Working Diagnosis:
Posterior sternoclavicular dislocation

Treatment:
The patient was sent to the Emergency Department where Pediatric Orthopedics took him to the operating room and initially attempted a closed reduction under anesthesia which was unsuccessful. An open reduction with internal fixation was performed with cardiothoracic surgery on standby given the proximity of the medial head to the superior vena cava and brachiocephalic artery. Intraoperatively, a shear of the medial clavicle physis was seen indicating a final diagnosis of medial clavicle physeal fracture with posterior displacement rather than a true posterior sternoclavicular dislocation.

Outcome:
The patient was seen at 1 week follow up by the orthopedic surgeon who noted the patient was doing well, without difficulty breathing or swallowing, and had intact distal pulses. He continued use of a sling with instructions of no overhead motion of the shoulder until his next follow up at 6 weeks. At the 6 week mark he continued to do well. The sling was discontinued and new serendipity views were obtained which demonstrated good alignment of the clavicular head with periosteal reaction noted Case Photo #2 . He was cleared to start physical therapy with no weightbearing through the chest and to begin non contact aerobic exercise. At the 12 week follow up he had progressed to partial weightbearing with therapy and reported feeling confident in his shoulder and was cleared to gradually return to full weightbearing and sport.

Author's Comments:
This case highlights the importance of having a high clinical suspicion for sternoclavicular dislocation and/or medial clavicular fracture following chest or shoulder trauma in adolescents. It is also important to recognize that routine views used for chest and shoulder radiographs are often inadequate at detecting this type of injury. Serendipity views (40 degrees of cephalad tilt) can help identify concern for dislocation or fracture. However, a limited cut CT chest should be obtained, when there is suspicion of an SC joint dislocation and/or displaced medial clavicle fracture, given the possibility of associated airway, neurovascular, and esophageal compromise that can be seen with posterior dislocations. In addition, true sternoclavicular dislocations are rare and medial clavicular physeal fracture with posterior displacement (sometimes referred to as a pseudodislocation) can mimic this presentation. The pseudodislocation can occur because the medial clavicular physis is the last physis in the body to close (ossification beginning around 18 years and fusion occurring between 22 and 25 years). The late physeal closure, coupled with strong adjacent sternoclavicular ligaments attaching to the epiphyseal portion of the medial clavicle results in a weak point located at the medial physis during force transmission through the medial clavicle.

Editor's Comments:
This case report does a great job of highlighting the importance of having a high index of suspicion for medial clavicle physeal injury following chest trauma in an adolescent who may present with concerns for an SC joint dislocation. A posteriorly displaced medial clavicle fracture carries similar complications and risks as a posterior SC joint dislocation. While rare, posterior SC join dislocations, only accounting for 10% of SC joint dislocation cases, recognizing both of these injuries is important. Posterior displacement of a medial clavicle fracture and/or SC joint can be associated with high morbidity and even mortality. These injuries can lead to damage of the internal jugular vein, subclavian artery, trachea, esophagus, and phrenic/vagus nerves.

References:
Glass ER, Thompson JD, Cole PA, et al. Treatment of sternoclavicular joint dislocations: a systemic review of 251 dislocations in 24 case series. J. Trauma. 2011; 70:1294-8.

Lee JT, Nasreddine AY, Black EM, et al. Posterior sternoclavicular joint injuries in skeletally immature patients. J. Pediatr. Orthop. 2014; 34:369-75.

Gove N, Ebraheim NA, Glass E. Posterior sternoclavicular dislocations: a review of management and complications. Am. J. Orthop. (Belle Mead NJ). 2006; 35:132-6.

Khalil H, Bourchier R, Walsh S. Case report-Vascular injury in association with posteriorly displaced medial clavicle fracture. Trauma Case Rep. 2021;33:100483. Published 2021 Apr 21. doi:10.1016/j.tcr.2021.100483

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