Sternoclavicular Dislocation

  • Traumatic injury resulting in either anterior or posterior dislocation of the medial clavicle in relation to the sternum
  • Usually due to a force on the shoulder with an abducted arm
  • Anterior dislocation is usually treated nonoperatively
  • Posterior dislocation is more serious because the trachea, esophagus, thoracic duct, and large vessels in the mediastinum may be damaged by the displaced end of the clavicle

  • Mechanism
    • Motor vehicle accident most common
    • Sports injury also common
    • Direct blow (e.g. another athlete falls on the SC joint)
      • Usually results in posterior dislocation
    • Indirect force (i.e. blow to the shoulder while unable to change position)
      • May be anterior or posterior
  • Timing of injury
    • Acute vs. chronic - has implications on disposition and management
  • Other locations of pain
  • Associated symptoms
    • Posterior dislocations can compress mediastinal structures
      • Paresthesias in the arm (neural impingement)
      • Venous congestion
      • Dyspnea
      • Dysphagia
      • Tachypnea
      • Stridor
  • Hand dominance (right vs. left hand dominant)
  • Profession
  • Anticoagulation
    • Last dose?
  • Last time the patient ate (NPO status)

    • Key to assess upon initial presentation especially if associated symptoms are present (dyspnea, dysphagia, etc.) as critical structures may be compromised

  • Deformity - anterior dislocation can lead to a palpable bump
  • Usually painful over the SC joint

Motor Exam:
  • Median Nerve/ Anterior interosseous nerve (AIN)
    • Flexion of wrist, fingers, thumb
    • A-OK sign” = AIN
      • Tests flexion of thumb IP joint (FPL) and flexion of index DIP joint (FDP)
  • Radial nerve/ Posterior interosseous nerve (PIN)
    • Extension of wrist, fingers, thumb
    • “Thumbs up” = PIN
      • Tests extension of thumb IP and MCP joints (EPL))
      • Palm on flat surface and lifting/extending thumb off the surface is also a good test for PIN (tests extension of thumb MCP joint (EPL))
  • Ulnar nerve
    • Finger abduction (spread fingers, “peace sign”), finger adduction, cross fingers (“promise”)
Sensory Exam:
  • Dermatomal numbness - nerve impingement
  • Median, Radial, Ulnar nerve distributions
    • Radial: Dorsal first web space
    • Median: Volar distal index finger
    • Ulnar: Volar distal small finger
Vascular exam:
  • Radial artery, Ulnar artery
    • If having difficulty with palpation radial artery, use a doppler
  • Capillary refill to digits
  • Venous congestion in the ipsilateral extremity?
  • Exam may improve by turning head to the affected side

  • Assess ROM at the neck, shoulder, elbow, wrist, hand (may be pain limited)

  • AP of the clavicle, AP/Serendipity view of the SC joints
    • Serendipity view - better for assessing anterior or posterior dislocation
      • 40 degrees cephalic tilt view of the bilateral SC joints
      • Anterior dislocation will have affected clavicle superior to contralateral clavicle
      • Posterior dislocation will have affected clavicle inferior to contralateral clavicle
  • CT scan - study of choice
    • Confirmatory test if there is doubt about direction of dislocation
    • Can also view the mediastinal structures if concerned about compression due to posterior dislocation
  • MRI - rarely needed
    • Can differentiate physeal injuries in children
      • Leave to discretion of the orthopaedic team

     Medical Decision Making

Chronic dislocation or atraumatic subluxation:
*** is a *** y/o ***R/L hand-dominant individual with a history of *** presenting with ***, found to have an ***chronic SC dislocation/subluxation. The patient reported a trauma to the shoulder ***time. On exam, the patient is neurovascularly intact with no poke holes or punctate wounds. There are no signs of venous congestion or neural injury. Imaging reveals ***. Given that the inciting injury occured >3 weeks ago with evolution of the symptoms, this appears to be a chronic process. The patient was immobilized in a sling and will follow up with orthopaedics surgery in 7-10 days.

Acute dislocation (anterior or posterior):
*** is a *** y/o ***R/L hand-dominant individual with a history of *** presenting with an injury to the *** shoulder which occurred while ***, found to have an posterior/anterior*** SC dislocation. On exam, the patient is/is not*** neurovascularly intact with vitals within normal limits. The patient denies/endorses*** dysphagia, dyspnea, and paresthesias. Orthopaedics was consulted and the patient was kept NPO. Orthopaedics to provide further recommendations.

Acute dislocation with signs of mediastinal compression :
  • Consult orthopaedic surgery immediately
  • Consult thoracic surgery immediately
  • NPO, preop labs (type and screen, INR, aPTT,  CBC, BMP)
Acute dislocation without signs of mediastinal compression :
  • Consult orthopaedic surgery
  • NPO, preop labs (type and screen, INR, aPTT,  CBC, BMP)
Chronic dislocation or atraumatic subluxation:
  • WB status: Nonweightbearing for comfort
  • Diet:  Regular
  • Analgesia: short course of narcotic pain medication, tylenol (scheduled)
    • Ex: 5mg oxycodone q4 - 25 pills
  • Immobilization
    • Sling immobilization for comfort
  • Disposition: Home with follow up in orthopedic surgery clinic in 1 week

Common ICD-10 Codes Brief Description
S43.2 Subluxation and dislocation of sternoclavicular joint
S43.21 Anterior subluxation and dislocation of sternoclavicular joint
S43.22 Posterior subluxation and dislocation of sternoclavicular joint
S23.420 Sprain of sternoclavicular (joint) (ligament)