P3.R353: Sternoclavicular joint dislocation: a shoulder injury you shouldn’t shrug off

Introduction: While injuries to the upper extremity are common in pediatric athletics, sternoclavicular joint dislocations are rare. A broad differential must be considered in patients presenting with shoulder and clavicle pain as to not miss additional or alternative injuries.

Case Description: Patient is a 14-year-old male who presents with right shoulder and clavicle pain after a football injury. He reports he was tackled, landed on his right side, then another player fell on top of him. Patient heard a crack and had immediate pain at the site. He has not had difficulty breathing or numbness/tingling of the extremity. Exam without obvious deformity. However, he had tenderness to palpation of the medial aspect of the right clavicle with decreased range of motion to the right shoulder. The right upper extremity was neurovascularly intact. XR of the clavicle was obtained without a fracture identified. Given the location of his pain, XR of the sternoclavicular joint was performed and demonstrated superior subluxation of the right clavicular head. To further evaluate positioning, CT was ordered and noted posterior and superior subluxation of the right sternoclavicular joint. Patient was taken for operative repair with orthopedic surgery with cardiothoracic surgery on standby. Closed reduction was successful, and he recovered without complication.

Discussion: While sternoclavicular joint dislocations are uncommon, accounting for just 1-3% of all upper extremity injuries, they can be life-threatening. This is due to the risk for associated vascular injury and subsequent hemorrhage, as well as the risk of neural, tracheal and/or esophageal injuries. Sternoclavicular joint dislocations most commonly occur from blunt trauma to the area. A high index of suspicion is needed for diagnosis. Reported symptoms of shortness of breath, difficulty swallowing, and/or numbness in the extremity should raise concern for associated injury of the surrounding structures. Exam should focus on neurovascular status, specifically the presence or absence of distal pulses, sensation, and motor function of the extremity. It is important to also evaluate for signs of respiratory distress or the presence of venous congestion in the head and neck. While initial imaging may be obtained with x-ray, computerized tomography is the gold standard, with the addition of angiography if vascular injury is suspected. Reduction of the dislocated sternoclavicular joint also poses the risk of vascular damage and hemorrhage, therefore it is recommended that reduction is performed at a center with orthopedic providers, as well as cardiothoracic surgery, interventional radiology, blood transfusion services, and intensive care.

Conclusion: Sternoclavicular dislocations are a rare but serious injury given the proximity of multiple vital structures. Diagnosis requires a high index of suspicion and management warrants a collaborative, multidisciplinary approach, ideally at a tertiary medical center.