A 60-year-old man is involved in a high-speed motor vehicle collision. He complains of severe pain at the right sternoclavicular joint. The pain is worsened with movement of the right arm as well as lying on his back. On physical examination of this patient, the medial end of the right clavicle is difficult to palpate and appears asymmetric compared with the left. Which of the following is most accurate?
Anterior sternoclavicular dislocation is highly likely, and the patient should be imaged with computed tomography and intravenous contrast.
+Anterior sternoclavicular dislocation is highly likely, and the patient may be discharged without attempted reduction.
+Posterior sternoclavicular dislocation should be suspected, and complications may include severe injuries to mediastinal injuries and pneumothorax.
+Posterior sternoclavicular dislocation should be suspected, and immediate reduction attempted in the ED.
+Routine radiographs are the imaging modality of choice and considered gold standard for both anterior and posterior sternoclavicular dislocations.
This patient sustained a high-energy injury to the chest, and clinically appears to have a posterior sternoclavicular dislocation as the medial end of his clavicle is difficult to visualize and palpate. Computed tomography with intravenous contrast is the next best step to detect associated mediastinal and chest injuries including compression or laceration of the great vessels, trachea, and esophagus, as well as associated pneumothorax. Plain films are frequently inadequate to diagnose this injury. Posterior dislocations are difficult to reduce, and this procedure is performed in the operating room in consultation with a vascular surgeon. Anterior sternoclavicular dislocations are more common and have far fewer complications. These injuries can be safely discharged without reduction, as the injury has little impact on long-term function.