Patients with simple sprains have pain and tenderness localized to the joint, whereas patients with dislocations have severe pain, which is exacerbated by arm motion and lying supine. In anterior dislocations, the medial clavicle is visibly prominent and palpable anterior to the sternum. In posterior dislocations, the medial clavicle is less visible and often not palpable. Symptoms of hoarseness, dysphagia, dyspnea, upper extremity paresthesias, or weakness may indicate life-threatening injuries to mediastinal contents, such as pneumothorax or compression or laceration of surrounding great vessels, trachea, and esophagus.
Diagnosis and Differential
CT is the imaging test of choice. IV contrast may be needed to detect injury to adjacent mediastinal structures. Consider septic arthritis in the nontraumatic patient, especially in injection drug users.
Emergency Department Care and Disposition
Treatment for sternoclavicular sprains and uncomplicated anterior dislocations includes ice, analgesics, and sling immobilization. Attempted closed reduction is not necessary as this injury is often unstable. Posterior dislocations require immediate orthopedic consultation for open reduction and internal fixation.
Patients with clavicle fractures present with pain, swelling, and tenderness over the clavicle. The scapula is a well-protected bone; therefore, fractures usually occur in association with injuries to the ipsilateral lung, thoracic cage, and shoulder girdle. Patients have pain and localized tenderness over the scapula, hold their arm in adduction, and resist any arm movement.
Diagnosis and Differential
Routine radiographs may miss some clavicle and scapular fractures. CT can confirm the diagnosis as well as identify any associated pathology.
Emergency Department and Disposition
The majority of fractures can be managed conservatively with sling immobilization, ice, and analgesics. Early range-of-motion exercises are important for scapular fractures. Orthopedic consultation is warranted for clavicle fractures that are open, have neurovascular compromise, or have persistent skin tenting. Presence of a scapula fracture mandates investigation for associated intrathoracic injuries. Displaced glenoid articular fractures, angulated glenoid neck fractures, and certain acromial and coracoid fractures may require surgical intervention.
Acromioclavicular joint injuries range from mild sprain to complete disruption of all ligaments that attach the scapula and clavicle. The classification of these injuries and their physical findings are described in Table 172-1.
Table 172-1 Classification and Physical Findings in Acromioclavicular Joint Injuries |Favorite Table|Download (.pdf)
Table 172-1 Classification and Physical Findings in Acromioclavicular Joint Injuries
Sprained acromioclavicular ligaments
Tenderness over acromioclavicular joint
Acromioclavicular ligaments ruptured; coracoclavicular ligaments sprained
Slight widening of acromioclavicular joint; clavicle elevated 25% to 50% above acromion; may be slight widening of the coracoclavicular interspace
Tenderness and mild step-off deformity of acromioclavicular joint
Acromioclavicular ligaments ruptured; coracoclavicular ligaments ruptured; deltoid and trapezius muscles detached