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             Anatomy of the sternoclavicular joint

• The sternoclavicular joint is a diarthodial saddle-type joint which provides a pivot for the shoulder girdle on the trunk.
• The joint capsule is reinforced anterioposteriorly by the anterior and posterior sternoclavicular ligaments.  Superomedially the joint is reinforced by the interclavicular ligament which joins both the upper boarder of both clavicles to the suprasternal notch.
• The clavicle is also bound to the first costal cartilage and the first rib by the costoclavicular ligament.

Clinical Presentation

Incidence

• Sternoclavicular dislocations account for 3% of all shoulder girdle injuries.
• 95% of SCJ dislocations are unilateral and anterior dislocations are far more common than posterior dislocations due to the weaker anterior sternoclavicular ligament (ratio 9:1). Bilateral superior dislocations, as in the case above, are rarely described.

Mechanism of Injury

• Dislocations of the SCJ generally occur following a fall on the outstretched hand or a direct blow to the shoulder. Sporting injuries and motor vehicle accidents account for the most causes of SCJ dysfunction. However, they can also occur without any history of injury.
• Patients commonly present with pain and swelling in the proximal sternum and sternoclavicular region. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing or coughing.
• Patients often laterally flex their neck towards the affected side to relieving pressure on the SCJ. Asymmetry is best appreciated when viewed from above the patient’s head.
• Additional symptoms include dysphonia, dysphagia or dyspnoea.

Diagnostic Imaging

• Plain X-ray: standard views may not provide a definitive diagnosis. Alternate views such as ‘serendipity view’ (40-degree cephalic tilt) may provide more information.
• CTA or MRA to determine direction of dislocation and potential for vascular compromise. A contrast study is required for definitive evaluation of surrounding structures.

Management

Simple sprain of the SCJ

• Patients will complain of mild to moderate pain and there will be no joint instability on clinical examination.
• Conservative treatment with ice, analgesia, shoulder sling for immobility will lead to complete recovery in 1 week.
• Subluxation of the SCJ will require the application of a clavicular splint or sling for 3 to 6 weeks

Anterior SCJ Dislocations

• Anterior sternoclavicular dislocations are usually managed nonoperatively.
• The clavicle often stabilises in its subluxed position, with asymmetrical ventral protrusion of the affected side. The arm should be rested in a sling which will assist in the reduction of pain. Patients generally experience a good pain-free functional outcome at 2-3 weeks. Very rare complications include chronic pain, periarticular calcifications with ankylosis and progressive deformity.
• Closed reduction may be indicated in rare circumstances where the patient is engaged in strenuous upper limb activities causing a painful SCJ. It is however, often unsuccessful. The application of direct pressure over the medial end of the clavicle may also reduce the joint.

Posterior SCJ Dislocations

• Posterior sternoclavicular dislocations should always be reduced in theatre because of the associated risk to intrathoracic and superior mediastinal structures.

Unilateral Posterior Sternoclavicular Dislocation

Unilateral Posterior Sternoclavicular Dislocation CT