THE CASE
A 16-year-old hockey player presented to our emergency department with sharp pain in his right upper chest after “checking” another player during a game. The pain did not resolve with rest and was worse with movement and breathing. The patient did not have dysphagia, dyspnea, paresthesias, or hoarseness. The physical examination revealed tenderness over the right sternoclavicular joint (SCJ) without swelling or deformity. A distal neurovascular exam was intact, and a chest x-ray showed no evidence of dislocation or fracture (FIGURE 1A). The patient’s pain was refractory to multiple intravenous (IV) pain medications.
THE DIAGNOSIS
A computed tomography (CT) scan with IV contrast of the chest demonstrated posterior and superior dislocation of the right clavicular head. Despite the close proximity of the dislocated head to the brachiocephalic artery (FIGURE 1B-1D), there was no vascular injury.
DISCUSSION
Posterior sternoclavicular dislocations (PSCDs) can be difficult to diagnose. Edema can mask the characteristic skin depression that one would expect with a posterior dislocation.1 Chest radiographs are often normal (as was true in this case). Patients may present with an abnormal pulse, paresthesias, hoarseness, dysphagia, and/or dyspnea. However, for more than half of these patients, their only signs and symptoms will be pain, swelling, and limited range of motion.1 As a result, a PSCD may be misdiagnosed as a ligamentous or soft tissue injury.1