Ms Maseda is from the University of Southern California, Los Angeles, Calif; Ms Clark is from the Department of Athletics, University of Southern Maine, Gorham, Me; Dr Tripp is from the Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Fla.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Natalie H. Maseda, ATC, University of Southern California, Division of Biokinesiology and Physical Therapy, 1540 Alcazar Street, CHP 155, Los Angeles, CA 90089-9006; e-mail: firstname.lastname@example.org.
Sternoclavicular joint (SCJ) injuries are rare in athletics; most SCJ injuries result from motor vehicle accidents.1 Dislocations or subluxations of this joint comprise 3% of shoulder joint dislocations2–4 and 1% of dislocations.3 Of the SCJ dislocations described in the literature, most occur in the anteroposterior direction.1 These dislocations can cause serious complications such as neural tissue compression, vascular compromise, and breathing problems; such complications are primarily noted with SCJ dislocations in the posterior direction.1 Injuries to this area can severely limit an athlete’s performance due to the joint’s integral role in scapular motion at the shoulder.1 Limited research exists that highlights superior SCJ dislocations in athletes.2 We present a superior SCJ dislocation with a unique clinical presentation that occurred in a young athlete from a sports-related injury.
A 17-year-old high school wide receiver returned to the sidelines during a game and complained of extreme pain over his right clavicle. He described the mechanism of injury as falling on the tip of his shoulder after being tackled. The patient reported point tenderness over the midshaft of the clavicle. During the initial assessment, the team physician noted tenderness on palpation over the midshaft of the clavicle. The athlete presented with decreased range of motion with forward flexion and horizontal adduction. Application of an ice bag and sling to reduce pain and relieve tension stress on the glenohumeral joint occurred after the initial injury assessment. After the game concluded, the athlete went to the emergency department for radiograph imaging to rule out a clavicular fracture. Radiographs were normal, and the emergency department physician instructed the athlete to rest, ice, and remain in a sling until symptoms subsided.
Three days postinjury, the athlete returned to the athletic training room complaining of localized pain over his right SCJ. On further evaluation, the clavicle appeared elevated and superiorly displaced (Figure 1). Local swelling and point tenderness was present over the SCJ, and crepitus and pain occurred with glenohumeral horizontal adduction and forward flexion. A percussion test over the SCJ and sternal end of the clavicle elicited pain, but no crepitus occurred over the shaft indicating a fracture. The certified athletic trainer’s differential diagnosis included a possible SCJ subluxation, dislocation, physeal fracture, or SCJ sprain. The team physician reevaluated the athlete and concurred with the athletic trainer’s differential diagnosis. Because the presentation of symptoms changed 3 days postinjury, the patient was referred to an orthopedic specialist the following day.
Figure 1. Photograph Showing Right Superior Clavicular Displacement 1 Week Postinjury.
Computed Tomography (CT) imaging was ordered to rule out a possible occult fracture or a fracture of the physeal plate. The radiologist diagnosed the athlete with a superior SCJ dislocation, displaced approximately 2 mm (Figure 2). Evidence apparent on the CT scan suggested either a prior injury or an avulsion fracture at the sternal end of the clavicle resulting in the SCJ displacement; ossific fragments presented posterior to the superior aspect of the manubrium (Figure 3). Because the athlete had no previous injury to the upper extremity or thorax, the fragments seen on the CT scan indicated an avulsion fracture at the sternal end of the clavicle.
Figure 2. Coronal CT Scan Showing Superior Displacement of the Right Clavicle.
Figure 3. Sagittal CT Scan Showing the Ossific Fragment Superior to the Clavicle of the Avulsed Portion of the Sternum.
The athlete rested for 2 weeks with no activity prior to a follow-up assessment with the orthopedic physician. Although prescribed formal physical therapy, the athlete chose to attend only one formal session during the 2-week period. Throughout his recovery period, the athletic trainer had the athlete complete cardiovascular and core strengthening activities (ie, jogging, body-weight squats, walking lunges, calf raises, crunches). Specific to the shoulder, the athlete completed Codman’s exercises (pendulums) to maintain range of motion and iced daily. After 2 weeks, the orthopedic physician cleared the athlete for full activity; functional assessment and closed kinetic chain upper extremity exercise performance suggested restoration of function. Although the deformity remains, the athlete reports no complications or residual symptoms.
The SCJ is the only direct skeletal attachment between the upper extremity and the trunk.5,6 Sternoclavicular joint sprains and dislocations typically occur secondary to an indirect blow transmitted through an outstretched arm1,7 or a direct trauma that strikes the clavicle or initiates torsion of the joint.1,7 The mechanism in the present case, landing on the tip of the shoulder, more commonly results in clavicular fractures or acromioclavicular pathology, rather than SCJ dislocations.5
Patients with a SCJ dislocation commonly complain of anterior chest or shoulder pain, which is exacerbated with arm motion or lying supine.6 Interestingly, the athlete presented with localized pain over the midportion of the clavicle, suggesting a clavicle fracture.7 However, radiographs did not support a clinical diagnosis of a clavicular fracture. A serendipity view,5 although not ordered in this case, may be a better option for determining clavicular position relative to the manubrium, potentially identifying avulsion fractures or SCJ displacement in the skeletally immature athlete. Patients with dislocations or fractures often describe hearing a pop in the region,8 but in this case, the athlete did not report hearing a pop or feeling a popping sensation. The SCJ initially did not appear to be displaced at the time of injury, likely due to the delay of swelling in the region. The accentuation of the deformity 3 days postinjury may have occurred secondary to the avulsion injury or from inconsistency with wearing the sling, resulting in exacerbated signs of displacement from the force of gravity.
Diagnostic imaging, specifically sagittal and coronal views on the CT scan completed on this athlete, confirmed the true diagnosis of an SCJ dislocation. Computed Tomography aids in the clinical diagnosis of SCJ dislocations, physeal injuries, and soft-tissue disruption.1,7 In this case, CT proved invaluable because the clinical assessment initially was insufficient to accurately identify the underlying pathology.
True SCJ dislocations are uncommon in skeletally immature patients,8 occurring more frequently with physeal fractures along the medial clavicular growth plate.4,8 Because the clavicular physis does not calcify until individuals reach their early 20s, the physeal plate is the weakest point around the SCJ, increasing susceptibility to ligamentous avulsion injury in this region.4 In our case, the skeletally immature athlete presented with ossific fragments on the sternal end of the clavicle, visible on the CT scan (Figure 3). The ligamentous avulsion injury, which occurred from the longitudinal force transferred from the ground through the shaft of the clavicle, resulted in the superior displacement of the SCJ. After the avulsion or joint disruption occurs, joint stability is compromised and may present as an SCJ dislocation. Although there is a disparity between the etiology and atypical pathology in our case, the skeletally immature athlete is more susceptible to an avulsion injury around the physis than a true ligamentous tear.
Normal course of treatment for SCJ sprains includes immobilization for 3 to 5 weeks, followed by reconditioning to minimize the high rate of reoccurrence.1,7 Our patient made an accelerated recovery (ie, 2 weeks), which may be attributed to the minimal displacement of the SCJ at the time of injury.
Clinicians should consider SCJ integrity when assessing the shoulder complex after traumatic injury, regardless of whether the clinical presentation differs from that normally found with SCJ injuries. Diagnostic imaging, specifically CT, is essential for proper diagnosis of an SCJ injury and to identify the direction and severity of the displacement.9 Suspicion of an SCJ injury in a skeletally immature athlete warrants diagnostic imaging to rule out a physeal fracture.8 After being confirmed, SCJ dislocations require immobilization and rehabilitation to restore the integrity and function of this joint and potentially minimize the high incidence of recurrence.7 Return to play following SCJ injury depends on the severity and direction of displacement, but general recommendations include an absence of pain during motion, improved strength in the muscles used to protect the SCJ (specifically the pectoralis minor, pectoralis major, and upper trapezius1), and restoration of function appropriate for the demands of the sport.1
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- Prentice WE. Arnheim’s Principles of Athletic Training: A Competency-Based Approach. 12th ed. New York, NY: McGraw-Hill; 2006.
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