Sternoclavicular Dislocation

Sternoclavicular dislocation (SCD) is a rare injury (<3% of all joint dislocations) that is frequently misdiagnosed in the ED.[1-2] The critical distinction is between anterior (more common, generally benign) and posterior (less common, potentially life-threatening due to proximity to mediastinal structures).[1][3] Over one-third of posterior SCDs are missed at initial presentation.[4]

• Mechanism of injury — the single most important HPI element:
• Anterior dislocation: arm pulled posteriorly with force, or indirect force through the arm in flexion/abduction/external rotation[3][5]
• Posterior dislocation: compressive anterior-to-posterior force on the chest, or lateral compression of the shoulder (e.g., pile-on in contact sports, MVC rollover)[3][6]
• Timing of injury and any prior episodes of SC joint instability
• Pain location: anterior chest/medial clavicle, often radiating to shoulder
• Ability to move the affected arm (typically decreased active ROM)[1]
• Symptoms suggesting mediastinal compression: dyspnea, dysphagia, hoarseness, choking sensation, arm swelling[2-3]
• Mechanism energy level: high-energy (MVC, contact sports) vs. low-energy (atraumatic instability)[7-8]

• Dyspnea or stridor → tracheal compression[1][3]
• Dysphagia or odynophagia → esophageal compression[2]
• Hoarseness → recurrent laryngeal nerve involvement[3]
• Ipsilateral upper extremity swelling, cyanosis, or venous engorgement → subclavian/brachiocephalic vein compression[2]
• Diminished or absent distal pulses → arterial compromise[1]
• Hemodynamic instability → vascular injury or hemorrhage[9]
• Palpable defect or "hollow" at the SC joint (vs. prominence in anterior dislocation) → suggests posterior dislocation[2]
• Pain-limited forward flexion — present in 83% of posterior SCDs in one pediatric series and should raise suspicion[4]

• Acute analgesia: IV opioids, NSAIDs, acetaminophen for pain control
• Procedural sedation: required for closed reduction attempts (propofol, ketamine, or midazolam/fentanyl per institutional protocol)[1]
• Post-reduction: oral NSAIDs, acetaminophen; short course of opioids if needed
• Avoid: Kirschner wires (K-wires) for fixation — historically associated with catastrophic migration into mediastinal structures; their use is contraindicated[2][8]

• If posterior dislocation with dysphagia is present, maintain NPO status pending CT evaluation and potential surgical intervention
• No specific long-term dietary considerations
• Standard hydration and nutrition for musculoskeletal healing post-reduction

• Respiratory: dyspnea, stridor, pleuritic chest pain (pneumothorax)
• Cardiovascular: arm swelling, color changes, pulselessness
• GI: dysphagia, globus sensation
• Neurologic: paresthesias, weakness in ipsilateral upper extremity (brachial plexus)[2]
• ENT: voice changes, hoarseness
• MSK: shoulder pain, decreased ROM, prior shoulder/clavicle injuries
• Constitutional: syncope or near-syncope at time of injury (suggests vascular compromise)

• Witnesses to mechanism (especially in sports — lateral blow to shoulder vs. direct anterior chest impact)[4]
• Prior episodes of SC joint subluxation or instability
• Generalized ligamentous laxity or connective tissue disorders (Ehlers-Danlos, Marfan) — associated with atraumatic SC instability[5]
• Family history of hypermobility syndromes
• In adolescents, confirm skeletal maturity status (medial clavicular physis is the last to fuse, ~age 23–25)[2][6]

• Contact/collision sports: football (especially offensive linemen), rugby, wrestling, hockey — most common cause (74–86% of cases in younger patients)[4][10]
• Motor vehicle collisions (especially rollover)[6-7]
• Age <25 years: physeal separation more common than true dislocation[2][6]
• Male sex: ~88–92% of cases[4][10]
• Generalized ligamentous laxity[5]
• Falls from standing height[10]

• Medial clavicle fracture — especially in patients <25 years (physeal fracture-separation mimics dislocation; MRI helps differentiate)[2][6]
• Clavicle shaft fracture with medial extension
• SC joint sprain/subluxation (grade I–II without complete dislocation)
• Sternal fracture
• Costochondritis or Tietze syndrome (atraumatic)
• SC joint septic arthritis (atraumatic, febrile, IV drug use risk factor)
• SC joint osteoarthritis (chronic, degenerative)
• Condensing osteitis of the medial clavicle
• Chest wall contusion — cannot-miss: posterior SCD masquerading as simple contusion (36% missed at initial visit)[4]

• Prior SC joint dislocations or subluxations (recurrent instability)
• Prior clavicle fractures
• Connective tissue disorders
• Osteoporosis (affects fixation strategy if surgical)[11]
• History of chest/mediastinal surgery
• Anticoagulant use (increases hemorrhage risk with posterior dislocation)

• Vital signs: tachycardia, hypotension (vascular compromise); tachypnea, hypoxia (airway/pneumothorax)

Inspection

• Anterior dislocation: visible/palpable prominence of the medial clavicle anterior to the sternum[3]
• Posterior dislocation: palpable defect or "hollow" at the SC joint; the medial clavicle is less prominent than the contralateral side[2]
• Swelling, ecchymosis over the SC joint
• Venous engorgement of the ipsilateral neck/arm
• Palpation: tenderness directly over the SC joint; compare bilaterally
• ROM: decreased active shoulder ROM, especially forward flexion and cross-body adduction[1][4]
• Neurovascular exam: distal pulses, capillary refill, sensation in the ipsilateral upper extremity[1]
• Auscultation: diminished breath sounds (pneumothorax); stridor

• Labs are generally not diagnostic for SCD itself

If hemodynamic compromise or suspected vascular injury

• CBC, type and screen/crossmatch
• Lactate, BMP
• Coagulation studies if on anticoagulants or if surgical intervention anticipated
• Pre-operative labs as indicated

• Plain radiographs: often miss the diagnosis; standard AP chest X-ray has poor sensitivity for SCD[1][4][12]
• Serendipity view (40° cephalic tilt AP): can show asymmetry of the medial clavicles — superior displacement (anterior) vs. inferior displacement (posterior) — but largely supplanted by CT[2][13]
• CT of the chest (with or without contrast): gold standard for diagnosis and evaluation of mediastinal complications[1][3][14]
• Axial cuts clearly demonstrate anterior vs. posterior displacement
• Evaluates for pneumothorax, hematoma, vascular compression
• CT angiography (CTA): warranted when vascular injury is suspected (hemodynamic instability, pulse deficit, arm swelling)[9][14]
• MRI: useful in patients <23 years to differentiate physeal fracture-separation from true dislocation; also defines soft-tissue/ligamentous injury[2][14]

• No validated scoring systems specific to SCD
• Point-of-care ultrasound (POCUS): may identify joint asymmetry or effusion at the bedside, but CT remains the definitive study
• Bedside swallow assessment: if dysphagia is present, to assess esophageal compression
• In patients <25 years, consider MRI to evaluate physeal status[2]

• ECG is not routinely indicated for isolated SCD

Obtain if

• High-energy mechanism with concern for cardiac contusion (blunt chest trauma)
• Hemodynamic instability
• Chest pain atypical for musculoskeletal etiology
• No specific ECG pattern associated with SCD

• Direction: Anterior (more common, ~80%) vs. Posterior (~20%, more dangerous)
• Severity: Sprain (grade I–II) vs. Subluxation vs. Complete dislocation (grade III)
• Timing: Acute (<3 weeks) vs. Chronic
• Age consideration: In patients <23–25 years, many "dislocations" are actually Salter-Harris physeal fracture-separations[6]

Key clinical pearl: Anterior SCD is generally a benign injury with good outcomes even without reduction. Posterior SCD is a potential surgical emergency due to proximity of the brachiocephalic veins, subclavian vessels, trachea, and esophagus.[1][3] However, recent large series suggest the actual incidence of clinically significant vascular injury is lower than historically reported — no vascular injuries requiring intervention were found in a multicenter series of 125 posterior SCDs, and a national database study of 140 posterior SCDs found zero vascular injuries.[10][15] Nonetheless, the potential for catastrophic hemorrhage mandates a cautious approach.[9][14]

Anterior SCD

• Closed reduction in the ED with procedural sedation: patient supine with a bolster between the scapulae; apply traction to the arm in abduction and extension, then direct posterior pressure on the medial clavicle
• High recurrence rate after reduction, but most patients remain minimally symptomatic[11]
• Sling immobilization for comfort, typically 4–6 weeks
• Surgical stabilization reserved for persistently symptomatic recurrent instability

Posterior SCD

• Emergent closed reduction if airway, hemodynamic, or vascular compromise is present
• Technique: patient supine with interscapular bolster; traction on the abducted arm; the medial clavicle may need to be grasped with a towel clip to pull it anteriorly
• Closed reduction is most successful within 48 hours (56% success vs. 31% after 48 hours)[17]
• Can be attempted up to 10 days post-injury[9]
• If no acute compromise, obtain CT first, then plan reduction in a controlled setting
• Orthopedic consultation is required for all posterior SCDs[1]
• Cardiothoracic/vascular surgery notification recommended, particularly for open reduction — though recent data suggest routine CT/vascular backup may be sufficient rather than mandatory CT surgeon presence in all cases[10][15]
• Open reduction and stabilization (ligament reconstruction, plate fixation) for failed closed reduction or chronic/locked dislocations[11][14][18]

Medications

• NSAIDs (ibuprofen 600–800 mg TID or ketorolac 15–30 mg IV) and acetaminophen
• Short-course opioids for severe pain
• Procedural sedation agents for reduction

Admit

• All posterior SCDs — for monitoring, CT evaluation, and orthopedic/surgical consultation
• Any SCD with signs of mediastinal compression, vascular compromise, or airway symptoms
• Failed closed reduction requiring operative management
• Polytrauma patients

Discharge (with close follow-up)

• Uncomplicated anterior SCD after successful closed reduction or if managed conservatively
• Sling, ice, analgesia, and orthopedic follow-up within 1 week

Observation

• Anterior SCD with associated fracture or equivocal exam — pending CT results and orthopedic evaluation

Consult triggers

• Orthopedics: all posterior SCDs, complicated anterior SCDs (with fracture), failed reductions
• Cardiothoracic/vascular surgery: posterior SCD with any mediastinal symptoms, planned open reduction of posterior SCD
• Thoracic surgery: if pneumothorax or esophageal injury suspected

• Orthopedic follow-up within 5–7 days for all SCDs[1]

Return to ED immediately for

• New or worsening shortness of breath, difficulty swallowing, voice changes
• Arm swelling, color changes, or numbness
• Increasing pain despite medications
• Feeling of the joint "popping out" again

Expected recovery

• Anterior SCD: sling for 4–6 weeks; gradual return to activity; may have residual cosmetic prominence[3]
• Posterior SCD (after successful closed reduction): mean return to sports ~3.1 months (range 1–6 months); 74% full return to sport[19]
• Patient counseling: recurrent instability is common after anterior SCD but usually minimally symptomatic; posterior SCD recurrence is less common but warrants closer surveillance[11]
• Avoid contact sports until cleared by orthopedics

1. Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department. — Carius BM, Long B, Gottlieb M. The Journal of Emergency Medicine. 2021.

2. Management of Traumatic Sternoclavicular Joint Injuries. — Groh GI, Wirth MA. The Journal of the American Academy of Orthopaedic Surgeons. 2011.

3. Acute Shoulder Injuries in Adults. — Simon LM, Nguyen V, Ezinwa NM. American Family Physician. 2023.

4. Posterior Sternoclavicular Joint Dislocations in Children and Adolescents: Missed Diagnoses and Management Outcomes. — Owens SP, Grady MF. Pediatric Emergency Care. 2026.

5. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. — Herring SA, Kibler WB, Putukian M, et al. Medicine and Science in Sports and Exercise. 2024.

6. Pediatric Posterior Sternoclavicular Joint Injuries. — Chaudhry S. The Journal of the American Academy of Orthopaedic Surgeons. 2015.

7. Traumatic Sternoclavicular Dislocations in Athletes: Diagnosis, Indications for Surgical Reconstruction, and Guide for Return to Play. — Brown L, Tamburini LM. Clinics in Sports Medicine. 2023.

8. Instability and Degenerative Arthritis of the Sternoclavicular Joint: A Current Concepts Review. — Martetschläger F, Warth RJ, Millett PJ. The American Journal of Sports Medicine. 2014.

9. Traumatic Posterior Sternoclavicular Joint Dislocation - Current Aspects of Management. — Ingoe HMA, Mohammed K, Malone AA, et al. Injury. 2023.

10. The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study. — Fournier MN, Sinclair MR, Zheng ET, et al. Journal of Pediatric Orthopedics. 2020.

11. Anterior Sternoclavicular Joint Dislocation Classification and Management: A Review of the Literature. — El Zouhbi A, Hammad A, Hammad M, Nassereddine M. JBJS Reviews. 2025.

12. Delayed Posterior Sternoclavicular Joint Dislocation in a Young Adult Managed With Plate Fixation and Cardiothoracic Collaboration. — Craddock G, Park A, Campbell B, et al. Injury. 2025.

13. Clinical Evaluation of Injuries to the Acromioclavicular and Sternoclavicular Joints. — Garretson RB, Williams GR. Clinics in Sports Medicine. 2003.

14. Advances in the Management of Sternoclavicular Joint Injuries. — Nielsen C, Dehghan N, McKee MD. The Journal of Bone and Joint Surgery. American Volume. 2026.

15. Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights From a National Sample. — Leonard DA, Segovia NA, Kaur J, et al. Journal of Orthopaedic Trauma. 2020.

16. Sternoclavicular Joint Dislocation: A Systematic Review and Meta-Analysis. — Sernandez H, Riehl J. Journal of Orthopaedic Trauma. 2019.

17. Posterior Sternoclavicular Joint Injuries in the Adolescent Population: A Meta-Analysis. — Tepolt F, Carry PM, Heyn PC, Miller NH. The American Journal of Sports Medicine. 2014.

18. Acute Dislocations of the Sternoclavicular Joint: A Review Article. — Obremskey WT, Rodriguez-Baron EB, Tatman LM, Pesantez RF. The Journal of the American Academy of Orthopaedic Surgeons. 2022.

19. Return to Sports After Closed Reduction of Acute Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review. — Damschen J, Nowak M, Murphy A, et al. The American Journal of Sports Medicine. 2023.