PMC7300244_01
A: AP radiograph of right clavicle on presentation which showed no obvious fracture or dislocation of the shoulder girdle. B: AP radiograph of bilateral sternoclavicular joints showed subtle joint space widening on the right side. The overlapping of medial structures such as the ribs, clavicle, sternum and vertebrae impedes visualisation of the sternoclavicular joint in direct antero-posterior films.
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On exam, she was neurovascularly intact, her initial X-rays were negative and she was discharged from the emergency department in a sling, managed as an occult, undisplaced proximal clavicle fracture (Fig. 1A & B).
Axial CT without contrast at the level of the joint revealed a Salter Harris 2 fracture with posterior displacement at the right sternoclavicular joint. There was a small fragment of bone at the superior-anterior aspect of the joint represents the ossifying epiphysis. The relationship of the medial clavicle to the subclavian vein and brachiocephalic vein may is seen by subsequent CT with intravenous contrast.
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A fracture line was noted anteriorly in keeping with a salter harris 2 epiphyseal fracture (Fig. 2).
CT angiogram with the patients right arm above their head showed the medial end of the clavicle was posteriorly displaced as noted previously. There was no evidence of any vascular compression, either arterial or venous. The subclavian, axillary and brachial arteries were also normal.
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CT angiography was performed with the arm abducted above the head to out rule dynamic compression and showed mild compression of the axillary-subclavian junction between the clavicle and first rib although this was deemed positional (Fig. 3).
XR at 12 months follow-up. Best seen on the right oblique radiograph, the anatomic relationship of the medial aspect of the right clavicle and the right sternum is abnormal with abnormal widening but unchanged compared to the previous XR. This reflects stable posterior SCJ fracture-dislocation.
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SCJ remains dislocated but stable (Fig. 4). She is currently 3 years post-injury and her symptoms have completely resolved other than mild venous congestion after extensive, repetitive overhead movements.