Working Diagnosis:
Left Posterior Sternoclavicular Joint Dislocation

Treatment:
The patient was referred to orthopedic surgery and underwent open reduction and internal fixation of the left sternoclavicular joint four days after his initial injury. The patient tolerated surgery well. Postoperatively, he was made non-weight bearing in the left upper extremity but cleared to do gentle range of motion exercises.

Outcome:
After two weeks, the patient was cleared for range of motion exercises. After six weeks, the patient was advanced to weight bearing as tolerated and allowed to participate in non-contact sports activities. After ten weeks, he re-injured the joint playing football and had increased pain limiting shoulder abduction. It was recommended that he work on range of motion exercises and not return to full contact play until range of motion was restored. After three months, repeat imaging showed extensive callus formation, with slight elevation of the left clavicle without evidence of redislocation. He was cleared for non-contact practice, with repeat radiographs in the future to reevaluate the left clavicle. He has not followed up since.

Author's Comments:
Posterior sternoclavicular joint dislocations are much less common compared to anterior dislocations, but are more dangerous because mediastinal structures are at risk. The sternoclavicular joint is inherently unstable as less than 50% of the medial clavicular surface articulates with the sternoclavicular joint. The most common cause for dislocation is trauma. Associated symptoms may include dyspnea, dysphagia, stridor or tachypnea that is worse when supine, diminished pulses, and paresthesias. All posterior dislocations require expedient diagnosis and treatment and must undergo closed reduction, usually under general anesthesia, and if unsuccessful, open reduction and stabilization. Symptoms of compression of retrosternal structures have occurred in up to a third of cases, which is why prompt diagnosis and management are essential.

Editor's Comments:
Posterior sternoclavicular joint dislocations are potentially dangerous injuries, and it is important to keep it on the differential diagnosis for acute chest and shoulder injuries. They are classically described in football injuries, but could be seen in other contact sports such as rugby. If swelling has not occurred yet, a depression may be seen. It is important to remember that oblique plain radiographs are often needed to appreciate the injury, as AP views often do not visualize the injury.

References:
Brukner, P., Khan, K., & Brukner, P. (2012). Brukner & Khan's clinical sports medicine. Sydney: McGraw-Hill.
Cruz, M. F., Erdeljac, J., Williams, R., Brown, M., & Bolgla, L. (2015). POSTERIOR STERNOCLAVICULAR JOINT DISLOCATION IN A DIVISION I FOOTBALL PLAYER: A CASE REPORT. International journal of sports physical therapy, 10(5), 700–711.
Deren, M. E., Behrens, S. B., Vopat, B. G., & Blaine, T. A. (2014). Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthopedic reviews, 6(1), 5245. https://doi.org/10.4081/or.2014.5245
Hoekzema, N., Torchia, M., Adkins, M., & Cassivi, S. D. (2008). Posterior sternoclavicular joint dislocation. Canadian journal of surgery. Journal canadien de chirurgie, 51(1), E19–E20

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