sternoclavicular joint dislocations

A 20-year-old, male, college football player tackled a fellow teammate in practice and had subsequent pain and decreased range of motion to the left shoulder. He was brought to the ED to be assessed the same day and notices that he is having trouble breathing when asked to lie supine on the gurney. His shoulder radiographs are negative for fracture or glenohumeral dislocation, and based on physical examination, you suspect a sternoclavicular dislocation.

What imaging study is preferred to make this diagnosis?

1. Bilateral clavicle AP

2. Plain film of clavicle with beam aimed at a 40-degree cephalic tilt

3. CT scan

4. MRI

 

Discussion

The correct answer is (C). Sternoclavicular dislocations, both anterior and posterior, are difficult to visualize on plain films. The serendipity view (beam at 40 degrees cephalic tilt) can help, but CT scan is still the preferred modality. The benefits of a CT scan include determining direction of dislocation, differentiation from a physeal fracture in patients less than 25 years of age, and can visualize mediastinal structures and associated injuries or compromise that should be addressed. MRI in an acute setting does not contribute any additional information for immediate treatment and takes longer to obtain.

You are concerned for a posterior sternoclavicular dislocation in this patient. All of the following is a physical finding related to a posterior dislocation but not an anterior dislocation EXCEPT:

1. Tachypnea

2. Decreased range of motion (ROM) of upper extremity

3. Stridor

4. Venous congestion in upper extremity

 

Discussion

The correct answer is (B). Decreased ROM due to pain can happen with a sternoclavicular dislocation in either direction. The main physical finding with an anterior dislocation is a palpable prominence at the joint which increases with abduction and elevation. A posterior dislocation happens when the clavicle moves posterior to the sternum. This can result in compression of mediastinal structures to include the bronchus (stridor and shortness of breath, especially when supine), the recurrent laryngeal nerve (dysphagia), the brachiocephalic vein (venous congestion), brachiocephalic artery (diminished pulses compared to contralateral side), and the brachial plexus (paresthesias). All of these physical examination findings should be looked for as they are included in the indications for surgical intervention.

What is the most important structure for sternoclavicular anterior–posterior

stability?

1. Posterior capsular ligament

2. Anterior sternoclavicular ligament

3. Rhomboid ligament

4. Intra-articular disk ligament

 

Discussion

The correct answer is (A). This ligament is the primary restraint to AP displacement. The anterior sternoclavicular ligament is the primary restraint to superior displacement of the clavicle. The rhomboid ligament is also called the costoclavicular ligament and prevents rotational and medial/lateral displacement with two fascicles. The intra-articular disk ligament prevents medial and superior displacement of the clavicle.

After imaging and physical examination are complete, it is determined that our patient has a posterior sternoclavicular displacement. Physical examination findings are notable only for decreased ROM of the left shoulder and dyspnea when lying supine.

What is the optimal treatment for this patient?

1. Medial clavicle excision

2. Sling for comfort, referral to physical therapy for range of motion, and instructions to sleep in a recliner until dyspnea improves

3. Closed reduction under general anesthesia with or without thoracic surgery

4. Open reduction and soft tissue reconstruction with thoracic surgery backup

 

Discussion

The correct answer is (D). Since this patient is experiencing shortness of breath, he should have surgery to relieve the pressure. This will need to be done open with a plan for reconstruction or other internal fixation to maintain a stable joint. Because of the mediastinal compromise, this should not be attempted without thoracic surgery backup available. Another indication for immediate open reduction is decreased peripheral pulses in the affected upper extremity. A medial clavicle excision is a treatment for chronic or recurrent sternoclavicular dislocations. Sling and physical therapy are treatment options for atraumatic subluxations or chronic dislocations (>3 weeks). Acute (<3 weeks) anterior and posterior sternoclavicular dislocations that are not associated with neurovascular or mediastinal compromise can have an attempted closed reduction.

Objectives: Did you learn...?

 

 

Diagnosis of sternoclavicular joint dislocations? Treatment of sternoclavicular joint dislocations?