Sternoclavicular Joint Injury Clinical Presentation
- Author: John P Rudzinski, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH more...
Determine the onset of pain and the mechanism of injury.
Sternoclavicular joint (SCJ) dislocations may follow direct trauma to the anteromedial aspect of the clavicle that drives it backward and causes a posterior dislocation.
More commonly, dislocations arise from an indirect force applied to the anterolateral or posterolateral shoulder that compresses the clavicle down toward the sternum. The direction the shoulder is driven determines the type of dislocation. When overwhelming compression propels the shoulder forward, the force directed toward the clavicle produces a posterior dislocation of the sternoclavicular joint. If the shoulder is pressed and rotated backward, the force directed down the clavicle produces an anterior dislocation of the sternoclavicular joint. (See the images below, all of the same patient.)
The presence of hypermobility such as with Ehlers-Danlos syndrome can reduce the force necessary for dislocation. Atraumatic SCJ dislocations can occur, though they are rare.
Patients commonly complain of chest and shoulder pain exacerbated by arm movement or by assuming a supine position.
Pain tends to be more severe with posterior dislocations.
Additional symptoms may be caused by associated injuries or by compression of adjacent structures by a posterior SCJ dislocation and may include the following:
Paresthesias and neurologic deficits
Swelling and pain in an upper extremity
Patients typically present with their head tilted toward the affected side, and hold the affected arm across the trunk with the uninjured arm.
Check vital signs, especially respirations. Tachypnea, stridor, hoarseness and other signs of respiratory distress (posterior dislocations) may be present, particularly in posterior dislocations. Verify adequacy of circulation. Venous congestion of the head, neck, and/or affected arm may also result from posterior dislocations. Neurologic and vascular deficits may be present.
The affected shoulder usually appears shortened and thrust forward. Generally, edema and tenderness are present over the SCJ. Pain manifests with any range of motion testing that affects the SCJ and becomes more severe when a lateral compressive force is applied to the shoulders.
When viewed from the level of the patient's knees, anterior SCJ dislocations demonstrate a conspicuous asymmetry, with the medial aspect of the affected clavicle appearing prominent. Palpation reveals a medial protrusion.
Physical findings at the SCJ may be more subtle with posterior SCJ dislocations, with swelling and a defect evident on inspection and palpation. The corner of the sternum on the affected side may be palpated more readily than on the noninjured side. Palpation often reveals exquisite tenderness medially. Soft tissue swelling may obscure any defect and create the false impression of an anterior dislocation.
Motor vehicle crashes are the most common reported mechanism producing sternoclavicular dislocation.
In a "pile-on" in football or other sports, the shoulder off the ground may be rolled backward, causing an anterior dislocation, or rolled forward, causing a posterior dislocation.
During a sporting event, an athlete lying on his or her back may be jumped on with the knee of the jumper landing directly on the medial end of the clavicle. A kick delivered to the front of the medial clavicle can also produce dislocation.
Falls (eg, a person falling on an outstretched abducted arm, driving the shoulder medially) are also responsible.
Dislocations of the sternoclavicular joint also may result from congenital, degenerative, and inflammatory processes.
Ligamentous laxity, more common in young girls, is associated with recurrent atraumatic anterior dislocations of the sternoclavicular joint. This tends to be a self-limited condition.
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