Sternoclavicular Joint Dislocation

Sternoclavicular joint dislocation is a relatively uncommon injury that can be easily missed or misdiagnosed. Bilateral posterior sternoclavicular joint dislocation is even rarer still…

The importance in determining the direction of dislocation is emphasised by the dichotomy of management. Hence, a thorough history and examination, especially looking for evidence of compression of retrosternal structures, is paramount. Specialised sternoclavicular X-ray views should be supplemented by CT/MRI if clinical suspicion is high. Posterior dislocations necessitate prompt orthopedic referral.

Case Report

A 30 year old man presented to ED with bilateral “shoulder pain” after a quad bike accident. Having taken a corner at high speed, he feel from the bike landing on his right shoulder and was crushed by the bike landing on his left shoulder.

On presentation, ABCs were intact. No dysphonia, dysphagia or dyspnoea.

Both right and left shoulders were dislocated anteriorly and were relocated at triage.

There was swelling and tenderness over both sternoclavicular joints and the patient was unable to abduct either shoulder actively despite glenohumeral enlocation. Passive movement of the shoulders was limited by pain “over the collarbone”, although the clavicles themselves were only tender near their junction with the sternum. Specifically, the AC joints and humerus were non-tender and arm neurovascular status was normal.

Initial Chest X-ray was performed and reported as normal

However in light of the high clinical suspicion for sternoclavicular joint injury; continued anterior chest pain and failure in shoulder abduction special plain film tomography views of both SC joints was performed:

There is widening of the right sternoclavicular joint when compared to the left side.  This appearance is suspicious for subluxation/dislocation. There is probable subtle widening of the left sternoclavicular joint as well. Several well-corticated bone ossicles are noted in the vicinity of the sternoclavicular joints bilaterally.

This was confirmed on CT scan:

Watch the 3D Video of the CT here

Superior dislocation of bilateral sternoclavicular joints. Associated fracture of the left 1st rib anteriorly noted.

Anatomy of the sternoclavicular joint

  • The sternoclavicular joint is a diarthodial saddle-type joint which provides a pivot for the shoulder girdle on the trunk.
  • The joint capsule is reinforced anterioposteriorly by the anterior and posterior sternoclavicular ligaments.  Superomedially the joint is reinforced by the interclavicular ligament which joins both the upper boarder of both clavicles to the suprasternal notch.
  • The clavicle is also bound to the first costal cartilage and the first rib by the costoclavicular ligament.

Original Description

Sir Astley Paston Cooper

Sir Astley Paston Cooper (23 Aug 1768 – 12 Feb 1841)

An English surgeon and pioneer in experimental surgery. He was the first to tie the abdominal aorta in treating an aneurysm (1817), among various other operations he performed successfully at a time before antiseptic procedures. He was devoted to the study and teaching of anatomy, and is said to have dissected daily throughout his career.

In 1820 he excised and infected sebaceous cyst from the scalp of King George IV. He was appointed sergeant surgeon to George IV, William IV and Queen Victoria. He was elected President of the Royal College of Surgeons on two occasions (1827 &1836).

Sir Astley Cooper is credited with the first report of thisentity in ‘A treatise on dislocations and on fractures of the joints‘ in 1824. Approximately 120 cases of posterior sternoclavicular joint (SCJ) dislocation have been documented in the medical literature since it was first described, a statistic which underlies its relative rarity.  Despite this statistic, emergency physicians should be familiarwith the condition the mechanismof injury and physical findings and the potentially life-threatening injuries.

Clinical Presentation

Incidence

  • Sternoclavicular dislocations account for 3% of all shoulder girdle injuries.
  • 95% of SCJ dislocations are unilateral and anterior dislocations are far more common than posterior dislocations due to the weaker anterior sternoclavicular ligament (ratio 9:1). Bilateral superior dislocations, as in the case above, are rarely described.

Mechanism of Injury

  • Dislocations of the SCJ generally occur following a fall on the outstretched hand or a direct blow to the shoulder. Sporting injuries and motor vehicle accidents account for the most causes of SCJ dysfunction. However, they can also occur without any history of injury.
  • Patients commonly present with pain and swelling in the proximal sternum and sternoclavicular region. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing or coughing.
  • Patients often laterally flex their neck towards the affected side to relieving pressure on the SCJ. Asymmetry is best appreciated when viewed from above the patient’s head.
  • Additional symptoms include dysphonia, dysphagia or dyspnoea.

Diagnostic Imaging

  • Plain X-ray: standard views may not provide a definitive diagnosis. Alternate views such as ‘serendipity view’ (40-degree cephalic tilt) may provide more information.
  • CTA or MRA to determine direction of dislocation and potential for vascular compromise. A contrast study is required for definitive evaluation of surrounding structures.

Complications

Many complications have been reported in the literature related to retrosternal (posterior) dislocation of the medial end of the clavicle including:

Management

Simple sprain of the SCJ

  • Patients will complain of mild to moderate pain and there will be no joint instability on clinical examination.
  • Conservative treatment with ice, analgesia, shoulder sling for immobility will lead to complete recovery in 1 week.
  • Subluxation of the SCJ will require the application of a clavicular splint or sling for 3 to 6 weeks

Anterior SCJ Dislocations

  • Anterior sternoclavicular dislocations are usually managed nonoperatively.
  • The clavicle often stabilises in its subluxed position, with asymmetrical ventral protrusion of the affected side. The arm should be rested in a sling which will assist in the reduction of pain. Patients generally experience a good pain-free functional outcome at 2-3 weeks. Very rare complications include chronic pain, periarticular calcifications with ankylosis and progressive deformity.
  • Closed reduction may be indicated in rare circumstances where the patient is engaged in strenuous upper limb activities causing a painful SCJ. It is however, often unsuccessful. The application of direct pressure over the medial end of the clavicle may also reduce the joint.

Posterior SCJ Dislocations

  • Posterior sternoclavicular dislocations should always be reduced in theatre because of the associated risk to intrathoracic and superior mediastinal structures.

Example of a Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation CT


Methods of reduction

The initial treatment of choice is a closed reduction. Various methods have been described:

  • Classical:  Patient positioned supine with a towel/sandbag between scapulae. Sedation is administered and traction is applied to the abducted arm with simultaneous extension. This has an 80% success rate.
  • Buckerfield and Castle: While shoulders are pushed posteriorly by an assistant, the ipsilateral arm is adducted against the torso and caudal traction is applied.
  • Towel Clip: Anterior traction force can be applied to clavicle by percutaneously applied towel clip, often used with one of the above methods.
  • A figure of eight sling is applied after the reduction for 4-6 weeks to allow for ligamentous healing.

If the SCJ becomes chronically unstable or if closed reduction is unsuccessful, then open reduction is indicated.

Discussion

Traumatic sternoclavicular joint dislocation is an uncommon condition whose diagnosis is often missed. The importance in determining the direction of dislocation is emphasised by the dichotomy of management. The posterior version of this dislocation has been associated with multiple complications and owing to the rarity of this injury, there is a relative lack of familiarity with the diagnosis, surgical anatomy and treatment options. [Reference]

A thorough history and examination, especially looking for evidence of compression of retrosternal structures, is paramount. Specialised sternoclavicular X-ray views should be supplemented by CT/MRI if clinical suspicion is high. Posterior dislocations necessitate prompt orthopedic referral.

References

ResearchBlogging.orgSaltzman, M., Mercer, D., Bertelsen, A., Warme, W., & Matsen, III, F. (2009). Bilateral posterior sternoclavicular dislocations Radiology Case Reports, 4 (1) DOI: 10.2484/rcr.v4i1.256

  • Jacques B. Jougon, MD, Denis J. Lepront, MD, Claire E. H. Dromer, M. Posterior Dislocation of the Sternoclavicular Joint Leading to Mediastinal Compression. [Reference]
  • Hoekzema N. Torchia M. Adkins M Cassivi SD. Posterior sternoclavicular joint dislocation [Reference]
  • Mirza AH, Alam K, Ali A Posterior sternoclavicular dislocation in a rugby player as a cause of silent vascular compromise: a case report. Br J Sports Med. 2005 May;39(5):e28. [Reference]
  • Asplund C, Pollard ME. Posterior sternoclavicular joint dislocation in a wrestler. Mil Med. 2004 Feb;169(2):134-6. [Reference]
  • Wirth MA, Rockwood CA Jr. Acute and Chronic Traumatic Injuries of the Sternoclavicular Joint.J Am Acad Orthop Surg. 1996 Oct;4(5):268-278. [Reference]
  • Brinker MR, Bartz RL, Reardon PR, Reardon MJ. A method for open reduction and internal fixation of the unstable posterior sternoclavicular joint dislocation. J Orthop Trauma. 1997 Jul;11(5):378-81. [Reference]
  • Saltzman, M., Mercer, D., Bertelsen, A., Warme, W., & Matsen, III, F. (2009). Bilateral posterior sternoclavicular dislocations Radiology Case Reports, 4 (1) DOI: 10.2484/rcr.v4i1.256
  • O’Connor PA. Nölke L. O’Donnell A. Maha Lingham A. Retrosternal dislocation of the clavicle associated with a traumatic pneumothorax [Reference]
  • Cooper A. A treatise on dislocations and on fractures of the joints. In: Longman, Hurst, Orme, Brown, Green, eds. London, 1824:359

An old Scotch physician, for whom I had a great respect, and whom I frequently met professionally in the city, used to say, as we were entering the patient’s room together, ‘Weel, Mister Cooper, we ha’ only twa things to keep in meend, and they’ll searve us for here and herea’ter; one is always to have the fear of the Laird before our ees; that ‘ill do for herea’ter; and t’other is to keep your booels open, and that will do for here.’ – Sir Astley Cooper

Research Credit – Dr Andrew Toffoli

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Comments

  1. says

    I took care of two such patients over 25 years ago. Thanks for the opportunity to relearn and expand beyond what I once knew. /Steve

    Gazak S, Davidson SJ. Posterior sternoclavicular dislocations: two case reports. J Trauma. 1984 Jan;24(1):80-2. PMID: 6694232

    Posterior sternoclavicular joint dislocations are thought to be exceedingly uncommon. Two recent cases are discussed in terms of diagnosis, management, and potential risk to the patient. One dislocation was successfully reduced with lidocaine infiltrated and the second, seen 72 hours postinjury, required closed reduction under general anesthesia. Soon after injury these patients have a hollow at the sternoclavicular junction. Sternal oblique X-rays and tomograms are helpful in diagnosis. This entity may be promptly recognized and treated in the emergency department with gratifying results. PMID: 6694232 [PubMed - indexed for MEDLINE]

    • says

      Thanks Steve
      I think this is one of the greatest aspects of the Medical Blog -- the ability to interact, read, review and comment on fascinating cases and medical literature reviews.
      Greatly appreciate your professional input on this case -- having read your Clinical Review…I may try a reduction in the ER next time!
      Mike Cadogan

  2. Kristie Kenefick says

    I’m hoping to get some advice. Back in Sept 08 while at work, I dislocated my clavicle at the sternum. Not much was done at first, slings and pain medication. After time, with no relief, I was sent to a surgeon for a rotator cuff tear due to the initial injury. I am currently, 6 months post op. However, the sterno-clavicular joint is still very painful. The more I use the arm the more pain I feel in that SC joint. (It is my left arm, and I’m left-handed.) My problem is that I can’t seem to find doctors that have any idea what to do about it. It has been recommended that I get steroid shots, but I’m allergic, so that option is out. The doctor that did the rotator cuff is about to release me from his care, and return me to work. But with the pain from the SC joint, I don’t feel I could work at this point. I am also concerned that if the SC is not dealt with, that there is a possibility of re-injury the future and at that point workman’s compensation will not cover it.
    So the question is, does anyone know of a procedure, treatment, etc for my problem. Any referrals to doctors, (preferably in Colorado,) that could treat this type of injury would be very helpful, as my doctors are at a loss as to what to do. I would appreciate any information that anyone could give me.

  3. Karen Blackwell says

    Thank you for this information. My husband is currently gorked out in the living room under a (in my opinion) light dose of hydromorphone. After being sent home with scrips for painkillers and anti-inflammatories by not 1 but 2 ER docs, we saw an Ortho doc today and were about to be sent away AGAIN when we insisted he take a look at the SC joint. Maybe Odoc was taken aback that we could actually use the word “sterno-clavicular” in a sentence; I don’t know. He was already talking acromial-calvicular blah, blah, blah…so I knew he wasn’t looking in the right place. He wasn’t diagnosing anything, he was just going with the statistics. It was the end of the day, everybody wants to get home. Everybody knows how that is.

    Sure enough, after poking around enough to make my husband come out of the exam chair several times (and me about to bean the doc over the head with the nearest blunt instrument), the doc decided we needed to schedule a CAT scan seeing as how the SECOND set of x-rays had come back “normal.” I know this is an uncommon injury, but when someone has been in this much pain (and hasn’t slept even when given hefty doses of Percocet and Raboxin) for 5 days, shouldn’t the 3rd doc be thinking “Hmm, what did the first two guys miss?”

    Now I can go to the hospital tomorrow armed with enough information to ask reasonable questions and have reasonable expectations. I just hope we find a little more empathy and a little less off-handed dismissal.

  4. Akshata says

    Mike thanks for the wonderful article. I have been having issue with my sc joint since one year. initially i went to the doctor for pain when i lifted my hand above shoulder level. he(All 5 doctors I have seem till now) suspected issue around AC joint. Though I mentioned pain in SC also. When i took Ultra sound and IFT the pain had also most vanished except at the SC joint. I assumed it will also heal with time.

    I was so wrong, it call came back with time and i noticed that slight swelling(I assumed it to be swelling) had not gone all during the process and even afterwards. I went to a different Physiotherapist(this was after consulting my 5th doctor) he suspected that it was not swelling but a dislocation. I went and got an xray, looks like i have SCJ dislocation .

    Now i am not sure what are the possible treatment. the dislocation is very little this happened when i was backpacking Europe. I positioned my strap on the bony structure as my muscles where hurting. Feels like biggest mistake of my life I have not been able sleep on the affected side since. can it be made 100% fine with proper treatment?

  5. Sternum Popper says

    I believe my sternum whatever whatever was dislocated for the last 6 months, after a very bad bout with bronchitis I noticed something was simply not right in my chest area. I had generalized weakness across my chest muscles and it literally felt like I needed to snap it back into place. I can recall exactly when it happened, I had been in the hot bathtub laying down for awhile and violently sneezed right as I was sitting up and I believe this force working against the already greatly relaxed but immediately tensed muscles somehow caused a severe misalignment. If I coughed, sneezed, anything involving the upper chest I would have the radiating pain from that central area and felt like I had no upper chest strength anymore, my left arm also seemed to be involved. So here is the good news, about a week ago I was pushing against a friends resistance with my arms stretched out in front of me while tensing my chest muscles and experienced a dizzying and learly audible “pop” and felt an immediate deep sense of realignment in the center of my upper sternum. The deep dull aching pain was there for a shortwhile but I could immediately breathe FAR better and felt like all my upper chest strength had suddently came back. I was a little sore the next day but a few days later I was certain that whatever was out of place had “popped” back into proper position and I have been moving around alot more now with much better overall mechanics and just feeling like a general back to myself kind of feeling now. So if anyone out there is experiencing this problem please rest assured it may very well resolve itself on it’s own and there is hope for your sternum! Another issue worth researching is costo-chondritis which also can cause similiar symptoms and is an inflammation of the chest cartidge, basically arthritis of the chest joints but that too can be resolved in time and excercise usually helps so do stay active and use your muscles it can only help.

  6. says

    Another reference FYI
    TRAUMA…Sternoclavicular joint injuries
    JE Smith, J. Kennedy, and M. Brinsden
    Trauma, April 2010; vol. 12, 2: pp. 117-122., first published on May 6, 2010
    … Cope R. 1993. Dislocations of the sternoclavicular joint. Skeletal Radiol…2006. Posterior sternoclavicular dislocations: a review of management…2006. Posterior sternoclavicular dislocations: a review of manage…

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