INTRODUCTION

The sternoclavicular joint (SCJ) is a saddle-type synovial joint that connects the sternum to the clavicle. Dislocations of this joint are uncommon, especially in pediatric patients, and are classified as either anterior or posterior. Posterior dislocations are less frequent but carry greater risk because of their proximity to major vascular structures, the trachea, and the esophagus [1].

CASE REPORT

A 12-year-old boy with no significant medical history presented to our pediatric emergency department complaining of pain in his right shoulder and an inability to move it, following a fight during which his cousin punched him multiple times on the right side of his upper chest. Immediately after the incident, he experienced shortness of breath and severe upper chest pain. He had no syncopal or fainting episodes, vomiting, loss of consciousness, breathing difficulty, weakness in any limbs, dysphagia, voice changes, or abnormal limb movement on the affected side. There was no history of blunt trauma to the abdomen, head, or chest.

On physical examination, the child was awake, oriented, and hemodynamically stable, breathing comfortably in room air without respiratory distress, and demonstrating equal bilateral chest movement and air entry. Bruising was noted over the right upper chest (Fig. 1). The right shoulder was held in adduction and mild internal rotation, but the shoulder contour was normal. He was unable to perform any active or passive movements at the right shoulder joint. Distal neurovascular status of the right upper limb was intact. The remainder of the musculoskeletal and neurological examinations was unremarkable.

The initial chest x-ray revealed asymmetry of the sternoclavicular joints (Fig. 2). Noncontrast computed tomography (CT) of the chest confirmed posterior dislocation of the right SCJ. Axial and coronal CT images demonstrated that the dislocated proximal right clavicle was in close proximity to the brachiocephalic artery (Figs. 3, 4). Both x-ray and CT findings indicated posterior dislocation of the medial clavicle adjacent to the brachiocephalic artery (Fig. 4).

The child was taken to the operating room the following day with a vascular surgeon present. Closed reduction was performed, and the shoulder was immobilized using a hanging brace and figure-of-eight bandage. The initial closed reduction was uneventful, but follow-up x-ray and CT revealed persistent dislocation with evidence of a retained bony fragment within the capsule, suggesting a higher likelihood of physeal injury rather than a true dislocation. The child was returned to the operating room under the same precautions, and a repeat closed reduction was attempted using a reduction clamp and towel clip (Fig. 5). Near-anatomic reduction was accepted to allow for spontaneous fracture healing and remodeling. No internal or percutaneous fixation was used. The child was followed up, and the most recent postreduction x-ray at 6 months is shown in Fig. 6.

Ethics statement

This study was approved by the Institutional Review Board of King Fahad Medical City (No. 1RB00010471). Written informed consent for publication of the research details and clinical images were obtained from the patient’s parents.

DISCUSSION

Blunt chest trauma in children is common and frequently encountered in emergency settings, often resulting in injuries such as rib fractures, lung contusions, pneumothorax, hemothorax, and visceral injuries. However, SCJ injuries or dislocations are rare occurrences. SCJ dislocations can be classified as anterior or posterior, depending on the mechanism and direction of the applied shearing force. Anterior SCJ dislocations are generally less concerning, typically presenting with a palpable deformity and often managed conservatively. Posterior SCJ dislocations, while less common, pose a much higher risk due to the potential for compression of mediastinal structures—including the trachea, esophagus, and great vessels—which can be life-threatening. Prompt recognition and appropriate management are critical to prevent serious complications [2]. Posterior dislocation of the SCJ in pediatric patients is rare but can be life-threatening because of its proximity to major vessels. SCJ dislocations account for about 3% of all shoulder girdle injuries and less than 1% of all skeletal dislocations [3,4].

Anterior SCJ dislocations are approximately nine times more common than posterior dislocations. A study analyzing sports-related SCJ dislocations in the United States from 2001 to 2020 reported that anterior dislocations accounted for 0.26% of cases, while posterior dislocations made up 2.9%; however, the direction of dislocation was unspecified in the majority of cases (71%) [5]. A thorough understanding of the anatomy of the sternoclavicular joint is essential for recognizing SCJ dislocation and its complications. The SCJ is a synovial joint formed between the medial clavicle, manubrium, and first costal cartilage, linking the upper limb to the axial skeleton and playing a key role in shoulder stability and movement. The joint is reinforced by anterior and posterior sternoclavicular ligaments (thickenings of the capsule), the interclavicular ligament (extending over the manubrium between the superomedial ends of the clavicles), and the costoclavicular ligament. Anteriorly, the SCJ is related to the sternocleidomastoid muscle, and posteriorly, it is adjacent to the sternohyoid and sternothyroid muscles, brachiocephalic veins, and origins of the great vessels [6].

A strong direct or indirect blunt force to the shoulder is the most common cause of posterior SCJ dislocation. A lateral blow to the shoulder may force the clavicle medially and posteriorly behind the manubrium, or a direct forceful blow to the medial clavicle may cause fracture and posterior displacement [7,8]. When such injuries are encountered in the emergency setting, a detailed history of the mechanism and a careful clinical examination are essential for identifying SCJ involvement. The medial clavicle physis remains open until around 25 years of age, so a high index of suspicion for SCJ injury is necessary in children, especially as physeal injuries are often initially missed when the impact is centered on the upper torso, such as after a fall onto the side of the body, being rolled over by a vehicle, or falling from a moving car or motorcycle [9].

In isolated shoulder trauma involving the SCJ, patients presenting to the emergency department often prefer to sit upright, holding the arm adducted and supporting it, with the head tilted toward the injured side. A detailed examination of the shoulder, acromioclavicular joint, and lateral clavicle should be performed. In polytrauma, associated severe injuries require urgent attention and may result in missed SCJ dislocations due to distracting injuries. Early recognition, supported by appropriate imaging, is crucial for diagnosis. Specific symptoms, such as difficulty breathing (due to tracheal compression or pneumothorax), swallowing difficulties (from esophageal compression), or voice change, should be elicited. High suspicion for pneumothorax or pneumomediastinum is warranted when the patient exhibits breathing difficulty or increased work of breathing. Assessment of limb perfusion, local temperature, capillary refill, and pulses is essential [10–12]. Any abnormalities in vascular supply to the limb, distended neck veins, or hemodynamic instability should raise suspicion for vascular injury. On chest radiography, asymmetrical placement of the sternal heads of the clavicle should prompt suspicion of SCJ dislocation. However, a specific “serendipity” view (with a 40° cephalic tilt of the x-ray beam toward the supine patient) is useful for detecting SCJ dislocation [13]. Ultrasound can also aid in diagnosis and assessment of proximity to underlying vascular structures, but its utility is limited by operator experience and acoustic window quality. The investigation of choice is contrast-enhanced CT, which offers superior resolution and enables three-dimensional reconstruction of the SCJ to determine its precise position and relationship to vascular structures [14].

Treatment should involve assessment by an experienced orthopedic surgeon, with reduction performed to maximize outcomes. Given the proximity to major blood vessels and the risk of serious vascular injury, decisions regarding reduction method (closed or open), reconstruction, and repair should involve both orthopedic and thoracic or vascular surgeons, with preparations made for potential bleeding complications. The choice between open and closed reduction depends on the nature and extent of dislocation and any associated vascular injury. Closed reduction in adults has a success rate of 38% to 50% when performed within the first 48 hours [15], but limited data exist for pediatric cases. Chronic SCJ dislocations (longer than 3 weeks) usually require open reduction with reconstructive SCJ procedures.

Conclusions

This case underscores the importance of considering SCJ dislocation in pediatric patients presenting with shoulder pain and deformity after direct trauma. Although anterior SCJ dislocations are more common, posterior dislocations, despite their rarity, demand heightened clinical vigilance due to associated risks. The choice of reduction method (open versus closed) should be based on the extent of peri-SCJ injury, the interval since injury, and limitations in shoulder function. In cases of posterior SCJ dislocation, closed reduction should be attempted in the operating room with a multidisciplinary team including expert orthopedic and cardiothoracic or vascular surgeons, immediate access to blood transfusion services, interventional radiology, and intensive care. Complications such as compressive symptoms and massive bleeding should always be anticipated.

ARTICLE INFORMATION

Author contributions

Conceptualization: AA; Investigation: AAB, AKA; Methodology: AAO; Project administration: AA; Visualization: AAO; Writing–original draft: AA, AAB; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Image of the impact injury.

Fig. 2.

Chest x-ray, showing asymmetry of the sternoclavicular joints (arrows).

Fig. 3.

Axial view of noncontrast computed tomography showing the right sternoclavicular joint’s sternal head displaced posteriorly behind the sternum (arrow).

Fig. 4.

Coronal view of noncontrast computed tomography. The dislocated proximal right clavicle is in proximity, impinging over the brachiocephalic artery (arrow).

Fig. 5.

Images obtained during closed reduction for guidance. Near anatomic reduction was achieved and accepted for healing and remodeling. (A) Closed reduction attempted by towel clip. (B) After closed reduction.

Fig. 6.

Follow-up x-ray 6 months after closed reduction. Right sternoclavicular joint asymmetry with ongoing healing process in form of mild periosteal reaction. Alignment appears near anatomical.

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Figure & Data

References

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