Working Diagnosis:
Posterior sternoclavicular joint dislocation

Treatment:
From our clinic patient was immediately sent for stat CT. Once CT results were back the same day, the patient was sent immediately to a tertiary hospital. Patient underwent a successful open reduction and fixation with sutures the next day in the operating room under general anesthesia, after closed reduction in the operating room was unsuccessful. Patient was put in a sling for six weeks with non weight-bearing in right upper extremity.

Outcome:
Patient followed up one week after surgery with his orthopedic surgeon at their outpatient clinic and was doing well. He was still in a sling and non-weight bearing in right upper extremity for the next six weeks. He was cleared to start scapular squeeze, curls with arms at side, and lower extremity exercises with body weight.

Patient followed up again at three the month interval with the surgeon. He reported no significant pain with rare exception of posterior shoulder pain with terminal flexion. He denied any numbness, paresthesia, or any other concerns. He was told to restrict contact activity until spring football begins. He was told to follow up as needed.

Author's Comments:
Posterior SC joint dislocation is a rare but potentially serious and life threatening injury that is usually caused by acute trauma. There is usually a large force required to cause sternoclavicular joint dislocation such as contact sports or motor vehicle accident. There is an indirect anterolateral or posterolateral force on the shoulder causing the damage to the Sternoclavicular and costoclavicular ligaments and causing anterior sternoclavicular joint or posterior sternoclavicular joint dislocation, respectively. There can also be a direct posterior force at the sternoclavicular joint which can also cause posterior sternoclavicular joint dislocation. Anterior dislocation is more common than posterior, however posterior is more serious and life threatening due to the vital structures such as vasculature, trachea and esophagus behind it. CT is the imaging of choice, and CT angiography if there is any vascular injury. Acute posterior dislocation less than three weeks old without evidence of vascular damage can be managed with closed reduction under general anesthesia. If there is any vascular compromise, it is a surgical emergency. Acute anterior dislocations are usually left alone, though some surgeons may attempt to do closed reduction at least once.

Editor's Comments:
This case represents an excellent example of understanding anatomical concerns with suspected fracture management. Initial plain X-rays can sometimes fail to show a sternoclavicular dislocation. In the setting of the deformity of this patient's sternoclavicular joint, his exam should prompt more urgent CT scan evaluation prior to this patient being discharged to follow up in the sports medicine clinic. Vascular and respiratory compromise are major concerns with this type of injury which warrants a detailed exam and history as done in this sports medicine clinic. Prompt surgical management is usually needed in posterior sternoclavicular dislocations. Football, wrestling, and biking are of the most frequently implicated sports for this injury.

References:
Sandler AB, Baird MD, Scanaliato JP, et al. Incidence of sports-related sternoclavicular joint dislocations in the United States over the last two decades. World J Orthop. 2023;14(6):427-435.

Hellwinkel JE, McCarty EC, Khodaee M. Sports-related sternoclavicular joint injuries. Phys Sportsmed. 2019;47(3):253-261.

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