II. Epidemiology

  1. Uncommon injury

III. Precautions

  1. Sternoclavicular Dislocations are associated with serious neck and chest injuries due to high force injuries
    1. See Associated Conditions below

IV. Mechanism

  1. High impact direct blow to chest (e.g. MVA)
    1. Results in posterior Sternoclavicular Dislocation
  2. Fall onto lateral Shoulder with compression
    1. Causes either anterior or posterior Sternoclavicular Dislocation

V. Types: Sternoclavicular Dislocation

  1. SC Joint Subluxation
    1. Partial ligamentous tear
  2. Anterior Dislocation (More common than posterior dislocation)
    1. Routine oupatient management
    2. May occasionally occur spontaneously without Trauma
      1. Older adult presents with painless sternal mass
      2. Affects sternal end of clavicle
  3. Posterior Dislocation (rare)
    1. Requires emergent Consultation for reduction
    2. High risk for underlying structure (Great Vessel, trachea, esophagus) injury (30% of cases)
      1. Leads to Dyspnea and vascular compression

VI. Differential Diagnosis

  1. Clavicle Epiphyseal Fracture (Salter Harris Fracture) in child
    1. Medial clavicular physis is the last Growth Plate to fuse (>age 20 years)
    2. Non-surgical management as with SC Dislocation

VII. Findings: Symptoms and Signs

  1. SC Joint Subluxation
    1. Pain and tenderness at the SC Joint
    2. However, visible deformity or prominence to the joint is uncommon
    3. Partial SC ligamentous tears
      1. In contrast, SC Dislocations are complete ligamentous tears
      2. Complete tears (dislocations) require significant force mechanism (e.g.MVA, sports collision)
  2. Anterior Sternoclavicular Dislocation (more common than posterior dislocations)
    1. Pain, tenderness and prominence at sternoclavicular Joint
    2. Sternoclavicular pain with any Shoulder Range of Motion
  3. Posterior Sternoclavicular Dislocation
    1. May be occult injury or divit seen at SC joint
    2. Underlying mediastinal injury may present in various ways
      1. Stridor, Dyspnea or hoarse voice (tracheal injury or compression)
      2. Neurologic or vascular deficits (Great Vessel injury)
      3. Dysphagia (esophageal injury)

VIII. Imaging

  1. Anterior Sternoclavicular Dislocation
    1. Sternoclavicular XRay
      1. SC Joint difficult to visualize on XRay
      2. View angled upward including uninjured side helpful (see Serendipity View as below)
    2. Sternoclavicular joint MRI may be necessary
      1. Physeal Fracture of medial clavicle may also occur and may be occult
        1. Clavicle physis is last in the body to fuse (age 23-25 years)
  2. Posterior Sternoclavicular Dislocation
    1. Chest XRay is often normal
    2. Serendipity View XRay (oblique view of SC)
      1. Patient lies supine on bed
      2. Xray angled 40 degrees toward manubrium
      3. Allows for visualization of both sternoclavicular joints
      4. Dislocated clavicle appears inferior compared with the unaffected side
    3. CT Chest with contrast (or MRI)
      1. Definitive and preferred imaging modality
      2. Also evaluates neurovascular structures and mediastinal impingement
    4. Bedside Ultrasound (linear probe)
      1. Measure distance between clavicle and Sternum (and compare to unaffected side)
      2. Bengtzen (2017) J Emerg Med 52(4): 532-5 +PMID:28087089 [PubMed]

IX. Management: Anterior Sternoclavicular Dislocation

  1. Reduction by traction and manipulation
    1. Reduction difficult to maintain
    2. Commonly recurs
    3. No loss of function (cosmetic only)
  2. Surgery (rarely indicated)
    1. Indicated for post-Traumatic Arthritis
    2. Excise medial 1 to 2 cm of clavicle

X. Management: Posterior Sternoclavicular Dislocation

  1. Emergent Consultation
    1. Orthopedics
    2. Cardiothoracic surgery
  2. Emergent reduction technique
    1. Indications
      1. Airway compression (e.g. Stridor)
      2. Pulseless extremity and orthopedics not immediately available
    2. Perform under Procedural Sedation
    3. Shoulder extension
      1. Patient supine with towel roll between Scapulae
      2. Extend and abduct the affected arm while another provider applies counter-traction
    4. May also attempt to concurrently pull medial clavicle anteriorly
      1. Clavicle may be grasped with pointed instrument (e.g. towel clamp)
  3. Open reduction by orthopedic surgery indications
    1. Dysphagia
    2. Shortness of Breath
    3. Decreased peripheral pulses

XI. Associated Conditions

  1. Anterior Sternoclavicular Dislocations
    1. Pneumothorax
    2. Hemothorax
    3. Rib Fracture
    4. Pulmonary Contusion
  2. Posterior Sternoclavicular Dislocations
    1. Subclavian Vein Injury
    2. Brachial Plexus Injury
    3. Pneumothorax
    4. Esophageal Injury
    5. Tracheal Injury
    6. Cardiac Dysrhythmia

XII. References

  1. (2012) ATLS, ACOS, Chicago, p.96
  2. Jhun and Roepke in Herbert (2015) EM:Rap 15(11): 10-11
  3. Kiel and Koneru (2019) Crit Dec Emerg Med 33(9): 17-27

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Related Studies

Ontology: Dislocation of sternoclavicular joint (C0347729)

Concepts Injury or Poisoning (T037)
ICD10 S43.2
SnomedCT 263009006
English Disloc sternoclav joint, dislocation of sternoclavicular joint, dislocation of sternoclavicular joint (physical finding), dislocation of sternoclavicular joint (diagnosis), sternoclavicular joint dislocation, Dislocation of sternoclavicular joint, Dislocation of sternoclavicular joint (disorder), dislocation; sternoclavicular, sternoclavicular; dislocation
German Luxation des Sternoklavikulargelenkes
Korean 복장빗장관절의 탈구
Dutch luxatie; sternoclaviculair, sternoclaviculair; luxatie, Luxatie van sternoclaviculair gewricht
Spanish luxación de articulación esternoclavicular (trastorno), luxación de articulación esternoclavicular

Ontology: Subluxation of sternoclavicular joint (C0434740)

Concepts Injury or Poisoning (T037)
SnomedCT 263048006
English Sublux sternoclav joint, subluxation sternoclavicular joint, subluxation of sternoclavicular joint, subluxation of sternoclavicular joint (diagnosis), Subluxation of sternoclavicular joint, Subluxation of sternoclavicular joint (disorder)
Spanish subluxación de articulación esternoclavicular (trastorno), subluxación de articulación esternoclavicular