Just My Puck: Posterior SC Dislocation Following a Hockey Game

CASE

An 18-year-old male with no significant past medical history presents with left shoulder pain after sustaining an injury while playing hockey. The patient reports that during the game he was tripped by another player, and subsequently hit the back board with his left upper torso. He immediately experienced severe pain and nausea. He was taken to the emergency department (ED) at this time. Pain is localized to the left shoulder, exacerbated by movement, and alleviated by immobilization. He denies shortness of breath, dysphagia, hoarseness, paresthesias, or any sensorimotor deficits.

VITALS

HR: 61 BP:124/86 RR: 18 T: 37 C SpO2: 98% on room air

Patient is hemodynamically stable.

PHYSICAL EXAM

Well-developed male in no acute distress. Depression and soft tissue swelling are noted at the sternoclavicular (SC) joint, with tenderness to palpation over the medial left clavicle. Breath sounds are clear to auscultation bilaterally. Circulation is intact with strong radial pulses and good capillary refill. Neurovascularly intact. 

IMAGING

Anterior-posterior (AP) chest x-ray shows normal left clavicle.

Computerized tomography (CT) of chest/neck without intravenous (IV) contrast shows posterior left sternoclavicular dislocation.

DIAGNOSIS

CT shows posterior sternoclavicular dislocation without underlying pulmonary or vascular damage.

DISCUSSION

Posterior SC dislocation is an exceedingly rare injury, accounting for less than 0.1% of all joint dislocations. Since 1824, approximately 100 cases have been documented, with the majority occurring during the past 20 years. [1] Case reports demonstrate that this injury occurs most frequently in young males, due to the decreasing mobility and laxity of the joint with age. [2] The mechanism is usually described as a violent blow to the postero-lateral aspect of the shoulder with the arm in adduction and flexion, [2] most commonly seen with sports injuries. [3,4] The patient described in this study had a similar mechanism of injury during a hockey game.

Despite the infrequent presentation of posterior SC dislocations, this injury is an orthopedic emergency. The proximity of the clavicle to important mediastinal structures can pose a risk for serious, life-threatening complications. This includes, but is not limited to hemothorax, pneumothorax, transection of the great vessels, or esophageal perforation. [2] As a result, it is important to ask the patient about associated symptoms such as hoarseness, dysphagia, dyspnea, and venous congestion. [2] The emergency medicine physician plays a vital role in prompt recognition and orthopedic referral for these patients. 

When posterior SC dislocation is suspected, especially in patients < 25 years old, a CT scan can help aid in the diagnosis. [2] As demonstrated in this case, an AP chest x-ray can appear normal despite underlying injury. Therefore, it is important for the emergency medicine physician to maintain a high index of suspicion in young patients presenting with clavicle pain after high impact scapulothoracic trauma, despite normal AP imaging. The serendipity view on x-ray is also a useful technique for diagnosis if CT is unavailable. This view involves tilting the x-ray beam of an AP image that is centered on the sternum to 40 degrees, in the cephalic direction. [5]

Treatment with open versus closed reduction of these injuries is controversial in the literature. In one meta-analysis, an attempt at closed reduction was recommended as first line treatment. [2] This would allow the patient to minimize the risks of surgery, such as hemorrhage, infection and damage to surrounding structures. Closed reduction was found to have the best outcomes when performed within 48-72 hours of injury. However, successful reduction has been reported up to 10 days after the initial event. [2] Despite this recommendation, closed reductions, in general, have a success rate of only 38%. [6] When closed reduction cannot be accomplished, open reduction should be performed by an orthopedic surgeon. There is also controversy regarding whether a cardiothoracic surgeon needs to be present during the operation, in the event of damage to surrounding structures. One systematic review showed that eighteen articles recommended having a cardiothoracic surgeon available during the procedure. However, there was not a single case anywhere in the literature where the cardiothoracic surgeon had to intervene. [2] Consequently, this recommendation is based more on a theoretical than evidence-based risk. In the patient described in this case, a cardiothoracic surgeon was notified and on hand, if necessary, but never scrubbed into the case.

CASE RESOLUTION

In the ED, the patient was placed in a sling and his pain was controlled with Tylenol and Toradol. He was taken to the operating room the next day with orthopedic surgery for open repair and internal fixation of the dislocation. A cardiothoracic surgeon was on backup throughout the procedure in the event of iatrogenic damage to mediastinal structures. There were no complications during the surgery. The patient began working with physical therapy on post op day 1 and was discharged home the next day.

TAKE-AWAYS

  • While posterior SC dislocations are rare, prompt recognition and treatment are imperative because these injuries can result in life threatening complications.

  • Suspect this injury in young patients following high impact scapulothoracic trauma, despite normal AP chest x-ray. Consider obtaining radiographs with the serendipity view or a CT scan.

  • Evidence supports attempt at closed reduction for these injuries before surgery is performed

  • Evidence is weak to conclude that the involvement of a cardiothoracic surgery is necessary during open repair of posterior SC dislocations. 

Author: Maiya Cowan, MD is a first-year resident at Brown University/Rhode Island Hospital

Faculty Reviewer: Kristina McAteer, MD is an attending physician at Rhode Island Hospital and Newport Hospital

REFERENCES

  1. Marker L, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. BrJ Sports Med 1996;30:71-72

  2. Sernandez H, Riehl J. Sternoclavicular Joint Dislocation: A Systematic Review and Meta-analysis. J Orthop Trauma 2019;33(7):e251-e255

  3. Gazak S, Davidson S. Posterior Sternoclavicular Dislocations: Two Case Reports. J Trauma 1984;24(1):80-82

  4. Jougon J, Lepront D, Dromer C. Posterior Dislocation of the sternoclavicular joint leading to mediastinal compression. Ann Thorac Surg 1996;61(2):711-713

  5. Cruz M, Erdeljac J, Williams R, Brown M, Bolgla L. Posterior Sternoclavicular Dislocation in a Division I Football Player: A Case Report. Int J Sports Phys Ther 2015;10(5):700-711

  6. Groh G, Wirth M, Rockwood C. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg. 2011;20:107–113.

Sports Medicine, OrthopedicsMaiya CowanBrown Emergency MedicineSC Dislocation, Orthopedics, Shoulder TraumaComment