skip to main content

Suspected posterior sternoclavicular joint dislocation — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModerateShoulder InjuriesSuspected posterior sternoclavicular joint dislocationMSRA

A 19-year-old man attends your GP surgery 4 hours after a rugby tackle in which he landed forcefully on the lateral aspect of his right shoulder. At an urgent treatment centre, an anteroposterior clavicle radiograph was reported as showing no fracture. He has worsening pain at the medial end of the clavicle and upper anterior chest. He now reports dysphagia and a sensation of pressure in his throat. Examination shows tenderness and a subtle depression at the right sternoclavicular joint. Oxygen saturation is 98% on air, radial pulses are equal, and there is no upper-limb neurological deficit. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Arrange emergency ambulance transfer to an emergency department for urgent contrast CT and trauma/orthopaedic assessment, without attempting reduction

Explanation lettering: D = shown as A · C = shown as B · B = shown as C · A = shown as D

This presentation is highly concerning for posterior sternoclavicular displacement. The relevant discriminators are a compressive mechanism to the lateral shoulder, focal medial clavicular symptoms, apparent sternoclavicular depression and new dysphagia. Posterior displacement of the medial clavicle may compromise mediastinal structures, including the oesophagus, trachea and great vessels. Normal oxygen saturation, equal radial pulses and an intact upper-limb neurological examination do not safely exclude this. He needs emergency transfer for urgent cross-sectional imaging and specialist trauma assessment. NICE recommends immediate CT for haemodynamically normal adults with suspected chest trauma; in suspected posterior sternoclavicular injury, contrast CT/CT angiographic assessment defines the position of the medial clavicle relative to mediastinal vessels and identifies vascular complications. Reduction should not be attempted in primary care because manipulation may precipitate major haemorrhage and requires an appropriately resourced specialist setting. A would be reasonable for a stable clavicular or uncomplicated anterior sternoclavicular injury, but not with compressive symptoms. B assesses superficial soft tissues but not mediastinal anatomy. C may occasionally assist diagnosis but risks delaying definitive imaging in a potentially dangerous posterior injury. E is inappropriate because MRI is not the urgent investigation for suspected mediastinal or vascular involvement.

Reference: NICE NG39: Major trauma: assessment and initial management, imaging to assess chest trauma (Published 2016; last reviewed 17 February 2016) — https://www.nice.org.uk/guidance/NG39/chapter/recommendations Sternoclavicular joint dislocation and its management: A review of the literature (2016) — https://pubmed.ncbi.nlm.nih.gov/27114931/ Traumatic posterior sternoclavicular joint dislocation - Current aspects of management (2023) — https://pubmed.ncbi.nlm.nih.gov/37634999/