The Forgotten Joint
Author: Raymond Zhou, MD
Peer Editor: Justine Ko, MD, CAQ-SM
Final Editor: Alex Tomesch, MD, CAQ-SM
A 51-year-old man complains of right-sided lower neck/chest pain and deformity after a trip and fall onto his right shoulder while playing basketball. The patient is otherwise asymptomatic. Examination reveals a palpable bump right of the sternum with tenderness to palpation.
Image 1. Case courtesy of Craig Hacking, Radiopaedia.org, rID: 92310
What structures does the physical exam suggest are affected? What is your suspected diagnosis?
Sternoclavicular (SC) joint and clavicle. There is widening of the right sternoclavicular joint suggesting possible SC joint dislocation.
The superior-lateral sternum (manubrium) articulates with the medial clavicle to form the sternoclavicular joint, joining the upper limb with the axial skeleton (Image 2) [1,2].
Image 2. Case courtesy of Craig Hacking, Radiopaedia.org, rID: 84425
In the setting of blunt trauma to the shoulder, palpable deformity of the medial clavicle is suggestive of sternoclavicular joint dislocation with anterior displacement of the clavicle [3].
What is the next step in management?
X-ray +/- CT scan of the chest. Prominence of the medial clavicle after blunt trauma to the shoulder should prompt radiographic imaging to assess for anterior SC joint dislocation and to rule out clavicle fracture.
What findings would be expected on confirmatory testing?
Anterior displacement, lateral displacement, and elevation of the clavicle.
Image 3. Case courtesy of Craig Hacking, Radiopaedia.org, rID: 92310
What life-threatening pathology should be considered with this type of injury?
If there is a posterior sternoclavicular joint dislocation, there needs to be a higher concern for internal chest injuries. Posterior displacement of the clavicle can compromise the lung apices, trachea, great vessels, and other mediastinal structures. As a result, 30% of posterior SC joint dislocations are associated with devastating complications, including pneumothorax, vascular injury, and acute limb ischemia [7,8].
Does orthopedic surgery need to be consulted?
If there is an anterior dislocation, orthopedic surgery does not need to be emergently or urgently consulted. These can follow up with orthopedics as an outpatient. However, if there is a posterior dislocation, emergent orthopedic evaluation is recommended. Urgent evaluation could be appropriate if no concerning findings on CT imaging.
References:
[1] Knipe H, Bell D, Ponte C, et al. Sternoclavicular joint. Reference article, Radiopaedia.org (Accessed on 05 Jun 2024) https://doi.org/10.53347/rID-29705.
[2] Hacking C, Sternoclavicular joint (Gray's illustration). Case study, Radiopaedia.org (Accessed on 05 Jun 2024) https://doi.org/10.53347/rID-84425.
[3] Redhead, Julian, and Jonathan Gordon (eds), 'Upper limb injury', in Julian Redhead, and Jonathan Gordon (eds), Emergencies in Sports Medicine, Oxford Medical Handbooks (Oxford, 2012; online edn, Oxford Academic, 1 July 2012). Accessed 19 May 2024.
[4] Murphy A, Fahrenhorst-Jones T, Deng F, et al. Sternoclavicular joint (serendipity view). Reference article, Radiopaedia.org (Accessed on 05 Jun 2024) https://doi.org/10.53347/rID-54319.
[5] Jones J, Campos A, Knipe H, et al. Sternoclavicular joint injury. Reference article, Radiopaedia.org (Accessed on 05 Jun 2024) https://doi.org/10.53347/rID-6858.
[6] Hacking C, Sternoclavicular joint dislocation. Case study, Radiopaedia.org (Accessed on 05 Jun 2024) https://doi.org/10.53347/rID-92310.
[7] Dhawan R, Singh RA, Tins B, Hay SM. Sternoclavicular joint. Shoulder & Elbow. 2018 Oct;10(4):296-305. DOI: 10.1177/1758573218756880. PMID: 30214497; PMCID: PMC6134528.
[8] Caine, Josh. “Sternoclavicular Joint Dislocation: Serious Concern or Not a Big Deal?” BROWN EMERGENCY MEDICINE BLOG, 5 Jan. 2018, brownemblog.com/blogposts/2018/1/5/scj-dislocation. Accessed 21 May 2024.