Sternoclavicular Dislocation
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Direct answer
A sternoclavicular dislocation is displacement of the medial clavicle relative to the manubrium, and posterior displacement is the dangerous variant because the clavicle can press on the trachea, oesophagus and great vessels. Anterior dislocation is the more common and usually benign form, but posterior displacement needs urgent CT assessment. In a skeletally immature patient the same force usually causes a medial clavicular physeal injury rather than a ligamentous dislocation.
What you must remember
- Anterior dislocation: the more common form, with a prominent palpable medial clavicle, usually managed without surgery.
- Posterior dislocation: the medial clavicle lies behind the manubrium and can compress the trachea, oesophagus and great vessels; dysphagia, stridor or venous congestion of the arm are warning signs.
- Diagnosis: plain films are often unhelpful, so CT is the investigation of choice when posterior displacement is suspected.
- Adolescents: the medial clavicular physis is the weak point, so a physeal injury is more likely than a ligamentous dislocation.
- Emergency: posterior displacement with mediastinal compression is urgent, needing airway assessment and reduction, often with cardiothoracic backup.
- Closed reduction: performed under general anaesthesia, typically with traction on the abducted arm, sometimes using a towel clip placed behind the medial clavicle.
- Unstable cases: open reduction with stabilisation or ligament reconstruction is considered when closed reduction fails or the joint remains unstable.
From suspicion to stabilisation
The sternoclavicular joint sits beside the trachea and great vessels, so the first question is whether the injury threatens the mediastinum. The rest of the pathway follows from that answer.
- Assess airway and circulation first: posterior displacement can cause breathlessness, dysphagia, stridor or venous congestion of the arm.
- Establish the direction: palpation identifies the anterior swelling, and CT defines posterior displacement when it is suspected.
- Check the age: in adolescents a medial clavicular physeal injury is more likely than a true dislocation, and management reflects the growth plate.
- Reduce posterior dislocation promptly: closed reduction under general anaesthesia, using traction and sometimes a towel clip, with thoracic surgical support on standby.
- Stabilise or observe: anterior dislocation is managed with a sling and analgesia, while unstable or irreducible cases need open stabilisation or ligament reconstruction.
- Follow up: check for recurrence, persistent pain and cosmetic deformity over the following months.
The examiner tests whether the candidate recognises posterior displacement as a mediastinal emergency. Anterior injuries are the benign counterpart and can be managed conservatively.
Where the exam tries to catch you
This injury is often dismissed as cosmetic, and that is the trap.
- Trap: dismissing posterior dislocation as a cosmetic problem Correct: posterior displacement can compress the trachea, oesophagus and great vessels and needs urgent assessment.
- Trap: diagnosing a medial clavicular dislocation in a 14-year-old without considering the physis Correct: in skeletally immature patients the medial physis is the weak point, so physeal injury is the likely diagnosis.
- Trap: trusting a plain radiograph to exclude posterior displacement Correct: CT is the investigation of choice when posterior displacement is suspected.
Frequently asked questions
Why is posterior sternoclavicular dislocation dangerous?
Posterior displacement can compress the trachea, oesophagus, great vessels and brachiocephalic structures. Patients may present with dyspnoea, dysphagia, stridor or venous congestion of the arm.
How is posterior sternoclavicular dislocation diagnosed?
CT of both sternoclavicular joints is the investigation of choice, because plain radiographs often miss posterior displacement. Clinical signs of mediastinal compression help set the urgency of imaging and reduction.
What injury occurs at the sternoclavicular region in children?
A medial clavicular physeal injury, a separation through the growth plate, is the usual injury in skeletally immature patients. It is commonly mistaken for a sternoclavicular dislocation.
How is posterior sternoclavicular dislocation reduced?
Closed reduction under general anaesthesia is attempted with traction, commonly using a towel clip behind the medial clavicle. If reduction fails or the joint is unstable, open reduction and stabilisation are considered.