Sternoclavicular Joint Injury in Emergency Medicine Clinical Presentation

Updated: Dec 20, 2019
  • Author: John P Rudzinski, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

History

In SCJ injuries, first determine the onset of pain and the mechanism of injury. 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 SCJ.

(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. [25]

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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Complications

Posterior SCJ dislocations can be associated with potentially life-threatening tracheal, esophageal, vascular, and neurologic injury and may involve the following specific complications [26] :

  • Pneumothorax or hemothorax

  • Thoracic outlet syndrome

  • Laceration, compression, or thrombosis of adjacent vascular structures

  • Neurologic injury including brachial plexus and cerebrovascular injuries

  • Recurrent dislocation

  • Residual swelling, deformity and/or decreased range of motion

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