01Approach to the Critical Patient/attcp34

Immediate threats

›Posterior SCD life threats

›Airway compromise

›Stridor or respiratory distress from tracheal compression

›Hoarseness from recurrent laryngeal nerve involvement

›Vascular compromise

›Absent or diminished distal pulses from subclavian or brachiocephalic injury

›Ipsilateral arm swelling, cyanosis, or venous engorgement

›Hemodynamic instability suggesting hemorrhage

›Esophageal or great vessel compression

›Dysphagia or odynophagia

›Signs of mediastinal shift

Stabilization priorities

›Resuscitation steps

›Two large-bore IVs if vascular compromise suspected

›Type and crossmatch immediately

›Activate trauma or vascular surgery team

›Airway management

›If stridor or hypoxia, prepare for definitive airway

›RSI preferred; have surgical airway backup available

›Hemodynamic targets

›SBP >= 90 mmHg

›MAP >= 65 mmHg

›NPO status for posterior SCD until surgical evaluation complete

Key decision points

›Anterior vs posterior classification

›Anterior: visible medial clavicle prominence, generally stable

›May attempt closed reduction in ED

02History/hx46

Mechanism and presentation

›Mechanism of injury

›Anterior dislocation mechanism

›Arm pulled posteriorly under force

›Indirect force through arm in flexion, abduction, external rotation

›Posterior dislocation mechanism

›Compressive anterior-to-posterior force on anterior chest

›Lateral compression of shoulder (pile-on, MVC rollover)

›High-energy mechanisms dominant: contact sports, MVC

›Symptom pattern

›Anterior chest or medial clavicle pain

›Radiation to ipsilateral shoulder

›Pain limiting active ROM

›Alarm symptoms suggesting posterior dislocation

›Dyspnea or stridor

›Dysphagia or choking sensation

›Hoarseness or voice change

›Ipsilateral arm swelling or color change

›Diminished distal pulses

Risk factors

›Epidemiologic risk profile

›Contact and collision sports

›Football, rugby, wrestling, hockey highest risk

›74-86% of cases in younger patients from sports

›Motor vehicle collisions

›Rollover mechanism particularly associated with posterior SCD

›High-energy blunt chest trauma

›Demographic risk

03Physical Exam/exam46

Vital signs and general

›Stability indicators

›Heart rate

›Tachycardia suggesting vascular compromise or pain

›Blood pressure

›Hypotension suggesting hemorrhage or great vessel injury

›Oxygen saturation

›Desaturation suggesting airway or pneumothorax complication

›Respiratory rate

›Tachypnea suggesting airway or pneumothorax complication

SC joint and shoulder exam

›Local findings

›Anterior dislocation findings

›Visible and palpable prominence of medial clavicle anterior to sternum

›Swelling and ecchymosis over SC joint

›Tenderness directly over SC joint

›Posterior dislocation findings

›Palpable defect or hollow at SC joint

›Medial clavicle less prominent than contralateral side

›Venous engorgement of ipsilateral neck or arm

›Range of motion

›Active shoulder ROM

›Decreased forward flexion: pain-limited in 83% of posterior SCD cases

›Decreased cross-body adduction

›Passive ROM to assess true limitation

Neurovascular exam

›Upper extremity perfusion

›Distal pulses

04Differential Diagnosis/ddx41

Life-threatening diagnoses

›Vascular emergencies

›Subclavian artery or vein injury

›ICD-10 S25.1 injury of subclavian artery

›Pulse deficit and arm ischemia

›Brachiocephalic vessel injury

›Mediastinal hematoma on CT

›Hemodynamic instability

›Pneumothorax

›ICD-10 S27.0 traumatic pneumothorax

›Diminished breath sounds, tracheal deviation

›Aortic injury

›High-energy mechanism

›Widened mediastinum on CXR

Musculoskeletal mimics

›Medial clavicle fracture

›ICD-10 S42.02 fracture of medial end of clavicle

›Especially in patients < 25 years (physeal fracture-separation)

›MRI differentiates physeal from ligamentous injury

›Clavicle shaft fracture with medial extension

›Deformity along clavicle shaft

›SC joint sprain or subluxation grade I-II

›No complete dislocation on CT

›Tenderness without significant asymmetry

›Sternal fracture

›ICD-10 S22.2 fracture of sternum

›Direct sternal tenderness

›High-energy mechanism

05Laboratory Tests/lt24

Trauma and hemodynamic labs

›Core trauma labs for suspected posterior SCD

›Complete blood count

›Baseline hemoglobin for hemorrhage tracking

›Crossmatch if vascular injury suspected

›Type and screen or crossmatch

›Posterior SCD with hemodynamic instability

›Surgical planning

›Basic metabolic panel

›Renal function for contrast CT planning

›Baseline electrolytes

›Coagulation panel

›Anticoagulant use or pre-operative requirement

›PT, INR, aPTT

Perfusion markers

›Lactate

›>= 2 mmol/l as tissue hypoperfusion marker

›Vascular injury or hemorrhagic shock concern

›Repeat in 2 hours if elevated

›Blood type and crossmatch

›Mandatory for posterior SCD with vascular compromise

›Reserve O-negative if emergent transfusion needed

When labs are not required

›Isolated anterior SCD without hemodynamic compromise

›Labs generally not diagnostic for SCD

›Imaging is the key diagnostic modality

›Pre-operative labs if surgical management anticipated

06Diagnostic Tests/dt48

Scoring Systems

›No validated scoring system specific to SCD

›Diagnosis relies on mechanism, clinical exam, and imaging

›Posterior vs anterior classification is the key clinical risk stratification

›High-energy mechanism with hollow SC joint mandates CT regardless of symptoms

›Injury severity classification

›Grade I: sprain, ligaments intact

›Grade II: subluxation, partial ligament disruption

›Grade III: complete dislocation, full ligament disruption

MRI

›MRI indications for SCD

›Age < 25 years with suspected SCD

›Medial clavicular physis last to fuse (~age 23-25)

›Differentiates physeal fracture-separation from true dislocation

›Critical: physeal injuries managed differently than true dislocations

›Soft tissue and ligamentous characterization

›SC ligament and capsule integrity assessment

›Retrosternal soft tissue involvement

›Brachial plexus assessment when paresthesias present

›Limitations

›Not appropriate for unstable patients

›Availability constraints in acute settings

›CT obtained first in all hemodynamically unstable patients

CT

›CT chest indications

›Gold standard for SCD diagnosis and mediastinal evaluation

›Clearly demonstrates anterior vs posterior displacement on axial cuts

›Evaluates pneumothorax, hematoma, vascular compression

07Disposition/dispo34

Admission and surgical indications

›Posterior SCD disposition

›All posterior SCDs require admission

›Surgical consultation: cardiothoracic and orthopaedic

›Closed reduction in OR with surgical standby

›ICU or monitored bed if vascular or airway compromise

›Emergent OR indications

›Airway compromise

›Vascular injury or absent pulse

›Failed closed reduction

›Hemodynamic instability

›Vascular injury disposition

›Immediate surgical intervention

›Subclavian or brachiocephalic injury

›Thoracic surgery and vascular surgery team activated

›Transfer to Level I trauma center if not available

Anterior SCD disposition

›Anterior SCD management pathway

›ED closed reduction attempt reasonable

›Procedural sedation required

›Orthopaedic consultation same visit or next day

›Post-reduction criteria for discharge

›Stable neurovascular exam after reduction

›Adequate pain control on oral medications

›Reliable patient with follow-up arranged

›Admission for anterior SCD

›Failed closed reduction

›Neurovascular compromise post-reduction

08Treatment/t70

Analgesia and sedation

›Pain management for SCD

›Acute pain control

›IV opioids for moderate to severe pain

›Morphine 0.1 mg/kg IV titrated to comfort

›Hydromorphone 0.015 mg/kg IV as alternative

›IV acetaminophen as adjunct

›1 g IV every 6 hours

›Reduces opioid requirement

›NSAIDs

›Ketorolac 15-30 mg IV or 10 mg IV in elderly

›Avoid if renal impairment or bleeding risk

›Procedural sedation for closed reduction

›Propofol 1-2 mg/kg IV titrated to effect

›Rapid onset and offset

›Apnea monitoring mandatory

›Ketamine 1-2 mg/kg IV

›Dissociative analgesia with airway preservation

›Consider for anterior SCD reduction in ED

›Midazolam 0.05-0.1 mg/kg IV plus fentanyl 1-2 mcg/kg IV

›Alternative moderate sedation protocol

›Monitor for respiratory depression

Closed reduction of anterior SCD

›Reduction technique

›Patient positioning

›Supine with ipsilateral arm abducted 90 degrees

›Bolster or sandbag between shoulder blades

›Reduction maneuver

›Lateral traction applied to abducted arm

›Direct pressure on medial clavicle in posterior direction for anterior dislocation

›Assistant stabilizes thorax during maneuver

›Post-reduction care

›Figure-of-eight clavicle brace or sling for 4-6 weeks

›Ice and elevation

›Oral analgesics: NSAIDs plus acetaminophen for 5-7 days

›Activity restriction: no contact sports for 6-12 weeks minimum

Closed reduction of posterior SCD

›OR-based posterior reduction

›Preparation

›Cardiothoracic surgery standby in OR

›General anesthesia preferred

›CTA to assess vascular anatomy before reduction

›Towel clip technique

›Skin incision and percutaneous towel clip placed around medial clavicle

›Lateral traction and anterior lever applied

›Success rate approximately 80% with this approach

›Post-reduction monitoring

›Post-reduction CT to confirm reduction and exclude vascular injury

›Neurovascular exam immediately post-reduction

›ICU monitoring if any vascular or airway compromise was present

Surgical management

›Indications for open surgery

›Failed closed reduction

›Persistent posterior displacement with symptoms

›Chronic unreduced posterior dislocation

›Recurrent instability after closed reduction

›Repeated anterior or posterior dislocation

›Ligamentous reconstruction required

›Acute vascular or airway emergency

›Open reduction with vascular repair

›Cardiothoracic surgery led procedure

›Hardware considerations

›K-wires absolutely contraindicated

›Migration into mediastinal structures is catastrophic and well-documented

›Alternative fixation methods required if internal fixation needed

›Figure-of-eight intramedullary fixation or tendon graft reconstruction preferred for chronic cases

Post-operative and post-reduction care

›Immobilization and rehabilitation

›Sling or figure-of-eight brace

›4-6 weeks for anterior SCD

›Longer for posterior or surgically managed cases per orthopaedic plan

›Physical therapy

›Passive ROM initiation at 4-6 weeks

›Progressive strengthening from 8-12 weeks

›Sport-specific rehabilitation before return to contact sport

09Special Populations/sp56

Pregnancy

›SCD in pregnancy

›Trauma mechanism unchanged but increased ligamentous laxity in pregnancy

›Progesterone-mediated ligamentous relaxation may increase instability risk

›Greater potential for physeal or ligamentous injury at lower energy

›Imaging approach in pregnancy

›CT chest with IV contrast if posterior SCD suspected

›Risk of missed posterior SCD with mediastinal compromise outweighs radiation risk

›Fetal radiation dose from CT chest is low

›MRI preferred over CT when hemodynamically stable and clinical suspicion lower

›No ionizing radiation

›Gadolinium avoided unless essential

›Analgesic safety

›Acetaminophen: safe throughout pregnancy

›NSAIDs: avoid after 20 weeks gestation due to premature ductus arteriosus closure

›Opioids: use with caution, short course, neonatal withdrawal risk with prolonged use

›Procedural sedation

›Propofol: limited data in pregnancy, avoid if possible

›Ketamine: may increase uterine tone, use with caution

›Obstetric consultation before procedural sedation in pregnancy

Geriatric

›Older adult considerations

›Bone density and fracture risk

›Osteoporosis increases medial clavicle fracture risk relative to dislocation

›Lower energy mechanism may cause significant injury in osteoporotic bone

›CT essential to exclude fracture-dislocation pattern

›Atypical presentation

›Mechanism may be low energy (fall from standing)

10Background/b54

Epidemiology

›Incidence and demographics

›Rare injury: fewer than 3% of all joint dislocations

›Represents less than 1% of all shoulder girdle injuries

›Frequently misdiagnosed: SCD missed in over one-third of posterior cases at initial ED visit

›Age distribution

›Peak incidence in patients aged 15-25 years

›Contact sport injuries dominant in this group

›Older adult presentation via low-energy mechanism or MVC

›Sex distribution

›Male sex in approximately 88-92% of cases

›Mechanism distribution

›Sports-related: 74-86% of cases in younger cohorts

›MVC: significant proportion in adult presentations

›Direction and severity

›Anterior dislocation: more common (approximately 75-85% of cases)

›Generally benign if neurovascular exam intact

›Posterior dislocation: less common but potentially lethal

›Mediastinal structure proximity creates risk for airway, vascular, esophageal injury

Pathophysiology

›Anatomy and injury mechanism

›SC joint anatomy

›Only joint connecting the upper extremity skeleton to the axial skeleton

›Fibrocartilaginous disc separates medial clavicle from sternum

›Primary stabilizers: anterior and posterior SC ligaments, costoclavicular ligament, interclavicular ligament

›Ligamentous failure pattern

›High-energy force exceeds ligamentous restraint

›Anterior force produces posterior dislocation

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Sternoclavicular dislocation home care

›Wear your sling or brace as directed, typically 4-6 weeks

›Remove only for gentle hygiene

›Avoid reaching overhead or across your body

›Ice the injured area for 20 minutes at a time, several times daily for the first 48-72 hours

›Take pain medication as prescribed

›Anti-inflammatory medication with food

›Acetaminophen may be taken together with anti-inflammatory medication if prescribed

›Keep the arm elevated when resting to reduce swelling

›Warning signs requiring immediate return to ER

›Difficulty breathing, shortness of breath, or noisy breathing

›Difficulty swallowing or a feeling of something stuck in your throat

›Voice change or hoarseness that is new or worsening

›Swelling, bluish discoloration, or coldness of the affected arm

›Pulselessness or numbness in the hand or arm

›Increasing pain not controlled by prescribed medications

›Chest pain or pressure

›Fainting or feeling faint

›Activity restrictions

›No contact sports, collision activities, or heavy lifting until cleared by your orthopaedic surgeon

›Minimum 6-12 weeks for return to contact sport

›Return only with physician clearance

›No overhead lifting or pushing with the affected arm during immobilization

›Driving may not be safe with a sling: discuss with your physician

›Follow-up

›Orthopaedic surgery follow-up within 5-7 days

›Attend all physiotherapy appointments once referred

12References/r20

Guidelines and key sources

›Key reference sources

›JAAOS (Journal of the American Academy of Orthopaedic Surgeons): SC dislocation management and classification

›Pediatric Emergency Care: posterior SCD miss rate and pediatric physeal injury data

›AFP (American Family Physician): mechanism, presentation, and ED management

›Injury (journal): vascular complications of posterior SCD

›Medicine and Science in Sports and Exercise: ligamentous laxity and atraumatic instability

›Emergency Medicine (journal): ED evaluation and imaging approach

Evidence levels applied

›Guideline and evidence classification

›Closed reduction with surgical standby for posterior SCD: expert consensus, Class I recommendation

›CT chest as gold standard for posterior SCD evaluation: expert consensus, ACEP Level B equivalent

›K-wire contraindication: well-documented case series, Class III harm recommendation

›MRI for physeal injury differentiation in patients < 25 years: JAAOS expert consensus

›CTA when vascular injury suspected: Class I recommendation, trauma guideline support

ICD-10 coding

›Relevant ICD-10 codes

›S43.20 Dislocation of sternoclavicular joint, unspecified

›S43.21 Anterior dislocation of sternoclavicular joint

›S43.22 Posterior dislocation of sternoclavicular joint

›S25.1 Injury of subclavian artery (if vascular complication)

›S27.0 Traumatic pneumothorax (if complication present)

›S42.02 Fracture of medial end of clavicle (physeal fracture-separation in young patients)

Evidence & Review

Evidence & Review