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Suspected posterior sternoclavicular injury with mediastinal compression symptoms — MSRA MCQ

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HardShoulder InjuriesSuspected posterior sternoclavicular injury with mediastinal compression symptomsMSRA

A 15-year-old boy is seen in general practice 2 hours after a rugby tackle in which he was driven onto the anterolateral aspect of his right shoulder. In the emergency department, an anteroposterior clavicle radiograph was reported as showing no fracture; he left before medical assessment because the department was busy. He now has severe pain over the right sternoclavicular joint and supports the arm against his chest. The medial end of the right clavicle is less prominent than on the left. Since leaving hospital, he has developed increasing dysphagia and a sensation of throat tightness when lying flat. He has no stridor and is speaking full sentences. Oxygen saturation is 98% on air. Radial pulses, capillary refill, hand power and sensation are normal. What is the most appropriate immediate management?

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

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Correct answer: A — Call 999 for ambulance transfer to an emergency department, avoid attempted reduction, and alert the receiving team to suspected posterior sternoclavicular injury with possible mediastinal compression

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

This is a suspected posterior sternoclavicular injury, which in an adolescent may represent posterior sternoclavicular dislocation or posterior displacement through the medial clavicular physis. The key discriminators are a compression mechanism to the lateral shoulder, loss of normal medial clavicular prominence, and evolving dysphagia with positional throat tightness. These symptoms raise concern for compression of the trachea, oesophagus or great vessels behind the sternoclavicular joint. Normal oxygen saturation, absence of stridor and intact upper-limb neurovascular findings do not make this safe for outpatient assessment: mediastinal compromise may be evolving and standard radiographs can miss posterior displacement. A current NHS emergency guideline advises acute orthopaedic review when posterior displacement is suspected and notes that CT may be required to assess proximity to major structures. Difficulty swallowing after trauma is itself an NHS red flag for ambulance transfer. B is inappropriate because outpatient CT risks delay in a potentially airway- or vascular-threatening injury. C is inadequate because further plain films do not provide the required emergency imaging or specialist capability. D treats this as a stable shoulder-girdle injury despite compressive symptoms. E is unsafe: reduction of posterior sternoclavicular injuries can precipitate major haemorrhage and should occur only in a controlled specialist setting with appropriate surgical support.

Reference: Emergency Department Medical Guidelines: Clavicle Fracture Guidelines (2025) — https://www.sheffieldchildrens.nhs.uk/download/1721/acute-injury-and-orthopaedics/64209/4-15-clavicle-fracture.pdf Injury to the throat (Reviewed November 2023; review due November 2026) — https://www.gloshospitals.nhs.uk/your-visit/patient-information-leaflets/injury-to-the-throat/ Traumatic posterior sternoclavicular joint dislocation - Current aspects of management (2023) — https://pubmed.ncbi.nlm.nih.gov/37634999/