Working Diagnosis:
Salter-Harris Type I Physeal injury/Posterior-Superior Sternoclavicular Dislocation Equivalent

Treatment:
Given the concern for posteriorly displaced clavicle from an SCJ injury versus Type IV AC Joint separation the patient was sent to the emergency department (ED) for further evaluation and orthopedic consultation. Imaging from ED included CT, CTA, and MRI. A closed reduction was performed under general anesthesia with the lateral portion reduced by applying longitudinal traction, hyperextension, and abduction.

Outcome:
Full return to play and regular activity following simple sling and gradual progression following closed reduction.

Editor's Comments:
Sternoclavicular injuries are rare injuries in children and adolescents and estimated to be less than 5% of all shoulder related injuries (1). However, these injuries are crucial to recognize and consider promptly, especially posterior sternoclavicular dislocations, due to the proximity of retrosternal vascular and neural structures along with the trachea and esophagus all of which have the potential to be compressed or damaged. The two main mechanisms of injury are either a direct anterior-posterior force to the medial clavicle or a posterior-anterior force to the posterolateral shoulder. The SCJ is stabilized by a thick capsule and ligamentous system and due to the thicker posterior capsule providing most of the stability, anterior dislocations are up to three times more common than posterior dislocations (1). As the epiphysis at the medial clavicle does not ossify until 18-20 years and only fully fuses between 22-25 years of age these injuries in patients younger than 25 are more likely to be salter harris 1 or 2 injuries as opposed to pure dislocations (2). Patients typically present with pain over the SCJ joint after a high-impact collision and usually holding their upper limb adducting across the body. Anterior dislocations may have a painful lump appreciated at the SCJ and patients with posterior dislocations may complain of compressive symptoms of dyspnea or dysphagia (3) . Commonly missed on plain films, if there is concern for a SCJ injury a serendipity view should be obtained during initial assessment and to rule out associated pneumothorax or pneumomediastinum. CT scan is the investigation of choice, and should include a CT angiography if concern for vascular injury is present. In younger individuals, in addition, an MRI should be obtained to adequately differentiate between a true dislocation and a physeal fracture (2). As most younger individuals are more likely to have Salter Harris injury with excellent healing potential as opposed to a true disruption of the capsule, in the absence of compression or injury to surrounding entities, treatment with a closed reduction with sedation historically has been preferred (2). Recent case reports suggest in the absence of respiratory or vascular compromise closed reduction may not be necessary (2). Open reduction is considered in cases involving compression or injury to surrounding entities or if attempts at a closed reduction are unsuccessful.

References:
1) Siebenmann, C., et al. (2018). "Epiphysiolysis Type Salter I of the Medial Clavicle with Posterior Displacement: A Case Series and Review of the Literature." Case Rep Orthop 2018: 4986061.

2) Wagner, Ryan J. DO; Symanski, John S. MD; Raasch, William G. MD; Young, Craig C. MD Successful Nonsurgical Management of a Posteriorly Displaced Medial Clavicular Physeal Fracture in an Adolescent Athlete. Clinical Journal of Sport Medicine: September 22, 2020 - Volume Publish Ahead of Print - Issue -doi: 10.1097/JSM.0000000000000878
3) Morell DJ, Thyagarajan DS. Sternoclavicular joint dislocation and its management: A review of the literature. World J Orthop. 2016 Apr 18;7(4):244-50. doi: 10.5312/wjo.v7.i4.244. PMID: 27114931; PMCID: PMC4832225.

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