nearby due to potential for great vessel injury during reduction / manipulation
• Create a sterile field with appropriate skin prep.
• A metal towel clip is inserted percutaneously and is used to grasp the medial clavicle, pulling anteriorly until reduction is complete
• May be observed afterwards due to severity of trauma and risk for vascular injury

Disposition

• Anterior dislocation
  • Ortho follow up within several days
• Posterior dislocation
  • Immediate ortho consult, with potential transfer to facility with BOTH Ortho and CT surgery

References

Authors

Daniel Ostermayer, Jonathan Snyder, Jordan Swartz, Ross Donaldson, Neil Young