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Sternoclavicular Joint Injury Clinical Presentation

  • Author: John P Rudzinski, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Nov 24, 2015
 

History

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.)

This 80-year-old woman presented 1 week after a fa This 80-year-old woman presented 1 week after a fall because of persistent pain and discoloration in the anterior part of her chest. Certain movements of her right arm were especially painful though not incapacitating. Note the extensive ecchymosis of the anterior part of her thorax and the swelling of the right upper parasternal/lower anterior neck area. The right sternoclavicular joint area was tender and edematous to palpation.
The right sternoclavicular joint appears edematous The right sternoclavicular joint appears edematous on lateral inspection. Palpation confirms the apparent anterior dislocation.
Comparison of the normal left sternoclavicular joi Comparison of the normal left sternoclavicular joint emphasizes the abnormalities.
The patient refused further workup and treatment b The patient refused further workup and treatment beyond a temporary sling, stating that the injury had not significantly affected her lifestyle. She was discharged home in the company of her daughter with over-the-counter analgesics.

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.[10]

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:

  • Dyspnea
  • Dysphagia
  • Paresthesias and neurologic deficits
  • Swelling and pain in an upper extremity
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Physical

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.

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Causes

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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Contributor Information and Disclosures
Author

John P Rudzinski, MD, FACEP Clinical Professor of Surgery, Department of Surgery, Clinical Professor of Medicine, Department of Internal Medicine, University of Illinois College of Medicine; Visiting Professor, American University of the Caribbean; Vice-Chairman, Emergency Department, Director of Medical Education, Rockford Health System; Staff Physician, Emergency Department, Rockford Memorial Hospital

John P Rudzinski, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Alina Perez University of Illinois College of Medicine at Rockford

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References
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  11. Ernberg LA, Potter HG. Radiographic evaluation of the acromioclavicular and sternoclavicular joints. Clin Sports Med. 2003 Apr. 22(2):255-75.

  12. McCulloch P, Henley BM, Linnau KF. Radiographic clues for high-energy trauma: three cases of sternoclavicular dislocation. AJR Am J Roentgenol. 2001 Jun. 176(6):1534. [Medline].

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This 80-year-old woman presented 1 week after a fall because of persistent pain and discoloration in the anterior part of her chest. Certain movements of her right arm were especially painful though not incapacitating. Note the extensive ecchymosis of the anterior part of her thorax and the swelling of the right upper parasternal/lower anterior neck area. The right sternoclavicular joint area was tender and edematous to palpation.
Superior mediastinal contents may be threatened in posterior dislocations of the sternoclavicular joint.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
The right sternoclavicular joint appears edematous on lateral inspection. Palpation confirms the apparent anterior dislocation.
Comparison of the normal left sternoclavicular joint emphasizes the abnormalities.
The patient refused further workup and treatment beyond a temporary sling, stating that the injury had not significantly affected her lifestyle. She was discharged home in the company of her daughter with over-the-counter analgesics.
 
 
 
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