SCJ Injury

History:

• •Specific high-energy mechanism: direct blow, contact sport, road traffic collision (motorcyclist is classic for posterior), fall, or scrum/pile-up
• •Atraumatic onset: hypermobility, repetitive overhead occupation
• •Pain and swelling at the medial clavicle and SCJ; mechanical symptoms (clicking, catching) suggest subluxation or instability

Examination:

• •Inspect from above the shoulders with the patient sitting upright; compare with the contralateral side
• •Anterior dislocation: visible and palpable anterior prominence of the medial clavicle
• •Posterior dislocation: palpable sulcus or step posterior to the sternal notch
• •Focal SCJ tenderness; cross-arm adduction reproduces pain
• •Atraumatic instability: mobile reducible medial clavicle; elevated Beighton score
• •Mandatory in any posterior injury: airway, respiratory, and neurovascular assessment - auscultate breath sounds, palpate distal pulses bilaterally, note hoarseness or stridor

Differentials: medial clavicle fracture; medial clavicle physeal fracture-separation (always in under-25s); condensing osteitis of the clavicle (chronic painful medial clavicular swelling in middle-aged women, benign); SAPHO syndrome; septic SCJ (intravenous drug use, immunocompromise); osteomyelitis; atraumatic instability; rarely rheumatoid arthritis; costochondritis.

Plain radiographs systematically underestimate SCJ injuries. Standard AP chest and clavicle views overlap the relevant anatomy and significant injuries are missed. The serendipity view (Rockwood; AP with a 40-degree cephalic tilt) can help but is often inconclusive.

CT with 3D reconstruction is the key next investigation when SCJ injury is suspected or plain films are non-diagnostic. It defines direction and degree of displacement, identifies any associated bony injury, and crucially distinguishes a true SCJ dislocation from a medial clavicle physeal fracture-separation in under-25s.

Other modalities:

• •CT angiography: any suspected vascular injury (weak or absent distal pulse, expanding haematoma, cool or pale limb, neurological change)
• •MRI: atraumatic instability assessment, capsuloligamentous detail, suspected infection, or condensing osteitis
• •Bloods (CRP, ESR, blood cultures): if septic arthritis is suspected

Post-reduction imaging (CT, or at minimum rigorous clinical and radiographic checks) is required after posterior reduction to confirm the result and exclude delayed mediastinal haematoma.

Initial approach: ABCDE assessment. If posterior dislocation with compressive symptoms is suspected, escalate immediately and arrange urgent transfer to a centre with cardiothoracic or vascular surgical support.

Anterior dislocation:

• •Non-operative management is the mainstay: broad arm sling for comfort (2-6 weeks), simple analgesia, progressive rehabilitation
• •Closed reduction is NOT routine first-line - the joint frequently re-dislocates on release of traction and recurrent prominence is common
• •Residual cosmetic prominence usually persists but is rarely functionally limiting
• •Operative stabilisation is reserved for the rare case with persistent functional symptoms, not for cosmetic prominence alone, because any SCJ surgery carries mediastinal risks

Posterior dislocation:

• •An orthopaedic and potentially vascular emergency
• •Urgent specialist management, usually in theatre, with cardiothoracic or vascular surgical support available per local major trauma practice
• •Closed reduction technique: supine with interscapular bolster, arm abducted, traction with external rotation; direct posteriorly directed pressure on the anterolateral clavicle, or percutaneous towel-clip grasp of the medial clavicle if closed techniques fail
• •Figure-of-eight bandages are CONTRAINDICATED: retracting the shoulders drives the clavicle further posteriorly and worsens retrosternal compression
• •Closed reduction should NOT be attempted at a peripheral hospital without cardiothoracic or vascular surgical support available - the risk of mediastinal vessel laceration on reduction is low but catastrophic
• •Post-reduction the joint is usually stable; sling for 4-6 weeks then graded rehabilitation
• •Open reduction if closed reduction fails or if a vascular injury is identified

Medial clavicle physeal fracture-separation (under-25s): anterior displacement is typically non-operative with significant physeal remodelling potential. Posterior displacement is managed as per posterior dislocation.

Atraumatic SCJ instability: structured 6-12 month physiotherapy (scapular control, rotator cuff strengthening, proprioception); most improve. Ligament reconstruction is reserved for refractory disabling cases.

Septic SCJ: IV antibiotics with microbiology guidance and surgical drainage where indicated, usually cardiothoracic or shoulder specialist-led.

Referral:

• •Urgent orthopaedic/trauma: posterior dislocation; any SCJ injury with airway, vascular, or neurological compromise; high-energy injury with concerning symptoms; suspected posterior physeal displacement
• •Routine fracture clinic: uncomplicated anterior dislocation; atraumatic instability; persistent post-conservative symptoms; suspected septic arthritis (with infection team); suspected SAPHO (rheumatology)

Safety-netting: worsening pain, new dysphagia or dyspnoea, hoarseness, or arm swelling or colour change should prompt urgent re-presentation.

Progression is individual and guided by pain, function, injury pattern, and any operative technique. Local protocols and physiotherapy advice take precedence.

Anterior dislocation (non-operative):

• •Broad arm sling for comfort 2-6 weeks
• •Pendular exercises from day 1-3 to prevent stiffness
• •Progressive active range of motion from 2-4 weeks
• •Strengthening from 6 weeks
• •Non-contact activity typically at 6-8 weeks; contact sport at 3-4 months guided by pain, function, and sport-specific demands

Posterior dislocation (post-reduction):

• •Sling 4-6 weeks
• •Graded range of motion and strengthening from 6 weeks
• •Return to contact sport typically at 3-4 months, guided by the operating team

Atraumatic SCJ instability:

• •Structured 6-12 month programme: scapular stability, rotator cuff endurance, activity pacing
• •Patient education about hypermobility and modifiable factors
• •Surgical referral only for rare refractory cases

Modifiable factors: smoking slows soft tissue healing - signpost NHS Stop Smoking services. Address psychosocial factors and graded return-to-work planning. Do not drive while wearing a sling; return to driving only when safe to control the vehicle and perform an emergency stop.

• •Allman classification - The working framework: Grade I sprain, Grade II subluxation, Grade III complete dislocation (anterior or posterior). High-yield exam framework.
• •BESS shoulder care pathways - Non-operative management is the default for anterior dislocation; posterior dislocation is escalated to a centre with cardiothoracic or vascular surgical support.
• •BOA Standards for Trauma (BOASTs) - Apply to associated high-energy trauma; do not provide an SCJ-specific protocol but guide initial trauma care and major trauma network pathways.
• •Salter-Harris Type I/II medial clavicle physeal fracture-separation - In under-25s the medial clavicular physis is the last epiphysis to fuse; CT distinguishes from true SCJ dislocation. Anterior displacement remodels; posterior displacement is managed as a posterior dislocation.
• •NICE CKS Shoulder pain - Primary-care framework that flags posterior compressive symptoms as red flags requiring secondary care escalation.

• •Posterior SCJ dislocation is time-critical because mediastinal structures lie immediately posterior. Red flags: dysphagia, stridor or dyspnoea, hoarseness, arm venous congestion, absent distal pulses, paraesthesia.
• •The medial clavicular physis remains open until approximately age 25. In under-25s an apparent SCJ dislocation is usually a physeal fracture-separation - always CT.
• •Figure-of-eight bandages are contraindicated in posterior SCJ injuries - they retract the shoulders and worsen retrosternal compression.
• •Closed reduction of posterior dislocation should NOT be attempted at a peripheral hospital without cardiothoracic or vascular surgical support available; the risk of mediastinal vessel laceration on reduction is low but catastrophic.
• •Anterior:posterior dislocation ratio is approximately 9:1. Anterior is managed non-operatively as default - cosmetic prominence usually persists but function is preserved.
• •Plain radiographs systematically underestimate SCJ injuries. CT with 3D reconstruction is the key investigation. The serendipity view (40-degree cephalic tilt, Rockwood) is historical and often inconclusive.